There is a week of predicted high temperatures in the UK. The recent mostly high temperatures have resulted in us being exceptionally busy over the last few days - 5,200+ calls per day.

Please follow the advice given and try to keep cool.

Heat exhaustion (AKA heat prostration and heat collapse). This is the most common heat-related injury, and its basic mechanism is the same as heat cramps. The basic causes are heat exposure, stress, and fatigue. (It doesn’t have to be particularly hot before heat exhaustion is a possibility — wearing multiple layers of clothing that limit the effectiveness of sweating will do the job just fine. So, if you’re out hiking, take off layers; when you stop to rest, put on layers.)

The signs and symptoms of heat exhaustion are:

• Dizziness, weakness, fainting, nausea, and headache.

• Onset while working in a high heat/high humidity/poor ventilation environment and sweating heavily. Infants, the elderly, and the unacclimatized may experience onset at rest.

• Cold, clammy, skin; ashen pallor.

• Dry tongue; thirst.

• Vital signs within normal limits, although the pulse may be rapid and the diastolic blood pressure (that’s the bottom number; the pressure when the heart isn’t contracting) may be low.

• Normal or slightly elevated body temperature.

What to do about all this: Take off any excessive layers of clothing, particularly around the head and neck. Get out of the hot environment (say, into the back of a nice air-conditioned ambulance). Drink a liter or so of water (slowly, so nausea doesn’t develop). Loosen restrictive clothing, lie down with your feet up, and use a fan for cooling.

I suggest that you go and read the whole article from the excellent Making Light then spend a few hours going through the archives. Although good luck trying to find an ambulance that has working air conditioning - I spent a long hot day in an LDV ambulance with the windows wound down gradually going deaf from the sirens. In a contest between hearing loss and headstroke, I guess I picked hearing loss*. Air-con seldom works in the newer ambulances either, and by the time it gets fixed there is normally snow on the ground...

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*All of which makes me laugh at the people who cower when we go past on sirens, remember folks - I'm sitting under the bloody things all day and if the air-con doesn't work I'll have the window wound down working on my 'trucker's tan'.

She tells me, at the start, that the reason that we have been called is that she fell over. Her friend is comforting her in the bedroom, but she's crying and her mascara is running.

"I just tripped over", she tells me.

I look her over, it seems that there is nothing too seriously wrong with her on the physical level. But still she seems upset, sitting quietly, then suddenly bursting into tears.

Her boyfriend comes with her to the hospital, he strokes her hair and tells her that it will be alright.

Something in the front of my brain tickles, his actions seem 'off' somehow - not in any way that I could describe, but in some vague way his actions ring as false.

They argue about a phone - she wants to phone her dad, he won't give her the phone.

Now it's not the front of my brain that is tickling, it's my whole body.

We get to the hospital, the triage nurse looks at her and seeing no obvious injury sends her to the minor injury waiting room. I voice my concerns, but the nurse still thinks that the waiting room is the best place for her.

It's busy and loud, not the best place for this young, tearful woman.

Before we get there she turns to me and, between sobs, tells me that she and her boyfriend were arguing and he pushed her. Pushed her hard.

I head back to the nurse, I explain that I'm really not happy to sit her out in the waiting room as she has just admitted to me this domestic abuse. The nurse now agrees and we sit her somewhere quiet.

Before I leave I crouch on my haunches in front of her and hand her a tissue, she's still crying. I offer to call the police for her, but she refuses. I tell her that the police have specially trained teams, that there are people that she can talk to. She still refuses.

The best I can do is show her how to use a hospital phone to call her father.

I leave the hospital, walking past her boyfriend who is pacing outside.

"Will she be alright?", he asks me.

"I'm sure she'll be fine", is the only answer I can give.

And inside I feel powerless.

As I mentioned in yesterday's post it can be hard to get feedback on the treatment that you have given a patient, was is right, was it the best, was our diagnosis correct?

It was the end of the nightshift, we'd been run ragged all shift without a break and my eyes were hanging out of my head. We were sent to an elderly man who was complaining of chest pain.

It is one of our bog-standard calls - an elderly gentleman of South Asian origin, complaining of something that could be cardiac chest pain. He has a previous history of diabetes, high blood pressure and previous heart attacks. The pain started an hour ago and is one of two things - either his heart or the recent chest infection he's suffering from.

No problem, we wheel him out to the ambulance and start checking his vital signs, pulse, blood pressure, respiratory rate and so on and so forth.

