'Male 56, fallen'

I turn around to the student who is working with us for this month and tell her that it's probably some bloke who is drunk - after all, that is the sort of job that I tend to get sent to.

As is traditional the call is on the other side of our patch to where we currently are, but thankfully we can whizz along the A13 to get there that much quicker. It's not even rush hour.

As we pull up outside the house my subconscious starts shouting at me, I don't know if it's the behaviour of the relatives or something else, but I yell to my crewmate that she should bring her big bag of paramedic tricks with her - I grab the oxygen bag and the defibrillator and make my way into the house.

I follow someone who I understand is the wife into the house, she leads me along the corridor telling me that she was making a cup of tea and when she came back from the kitchen her husband had fallen over.

Before I enter the living room all the alarm bells in the back of my head are ringing - I couldn't tell you why I had that feeling, but I've learnt to listen to my inner voice when it is screaming at me, it doesn't send me wrong.

Sure enough our patient is face down on the carpet, not breathing and his skin is that deeply unhealthy bluish-purple that tells me that he hasn't got a pulse.

Over my shoulder I hear the wife ask if he will be alright, another woman ask if he'll be alright for the disco tonight and a boy wailing.

I'm on my own for the minute, my crewmate and student are still gathering the kit from the ambulance. I have long legs and I tend not to hang about getting to the patient, especially when I'm getting the 'bad vibes'. Unfortunately this can put me some way ahead of my shorter-legged colleagues.

I roll the patient over and start the CPR - he looks pretty far gone to me, but you never know. The training takes over, I haven't been flustered at a cardiac arrest for years and I settle into the familiar patterns.

Crack, crack, crack, crack go four of his ribs. I always wince when I break someone's ribs, sadly it's pretty much unavoidable if you are doing CPR properly - it's worse when you feel the ribs go on the little old ladies that have bird-like bones.

I pump away and can hear my crewmate asking where I am. I think for a moment, trying to remember my route into the flat.

"Down the end of the corridor, and it's a suspended!", I shout.

My crewmate and the student arrive, I tell the student to place the defib pads on the patient's chest which she does perfectly. Someone gets out the ambu-bag and I suggest that I 'bag' the patient (breathe for him), while our student can do the CPR and my paramedic crewmate can do all the other things like popping a needle in his veins and preparing to intubate him.

At some point I send our student back to the ambulance to call for another crew - with a cardiac arrest it's always handy to have a second ambulance to help out.

The defib tells us to stand back as it wants to analyse the heart rhythm to see if we should 'shock' the patient - I look at the screen, it's a pretty obvious case of VF, something that we do shock. For some reason the machine isn't completing it's analysis, it keeps telling us to move away from the patient even though we aren't touching him.

Just as I'm about to put the defib in manual mode and do it my own damn self it decides that yes, perhaps a shock is advisable.

Our student gets the honour of hitting the button. She checks that we aren't touching the patient, presses the button to shock him and our his body gives a shudder.

The relatives keep asking if he will be alright, one of them mentions a disco again and I think then leaves the house. I have my mind on other things, but find the time to tell them that because our patient is very sick we are pumping his heart for him and breathing for him.

I ask my crewmate if she wants to secure his airway by intubating him, she's been trying to get a line in because she knows that I can handle airway management pretty well. She throws me a cannula in it's packet and tells me to get venous access, while she starts lays out the kit she needs to pass the breathing tube.

Our student keeps up the CPR, and it's good CPR at that - training school seem to have been doing a good job in teaching CPR.

I insert the cannula and secure it while my crewmate gets the breathing tube down in one swift, smooth movement. At the hospital the anaesthetist will compliment my crewmate on her intubation skills. She won't tell the doctor that she had to tube the patient while half curled up in a tiny space half under the TV.

One lot of drugs go in through the cannula, the patient gets shocked again and would you believe it, he gets his pulse back and starts breathing.

The trolley is fetched and we continue to stabilise the patient. It's looking pretty good, he's got nice strong breathing and a very strong and regular pulse. He could be sleeping were it not for all the bits of medical kit sticking out of him.

We lift him onto the trolley and are loading him on the ambulance when two FRUs and another ambulance turn up.

"You're too late", I tell them, "we've got it sorted - look he's even breathing for himself".

"Sweet", comes the reply from a FRU responder.

We plug him in to our ambulance equipment - his vital signs are all exceptionally good, better than mine at that moment I would guess.

We pre-alert the hospital and make a run for it, our student is driving while me and my crewmate monitor our patient - it's looking pretty good for him.

