As I mentioned yesterday, my crewmate is, I don't know, sunbathing topless on a French beach or something, so I have brand-new people to work with. And there are a lot of brand new people coming out of training school ready to be scarred for life educated by myself.

Working with someone fresh out of training school is normally quite enjoyable - I can show off, while they can tell me how whatever I'm doing isn't part of current educational theory on pre-hospital care. It's a win-win situation.

The first job I had with the shiny new recruit was a woman who'd fallen downstairs - often a nice and easy job and, as I blue-lighted us towards it, I checked up on what my crewmate knew about such things. As it was she wasn't confident about clinically clearing a neck injury, so I thought this would be a good chance to show her how it is done.

Our patient had fallen the entire length of the stairway, about thirteen steps rolling head over heels down them. She was complaining of neck and shoulder pain but had got herself up off the floor to sit on the sofa.

I'd gone over the finer points of clinically clearing a neck on the way to the patient, so what was left was for me to actually feel down the neck to see if there was any bony tenderness.

Down the bones of the neck I felt - C1, C2, C3, C4, C.... Oh dear, judging by the way she yelped in pain she seems to have a rather sore neck at the level of C5.

A really nice patient (and family) and we were going to have to truss her up like a turkey in order to make sure that her suspected neck injury didn't get any worse.

So that is exactly what we did, c-spine collar, strapped down and as smooth a ride into hospital as I could manage.

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We returned to the hospital a little later and they confirmed that our patient did indeed have a broken neck, it was just then a question of if they were going to treat it conservatively (with a collar), or if she would need surgery.

"You see", said the doctor to me as I asked about our patient, "anyone with a bony pain in the neck needs to be collared".

I didn't bother explaining that this is exactly why we had brought her in strapped down and with her neck immobilised.

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I don't know why, but my regular crewmate and I don't do 'trauma' - but as soon as one of us goes on holiday the other is left having more trauma in those few days than we would otherwise have all year.

'Swine flu', which for those following me on Twitter, seems to be one of the things I'm encountering more and more often these days. Let me explain some of the ways in which it is impacting my working life of late.

• While the government leaflet says that masks offer no protection from the 'flu, our latest flowchart for dealing with it mentions not only masks, but also aprons and gloves. We have gone from having a pair of masks and a pair of aprons in our infection control kit to having as many masks as you want. To be fair we did have to steal resource masks from the hospitals that we went to at the start of this outbreak, but supply problems seem to have been sorted out.
• Our call rate has gone from the normal 4,200-4,500 calls per day to around 5,200-5,700 in the last few days. This is an increase of around 26% Rather obviously this is having us run ragged. I have no idea if our sickness rate has increased (with staff being off with the Death Plague). What this has done is raise our DEFCOM level to 4. Which I don't think makes a huge difference to those of us on the road.
• Hospitals are refusing to see Swine 'flu patients unless they are incredibly unwell. I was nearly turned away from the hospital when taking in a woman with vaginal bleeding and dizziness because she had possible Swine 'flu. Do GPs do vaginal examinations and diagnosis? Or would this woman have been sent in by the GP anyway (given some of the... 'quality' GPs we have in my area it wouldn't surprise me if she were just sent up to the hospital without an examination). There is huge paranoia about letting anyone with a high temperature and the sniffles within hospital grounds. My question is, will hospitals be turning patients away in the Winter when the more dangerous 'flus are epidemic?
• We are seeing plenty of people who call us for Swine 'flu symptoms, as well as those who just mention 'chest pain' to our calltakers - thus guaranteeing an ambulance response. Quite a lot of people think that Swine 'flu is a death sentence even though this particular strain of 'flu seems to be a lot less dangerous than the normal seasonal 'flus.
• We have the normal increasing number of people collapsing from the heat - often their first thought is that they are dying of Swine 'flu.
• We are being told to leave people at home to look after themselves (heh, people actually looking after themselves, whatever fantasy scenario will our people think of next); this makes us ambulance staff somewhat nervous - after all there is the perception (if not the fact) that leaving people at home will only have us losing our jobs when someone dies.
• An example of one of our 'clients' - she called four ambulances over four days as her child has Swine 'flu, which isn't 'getting any better', despite being told that it can take over a week to feel better. Needless to say the child involved is fine if a bit generally unwell - certainly nothing that requires hospital treatment. Multiply this by the number of people across London and you can see one more reason why the number of calls is raised.

So, lots of panic, lots of fear, lots of misinformation along with the normal misuse of the ambulance service has resulted in many more calls for us, which then results in delays for people actually needing treatment. For example the police were with an assault patient for an hour waiting for an ambulance to arrive.

Unfortunately there isn't much that we can do, we can't suddenly make the public realise that they may be capable of looking after themselves without us holding their hands - and we can't magic up new ambulance staff from nowhere.

Except maybe get all the officers (that were road trained) up in Waterloo Control to man resource up trucks and get out on the road - I'm sure that for a few weeks we can do without the assistant staff officer to the staff officer for the diversity department* (or similar) and that they might be more use on the road at the moment.

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*I have no idea if this is a genuine position, although it sounds about right - I couldn't tell you how many levels of management there are between me and my boss, nor all the 'performance improvement' staff that float around up there in Waterloo.