Then we do an ECG, a heart tracing.

I've mentioned before that one of the things that the LAS and NHS in London do extremely well is the diagnosis and care of heart attacks. If the patient is having a heart attack that is detectable on the ECG done by the ambulance crew then, instead of going to the local A&E, they instead head straight to an angioplasty lab where the top level treatment is available.

It works really well and is the thing that the NHS and LAS does that I'm most proud about.

Our patient's ECG was just under the threshold of going directly to the angioplasty lab. In part this was due to the poor quality of the ECG we were able to get. Essentially one heartbeat just about looked like it should go to the angioplasty lab, the next heartbeat looked like it should just about go to the local A&E.

We spoke to the history, did another three or four ECGs and needed to make a decision.

When it comes to the interpretation of ECGs my crewmate tends to look to me - as an A&E nurse I used to do twenty or more ECGs every shift and, because I find ECGs interesting, I used to study each non-normal one that I took. She recognises that I have a lot more experience looking at these things.

Normally I can tell at a glance whether we should go to the A&E or the angioplasty lab.

In this case I wasn't sure.

I squinted and strained my eyes. I took my glasses off. I used a ruler to see what straight lines I could and I used the pattern recognition part of the human brain to try and come up with a decision (for those medically trained, all our ECGs had mildly wandering baselines and I was seeing if the ST segment was elevated by 2mm or more).

The decision that I made was that the patient didn't fit the criteria based on the history and the ECG. But it was pretty borderline. I suspected that a blood test would need to be done and some more ECGS taken at the hospital to be sure of a diagnosis.

So we headed off to hospital, pre-warning them that we were bringing in a chest pain patient.

We were met at the hospital and before we could off-load the patient a doctor who I've only seen once before asked to see the ECG.

"This is ST elevation", she said rather forcefully, "You should have taken them to the angio lab".

"It might look it Doc", I replied, "but the wandering baseline needs to be taken into account".

She grumbled a bit.

We got the patient out of the rain, but the doctor stopped us just outside of the resus room to question us some more.

Essentially she was convinced that we should have taken the patient to the angioplasty lab - I let her know that if she was that sure we could easily load the patient back up and take him there. I'm not too big to admit a mistake and I'd rather the patient get the care that they need rather than massage my ego.

For some reason though the doctor didn't seem ready to commit us taking the patient off to the angioplasty lab on her say so, so we left our patient in the A&E department. The doctor then wouldn't listen to our handover and was generally very rude towards us.

If it had been earlier in the night I may well have been annoyed, as it was I wasn't in the mood to argue. So I let it slide.

But it played on my mind - had I done the right thing? Had I misdiagnosed a patient? Had I taken the patient to the A&E department instead of the angioplasty lab for some ulterior reason?

So I had a bit of a sleepless day, even after examining my role in the care of the patient and so I resolved to find out what had happened to him.

The next day we looked up our patient's notes - turns out that the pain was being caused by his chest infection and that his ECG was 'normal for him'.

So I was happy - I'd made the right diagnosis, I'd treated the patient correctly and I could rest easy knowing that he'd been taken to the right hospital.

Leaving the area where the notes are stored I saw the doctor again, she was writing some notes - I didn't bother her, I'm not about scoring points, even towards people who were quite incredibly rude towards me and my crewmate.

But I will remember it, should she choose to be rude to me again.

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The point of this isn't that the doctor was wrong at the first glance of the ECG, nor that she was rude. The point is that, without that feedback from looking at the patient's notes, I had a sleepless day and would probably still be fretting about it. I think it would be very beneficial if there were a more formal feedback procedure that went beyond making complaints.

Continued from yesterday's post

All I can see is the back of her head, some blood and the shattered windscreen. All I can feel is her head, neck and shoulders and yet something tells me that she is slipping into unconsciousness.

Cramped up in the back of the low roof van a firefighter appears beside me, he's trying to remove the metal plate that separates the two sections of the van and I have to wriggle to the side to let him see how securely it is fixed. He tells me it's going to take some time before the roof can come off.

I shout through to the FRU and ask him if my patient is still conscious.

"It don't look it", comes back the reply, he's busy getting some venous access while stretched across the passenger seat.

This means it's decision time - do we wait until the roof is cut off in order to fully protect the neck and spine, or do we just manhandle her out as smoothly as possible because of the real risk of her losing her airway and choking to death. Also, if there is a serious head injury then they may need their skull drilled and waiting for the roof to come off may take longer than this patient has.