At the hospital our patient starts to wake up, so the doctors knock him out so that he can rest and so they can do some more diagnostic tests without him fighting them. There is no obvious reason for his cardiac arrest and some of the other tests performed are pretty hopeful for his recovery.

We later find that he was moved to another hospital as that is the nearest with an empty ITU bed. It's a bit of a shame as it means I won't be able to follow him up to see if he survives to discharge. It's a shame, I'd really like to know how it works out.

To see if he survives his 'fall'.

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On May the first I'll be at this event - Cory Doctorow and Charlie Stross (two of my favourite authors) will be talking about how to escape the surveillance society. Proceeds go towards the excellent Open Rights Group. Doctorow is an annoyingly effective and engaging talker and, while I've never heard Stross talk in public, I would imagine that it will be an very entertaining and educational evening.

You can register for tickets at eventbrite. Well worth £10 of anyone's money, or if you are feeling particularly wonderful, for the cost of a subscription to the ORG. If you come along do say hello.

Copied from the LAS News website.

A paramedic has been attacked after he disturbed thieves trying to steal drugs from an ambulance station.

The paramedic was hit over the head with a fire extinguisher, punched and kicked during the burglary at Pinner Ambulance Station, Harrow.

Police are now searching for four men in connection with the assault which happened at approximately 1:30am on Saturday (14 March).

The staff member, who is a team leader at the station, does not wish to be named. He said: “I was on my break at the station and as I walked into the garage four men sprung up from behind one of the cars and just came at me.

“They ran straight at me, throwing punches and kicking me as I tried to fend them off. Then I felt an almighty thump on the back of my head from a fire extinguisher. I was dazed and was stumbling around which gave the men the chance to run away.

“The whole thing lasted not more than two minutes, it was all over before I knew it.

“Afterwards, I was fuming. Then I found a slash on my forearm and saw the slit through my shirt with a wound on my stomach – it transpired later that a knife with blood on it was found outside the station – I realised then how lucky I had been.

“When you are at your ambulance station you just don’t expect anything like this to happen. I’ve been doing this job for 19 years and have never been assaulted like this.”

Following the attack the paramedic was taken to Northwick Park hospital for a check-up.

Ambulance Operations Manager for Pinner Sean Brinicombe said: “We are doing everything we can to support him through this and to aid the police in pursuing a prosecution.

“I am shocked that people would sink so low as to steal from an ambulance station and attack a paramedic in the process.

“Thankfully he is okay, but this incident could have been a lot worse. Our staff shouldn’t have to work in fear of attack, especially from the very community they are trying to serve.”

No comment needed beyond hoping that he gets well soon.

Yesterday Google released it's 'Streetview' service in the UK. This allows people who use Google's mapping website to look at panoramic photographs of the areas covered.

The first place that I looked was for my house, sadly the Google camera car stopped one street away. I looked for my Mum's house, and again the photographs stopped one street away.

Then I looked for my ambulance station.

View Larger Map
All very clever, and as the streets are public, not a problem. Anyone with nefarious purposes are better served by actually visiting the place in question. For example, in these pictures of our station, you can't see the security cameras...
But then I thought about the road outside Newham hospital, had the camera car been down there?

Sure enough they had, and what was shown was a patient being unloaded from an ambulance.

Now, I'm not too sure if the road that the hospital on is public property or not, but ethically there is surely an expectation of privacy when you are on an ambulance or being wheeled into A&E? It is this expectation of privacy which is important¹.
Being a bit busy I just twittered about it and thought nothing more about it.



However it would seem that someone with a bit more energy behind their ethical standing took notice of it and reported the image to Google, and being generally good guys, they quickly removed it.
Then today I saw exactly the same picture printed in The Metro, with a screaming headline about privacy concerns. Really, if they were that concerned about privacy, they shouldn't have printed the picture along with the story...
I suspect that someone on the Metro reads my twitter feed (actually, I personally know someone who does, but they are quite smart and are unlikely to have been involved in printing the picture). But what it does show is the surprising speed of information via various 'social media' networks.


¹Here is an excellent guide for UK Photographers and the law.

A quick recap for those who haven't yet seen me write about ORCON. ORCON is the government target that tells all ambulance services that they have to keep the time between the phone ringing up in Control and the ambulance arriving on scene to under eight minutes for our highest priority calls. There is also a nineteen minute target for not-so-serious calls. For the low priority calls, like grannies with broken hips, we can leave them on the floor for up to four hours.

This eight-minute target is based around outdated research and has little clinical significance for the majority of our patients, something admitted by our own chief executive as 90% of our calls come from people who do not need an emergency ambulance. This 90% figure is based on the London Ambulance Service's own research¹.

It's easy to tell when to 'start the clock', as soon as the BT operator connects the 999 call to our Control, but when do you 'stop the clock'?

The target states that the ambulance should be on scene. Does this mean when the ambulance pulls up outside your house and I hit the big 'At Scene' button? Does it mean when the keys are out of the ignition of the ambulance (because we track that)? Does it mean when I poke my ugly mug around the bedroom door to find you on your bed with bellyache (and if you live in a block of flats with no working lift it might take me over a minute to actually reach you)?

All these are reasonable ways of measuring the time. When we pull up, or when the keys are out the ignition are easily measured due to the tracking devices in our ambulances. Being face-to-face with a patient would need us to have an accurate watch and to note the time ourselves, so accuracy would be a problem but it would better match the 'patient experience'.

How about marking us as 'on scene' when we are within 200 meters of the address? This is what many of us on the road suspect of happening - when we get within 200 meters or so of the address our MDT 'updates'.

It doesn't matter if you have crashed your car on one side of the dual carriageway and we have to drive an extra five miles to get on the correct side. It doesn't matter if we have to creep around tiny winding estate roads, wary of knocking off the wing mirrors of parked cars. It doesn't matter if the address is a bit wrong, if we are where the computer says we should be then we are 'on scene'.

As the time arrives when we have to finally collate our ORCON success rate approaches (appropriately enough April the 1st), so we find the percentage of calls that we make on target start creeping up towards the magic 75% mark.

Why is this? Well, in the words of our own Chief Executive,

"...our Management Information team check all our records to ensure we capture everything correctly. [The] team are checking every missed call, and with over one million calls, inevitably they are finding some that can be legitimately included."

Which makes me think that they go over every call, and if we were within 200 meters of the address when the eight minutes are up, they then count us as being 'On scene' and therefore the job can be seen as a 'success', regardless of patient outcome.

As always, the LAS and LAS management have the full right to reply to anything that I write here. It would be nice if they could confirm, or deny, us being within 200 meters as being part of hitting our targets, and to what 'legitimately included' means.

¹Taking healthcare to the patient: Transforming NHS ambulance services (Page 8)

Two cases, one I, sadly, have come to expect, the other was a bit more surprising.

In the first we find ourselves going to an elderly man who has fallen out of bed, normally a nice simple job that doesn't require much from us apart from a quick dusting off, a check to make sure that they aren't hurt and to make sure that this simple 'mechanical' fall isn't the start of something more serious.

Being the eagle-eyed medical professionals that we are, we notice that our patient has a lot of sores on his body - so we ask him about them.

He's been getting them for a while and the district nurses have been out to dress the sores on his legs for a few weeks now. The sores have since spread to his arms, but the nurses won't dress them as it's not in their care plan. He has been trying to dress them himself - with little success.

Once upon a time I did a nursing placement with a district nurse service, one of the things that you get very good at very quickly is the ability to dress leg wounds. You see so many ulcerated legs you start thinking that everyone over the age of sixty must have them.

You learn how to dress these wounds so that the dressing stays on, so that it is clean, and you make sure you use the best dressing for that particular type of wound.

I look at the dressings on the man's legs. These dressings are awful. They are secured (and I use that word loosely), not with medical tape, but with Sellotape. The bandages are the wrong sort of bandages so they are just falling off his legs. I wasn't too impressed with the underlying dressing either, the layer that is supposed to promote the healing of these sores.

I could maybe understand the dressings not being of high quality if the patient were the type to undo his dressings but he isn't. Couple this with the open sores on his arms that hadn't been dressed at all and I could only really say that this was a very poor example of nursing care.

So I did the only thing that I could, I took him to hospital so that his wounds could be treated properly, and then I filled in one of our 'vulnerable adult' forms, hopefully someone higher up the food chain will take notice of my concerns and do something about the terrible treatment of this patient.

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I'm used to poor care in the community, I expect better in hospitals.

We were called to transfer a patient with many broken bones from a ward in one hospital to another hospital, a fairly simple job although the journey would take over an hour. Little did I know we'd take about the same amount of time picking the patient up from the origin ward.

We arrived on the ward and found that our patient was quite a chirpy fellow, he was covered in plaster casts and had an external fixator through his pelvis. No problem, this wouldn't be a tricky transfer.