It's all about potentials - potential neck injury (that if we aggravate could stop her breathing) versus a potential airway problem versus the potential need to be in hospital for neurosurgery before her brain squeezes, like toothpaste from a tube, out the bottom of her skull.

Then that familiar flash of imagination - me standing before the Coroner, explaining my actions and my reasoning.

"Sod it!", I say to the FRU, "We need to get her out now, we can't wait for the roof".

The spinal board is squeezed under her buttocks, then as carefully as possible we rotate her out and lay her flat on the board and then onto the trolley-bed. Securing her we move her to the ambulance.

She's now deeply unconscious.

Cutting off her clothes we make a quick check of the basics - the airway is still open, so we can manage that using the tools we have on the ambulance, she's still breathing - which is always handy, the slightly worrying thing is that her pulse is starting to drop although the blood pressure is remaining stable. A dropping pulse can mean a serious head injury.

The next question leaps to my mind, do we wait for the HEMS doctors to turn up, or do we make a run for the hospital.

"HEMS are eight or nine minutes away", my crewmate tells me, radio mike in hand. It would seem that she is reading my mind.

"OK, we'll go", I say, I know my mates driving - in nine minutes we'll be at the hospital. I go to secure the back doors of the ambulance and see the HEMS car pull up.

Stay and play a bit then.

The doctor jumps on board - as always polite and professional and starts to assess the patient. The doctor thinks that they should sedate the patient and intubate in order to protect the airway and I don't disagree - she'd need to be intubated before surgery anyway and this way the airway is definitely secure for the transport to hospital.

As they always do, they take the patient off the back of the ambulance so that they have more room. I know it's not the same thing but I feel pride for my crewmate who manages to intubate both in the back of the vehicle and when the patient is stuck under a wardrobe.

The doctor first wants to wrap the patient in bubble wrap to keep them warm - I bite my tongue at the thought that the back of my ambulance is perfectly warm, and besides what happened to therapeutic hypothermia? But HEMS are fully informed on the latest trauma research so I am more than happy to let them do what they want. The responsibility isn't on me anymore, it's on the HEMS doctor and I'm sure that they have also got the same 'Coroner's court' vision in the back of their mind that I have.

But I really should ask them about it the next chance I get.

Just as the doctor is about to intubate the patient she starts to come around. Suddenly she is no longer unconscious, but awake, alert and orientated.

That's good, but again, this can be the sign of a serious head injury.

"OK", says the doctor, "let's go without sedating them".

We load the patient back up onto my ambulance, change over the monitoring machinery (for the third time) and make our run to the hospital, the doctor in the back of the truck making notes while I make sure that our patient doesn't move around too much on the trolley-bed. Our patient's consciousness drops and rises during the trip.

The trip takes eight minutes - I swear that my crewmate channels Stirling Moss and I trust her driving completely (except for her reversing, but that's another matter).

Into the resuscitation room and the HEMS doctor hands over to the staff there, our patient is awake again and so the hospital doctors can get a better history from the patient. I go out to the ambulance and start the long process of documenting everything while my crewmate cleans up the back.

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There is no closure to this story.

I'd love to be able to tell you how the patient got on but I never knew her name, so I can't ask the reception staff to pull their A&E notes so I can have a look at what the CT scan showed. I don't see HEMS often enough to ask them about the progress of our patient, when I next see them they will have seen countless other seriously ill patients. The police probably won't ask me for a statement on the accident in question. I'll likely never know if my decision to move the patient before the roof was off was the right one, or if I did more harm to them. I'll not get a thank you letter and I don't expect one. The only way I think I'll know about my patient is if they die and it goes to the Coroner's court.

In which case I'm happy to remain ignorant.

So I'll probably never know what happened to my patient and that is the usual course of events. Just clean the ambulance and move to the next person.

I'm woken up by the phone ringing, we'd returned to station at four in the morning and had been put on a break, we had wasted no time in get our head down for some well needed sleep. So far it had been a busy nightshift.

"Morning!", came the cheery voice of Control down the phone, "We have a car vs. car RTA for you".

Barely functioning, let alone awake, we headed to the ambulance and started the engine - thankfully the call wasn't far away. Often with RTAs you can guess what type of call they will be depending on what road they occur. Small roads tend to be more bumps than crashes while there are a few roads on our patch which are notorious for having horrendous smashes (markedly lessened by the introduction of speed cameras it has to be said).

The road we were going to was a sliproad off of a dual carriageway - there was a high probability that this was a high speed collision.

Reaching the scene we saw that the accident had been caused by a low roof van driving into the back of a car, pushing it halfway across the junction. Two FRU's were on scene.

While my crewmate parked up in a way to protect the area we were working on, I jumped out to find out from the FRUs what was going on.

"This one's all right, just a bit shaken up", shouted one FRU, the other looked a bit more worried so I went around to him.

Even half asleep I could see that this was going to be a serious call.

Dear reader, I would like you to consider exactly how tough windscreen glass is - it's actually a fairly strong thing and it's for this reason there are special tools used for breaking them. This is why sensible people wear seatbelts. Even when people wear these we come across people who have cracked the windscreen, 'bullseyed' it in our own particular jargon.

This person hadn't been wearing a seatbelt, she'd been going at a fair speed, then she'd come to a sudden stop. Well... her vehicle had come to a sudden stop, she'd kept going, smashing herself first into the steering wheel then into the windscreen.

There wasn't a crack in the windscreen, instead it had shattered, held together it had a huge bulge in it perfectly matching the shape of our patient's head.

So immediately I'm thinking neck injury and brain injury, let alone what it's done to her face.

"She's admitted not wearing a seatbelt", the FRU told me as he finished putting a neck collar on her.

So if the patient is talking her airway is alright. That's one thing in her favour.

I jogged round to the back of the van and opened the door, thankfully the van was empty and I crawled in and took the patient's head in my hands. The FRU told me more about his initial assessment, but he'd only been here a little longer than us.

As I was holding the head I was free to do some thinking and start directing the people around me. I checked that the other emergency services had been called, the police to close off the road and the fire service to cut the top off the van so we could get the patient out safely. I got the FRU to do some more in depth assessment and set up monitoring - he'd do it anyway, but I'm a bossy swine sometimes. My crewmate was calling for the doctors on HEMS as I thought that we could do with a hand from them.

The patient was still alert and orientated, but I was worried that this would change.

The fire service arrived and started the preparations to cutting the roof of the van, meanwhile the FRU kept telling me his findings while I was thinking of the next step.

I don't know what it was because I couldn't see my patient, all I could do was feel her neck - but something told me that she was starting to lose consciousness...

To be continued.

Often when there is a bit of news about an ambulance service in the news I'll try to expand on the reporting by suggesting ways in which a, perhaps short-sighted, bit of journalism is obscuring the probable truth.

I don't do this just to provide 'balance', in some idealistic 'everyone who has an opinion is equally important' fashion, but instead to give as much of a voice to a member of staff or Trust that can't necessarily be as blunt as I can.

This goes doubly so for some of the more lurid tabloid reporting.

However, in this particular case, I can't think of any reason why the person involved in this shouldn't be fired.

A 999 patient died after an ambulance driver diverted to the depot instead of going to hospital-because he had over-run his shift.

The driver complained to a colleague that he was 15 minutes past the end of his duty and wanted to clock off. He got out of the ambulance without even telling his replacement there was a cricically <sic> sick case being tended by another medic in the back.

The new driver sped on to hospital as quickly as he could - but the detour had added half a mile and four crucial minutes to the journey. The patient, who had suffered a stroke, deteriorated during the drive and died of a suspected heart attack soon after arriving at A&E.

While I doubt that the four extra minutes travel time contributed to the death of the patient (although that isn't a certainty) there is no way that this is acceptable behaviour. If this story is true (and while the News of the World isn't exactly a top quality paper, I doubt they'd make this story up) then the driver has no excuse for their actions.

It's part of our job to sometimes be off late, we try not to be but in some cases it's unavoidable. I've been late off work more times than I can count, in fact it's the norm that I'm at least five or ten minutes off late.

To impact patient care in such a fashion in order to get off on time is frankly criminal and the person involved should have the book thrown at them.

Because I'm spending most of today running around like a runny-around thing, I'm going to cheat and show you a rather splendid film on EMS called 'Level Zero'. It's about twenty minutes long and I hope you enjoy it.

LEVEL ZERO - The Movie from Thaddeus Setla on Vimeo.

You can find out more about it here.

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You can also hear me try to make some sort of sense on the EMS Garage podcast. I say 'try and make sense' because it is recorded at around 3am my time, so I'm not at my best you understand. I've just taken part on another one that should be posted fairly soon. Which is why I'm posting this at 4:45 am.

The sun is coming up, that means I need to go to bed...