I asked the handover nurse what sort of pelvic fracture he had, while it's been some time since I studied orthopaedic treatment (in a non-emergency setting), I suspected that due to the presence of the fixator it would be a an 'open book' fracture.

The nurse told me that she didn't know, and handed the notes at me.

Non-plussed at this lack of knowledge about the patient that she was looking after I asked what else he'd broken.

"Dunno", I was told by the nurse.

I gritted my teeth.

There was a strange contraption attached to the patient's leg - to be honest I wasn't sure what it was, so I asked the nurse.

I wasn't altogether surprised when she told me that she had no idea what the device was for.

It was about then I started to see red - as a nurse you need to know about your patients, you should definitely know what the various bits of equipment hanging off the patient are for and how to look after them. Imagine if this bit of kit needed to be removed once an hour - without knowing this you could put the patient at risk of serious harm.

If you get a patient arrive in your ward with something unusual you find out what it is and how to look after it, to do otherwise is, in my eyes, a basic failure of nursing ability.

The nurse noticed I was getting annoyed at her lack of knowledge and at her apparent apathy towards the care of her patient.

"It's not like I've lied to you", she said referring to the machinery, "I could have said I knew what it was for".

"That's not the point", I replied, "the patient came down from ITU with it attached to them, you should have asked how to look after it when it was handed over to you - or you could have rung up ITU at any point during the day and asked them over the phone. It's hardly rocket science".

She stomped off in a strop. I don't think that she understood the point I was trying to make.

I checked the notes that we'd been given - there wasn't a CD of the patent's x-rays in there.

"The orthopaedic nurse will have it", I was told by another nurse, "she'll have gone home by now".

"Can you not get another copy", I asked.

"I don't know how".

"Tell you what", I offered, "bleep the Ortho SHO and get them to burn you a new copy, because otherwise the receiving hospital will think you are all idiots here".

"Oh - that's a good idea", she agreed.

So finally - after an hour at the hospital we were ready to move the patient onto our trolley. I looked at the patient's drug chart.

"He last had his painkillers seven hours ago", I told the nurse.

"Yes?", she said, "he's not in pain".

"Ah, but just think", I explained, "we are going to drag him from his bed across to our trolley, then wheel it through the hospital and into the back of an ambulance. We are then going to drive that ambulance over the horribly bumpy streets of London for an hour. Might he not benefit from a bit of pain relief before we head off?"

'Oh.... Yes".

After an injection of what I wold consider a homeopathic dose of analgesia I then had to browbeat some of the nurses to help us move this immobile man across onto our trolley. I also had to teach them how to safely move someone who has half a tonne of metal holding them together .

So... I know that this isn't a specific orthopaedic ward - but all I was looking for was a bit of common sense, even for someone to realise that their current knowledge isn't good enough for this patient and ask for help. But, sadly, there wasn't any of that self-awareness that I'd hope to see in a sentient life-form, let alone a professional.

I don't know - sometimes I feel like returning to nursing so I can stalk the wards with my 'Big Stick o' Learning' gently tapping people on the head until they realise that NHS shouldn't be a watchword for slapdash care.

Or is it just me, is this acceptable care these days? Should I stop being so harsh on other people, expecting them to do at least as well as I would think I could do? Am I just judging these others as being incompetent while blind to my own inadequacies? Would I really prefer a return to 'old fashioned' matrons who would tear you off a strip in public, thus humiliating you and making the lesson stick in your head - or are the 'modern matron' with their clipboard and 'softly, softly' approach in fear of 'stressing out' an employee the way forward?

I dunno - I just drive a van.

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The Peter Principle is the principle that "In a Hierarchy Every Employee Tends to Rise to His Level of Incompetence.", something that seems particularly apt in the NHS. However, I sense that this works in all forms of life and work. Consider this my Monday Question - What is the worst sort of incompetence you have come across lately.

Commentors who just post 'The Government' will be mocked for their stating of the obvious and their lack of imagination.

Go on, have a moan...

It's only when I get close to the address that I recognise where I'm going. I've been to her a couple of times, a seven year old who has regular fits - the mum never panics and it's normally a pretty easy job to get the child out to the ambulance and down to the hospital. It's the end of our shift so for us it looks like it's going to be a nice little 'off job'.

The mum waves at us from the front door, she seems unconcerned which is always a good sign, she's seen her child fit before and obviously it can't be too bad an episode. She directs us upstairs.

Lucy, the little girl, is apparently asleep on the bed, a damp patch near her head means that she has either vomited or drooled during her fit.

I start with the basics, airway and breathing - it's a check that we do without thinking, almost all of our patients are breathing.

This one isn't.

'Pass me the ambu-bag', I ask my crewmate.

'That can't be right', I think. I bend down, sitting on my haunches so that my eyeline is level with Lucy's chest, it must just be a trick of the light.

Nope, she's not breathing.

Still thinking that my eyes are playing tricks on me I put my hands on either side of her chest, hoping to feel the rise and fall of the chest.

There isn't any.

So I start breathing for her. My crewmate has already put the oxygen monitor on Lucy's finger, it's showing 78%, much, much lower than it should be.

As I 'bag' her, my crewmate asks the mother what happened. Lucy was having a fit so her mother gave her some medication to stop her coming out of the fit. She used to have one type of medicine but it was discovered that she was over-sensitive to it and as well as stopping the fit it would also stop her breathing.

The doctors, being wise, realise that perhaps another drug would be advisable. Perhaps this drug other drug wouldn't stop her breathing.

No such luck.

However, I'm fairly relaxed. Lucy's oxygen levels have come up to 100% and she's moving around under her own steam. It's always weird to have a patient who isn't breathing for themselves start moving around under you, it's even weirder if you are doing CPR on someone and they are trying to fight you off.

She's still not making any effort to breathe for herself but that's no problem - she's got a nice open airway and it's an easy job to breathe for her.

Time to go, so I pick her up, sling her over my shoulder and have a quick trot down the stairs and out to the ambulance.

She must have had a growth spurt as I can't remember her being this heavy...

I put her down on the ambulance trolley, re-check her airway and continue bagging her. She's still got a bit of a gag reflex so we can't pass a breathing tube into her airway. We are only a few minutes away from the hospital, so we decide to have a nice relaxed 'Blue Call' into a pre-alerted hospital

Nice and easy, bag her all the way in, no problem.

And then, that beautiful, clear, open airway disappears under a mountain of vomit. All hope of getting air into her lungs vanishes with it.

I reach for the suction, with a bit of effort I clear away the debris of dinner - whole chunks of food that were in her airway and now spread around the floor of the ambulance.

A part of my brain asks why, at this late stage of the night, there is so much undigested food in the girl's stomach.

The airway is now clear and I can resume breathing for her, sadly our ambulance is now covered in chunks of partly-digested stew. It's going to take quite a while to get it clean.

We roll up to the hospital and are met by my favourite paediatric nurse (actually, that's a lie - all the paediatric nurses at this hospital are my favourite).

'I knew it would be Lucy', she says to me as we wheel the trolley through the Resus doors. By now she is making some effort to breathe, so it's all looking rather good.

My crewmate and I are happy, even though we have a big clean up job ahead of us because this is what we get paid for.

Another call from the police, another assault in the street that was somewhat unusual as it was given as an injury sustained in the course of a mugging. Despite what the media would have you think I would suspect that the fear of mugging is much worse than the actual rates of muggings.

I base this on no evidence apart from the distinct lack of assault calls that I go to where mugging is a motive.

We arrived to find the police already there and a young man sitting, somewhat battered, by the side of the road. Cuts and bruises from a couple of punches to the face, nothing too serious, but painful nontheless.

What made us smile was that this was the mugger, not the victim.

In broad daylight this scumbag decided to steal a woman's handbag. He'd grabbed it and started running down the busy street.

What he didn't reckon on was a bit of 'community policing' and someone gave chase, punched him in the face a couple of times and disappeared before the police arrived.

Not a serious injury, but our 'victim' was left whinging about the pain while we, and the police, contemplated the mugger's bad luck. He'd need some stiches to his face, but was otherwise not seriously hurt.

Obviously I treated him clinically as I would any other patient, but perhaps without the same 'bedside manner' as I would give to, say, a little old lady who'd spent a few hours on her bedroom floor.

The police officer and I discussed how much of the money that I pay as taxes would go towards this person's treatment.

I don't think (and hope) that the police will look too hard for the person that stopped this thief.

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Monday's question - In your own work, or day to day life, what events give you joy? Obviously the above story made me happy for the rest of the day, but I also like going to patients that say 'Thank you' at the end of their time with us. I also like transfers to the country, where there is green stuff, trees and the like. I'd think that even if I worked in an office there would still be something that would make my day, so, what is yours?