Yes it is uncomfortably hot at the moment, and yes I have been going to plenty of 'faint' and 'near-faint' calls. One or two 'swine flu' cases (for which we have lovely new masks and guidelines to leave people at home - I wonder if this will continue with the normal winter flu' that are normally much more dangerous)

Thankfully I've not had too much lifting of heavy patients, in this weather the sweat dripping from my nose isn't just because I'm lugging some 20stone+ heart attack victim down five flights of stairs.

OK, it's mostly due to me lugging some 20stone+ heart attack victim down five flights of stairs - but the heat doesn't help.

I did have a very tricky extraction the other day. We were sent to a young man with a high temperature who was unable to move. We turned up to find our patient not only at the top of the house, but in a bunkbed.

A bit of talking with him revealed a fear of swine 'flu as well as an utter inability to move anything below his neck.

He hadn't been in any trauma, so the chances of a neck injury were slim, likewise the speed at which this had happened made me think that it wasn't some sort of progressive disease. However he did mention that it had al started with a tingling sensation in his feet that moved up his body.

I was put in mind of a disease that I can spell, yet never pronounce as it uses them furrin words.

Now, if he were on a normal bed we might try to simply manhandle him into our carry chair, unfortunately he'd managed to make it to his bunkbed, which as well as being quite tall had a rail around the outside of it.

Clearance from the bed to the ceiling was around one and a half feet.

Our plan was to get our split scoop under him and get him out that way. What didn't help was the the room was a sweatbox and out patient was almost glowing due to his high temperature.

I would need to get close to him.

So I found myself straddling the lad while puffing and panting, trying to get the scoop under him - my size twelve boots trying to find balance on the mattress, him possibly breathing droplets of pig death virus in my face (we'd already used out one pair of masks earlier in the shift).

Did I mention that the boy was a shade under six foot and had the build of a rugby player?

It took a long time to get him on the stretcher, and by now I was dripping with sweat. We then had to rotate, carry, twist and use brute force and ignorance to get him down from the bunk.

It was only once we had him down that I did a comparison of me and my crewmate.

I am 6'1", size twelve boots, has a bad back and knees, tight trousers and a still slightly painful testicle. I'm not as flexible as I used to be. I was the one clambering around the bed in the enclosed space between the mattress and the ceiling.

My crewmate on the other hand is slim, 5'6", younger than me, pole dances for exercise and used to be a gymnast. She obviously has no painful genitalia, she also has untight trousers and is much, much younger than me.

So, while I was killing myself trying to get the scoop under the patient she was clapping and shouting encouragement from the bedroom doorway*.

We took the boy to hospital and heard nothing more.

Sitting outside the hospital finishing my paperwork I realised that we both needed something cold and sugary to drink - so I called up Control and told them that, while they may well see our ambulance driving down the road to the nearest shop, it was so that we didn't keel over and drop dead**.

I think Control understood, it may have been the extended time we spent on scene, or it may just have been the breathless manner in which I spoke to them.

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*I exaggerate a bit, she wasn't shouting encouragement.

** I say 'we', what I actually mean is me. The one who did all the work.

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Before people get the wrong idea, she did indeed help, I exaggerate for effect - but I was still the one stuck on top of the bed and when I queried this with her she just laughed and said that I'm always the first one to climb a wall or get in through a window when the chance appears and she has too much fun watching me get on with it. I make a rod for my own back really...

We are led into the living room by the patient's daughter, she shows us her mother - small, birdlike and perched in a chair. A tiny thing of skin and bones in a nightdress, head bent over, not making eye contact.

The GP had called us, the daughter handed me the letter the GP had left.

'Weight loss, chest infection, depression. Lost the will to live'. The letter said more, polite words to introduce this woman to the doctor at the hospital, but this is what it boiled down to.

Barely able to stand, unable to walk, we had been called to take this woman into hospital.

We explained what we were going to do and lifted her incredibly light body into our carry chair. Younger than my mother, but looking so much older we wrapped her in a blanket to keep her warm.

Into the ambulance and the normal tests were run, pulse, temperature, blood sugar. We took her blood pressure, her arm so thin we had to use the cuff we normally use for small children. Through this poking and prodding the head never lifted up, the eyes barely opened, the mouth spoke no words. Her vital signs were normal, this was an illness of the mind.

You can tell when there is someone with depression in the room, it is an aura that all but the most oblivious can notice - the people around them talk quietly, walk softly, try not to disturb them. No-one wants to say the wrong thing, hurt the person more than they are already hurting.

The ambulance moves off and I start with some simple questions, yes or no answers, my voice kept soft.

She answers and emboldened I start to talk to her about other things. Slowly her eyes open and her head lifts up. She tells me about tragedies, about illness, about loss. When you have depression it is impossible to remember the good times, only the times that keep you low, under the thumb of this illness.

I wish there was something I could say to make her feel better, but I know that nothing I say can help. I want to tell her that it will be all right, that one day she will feel happier - but I can't say that because it probably isn't true. I can make sick people happier just by talking with them, but I know that this illness has me beaten. She will sit there and she will refuse food and she will probably die.

And I feel powerless to help her.

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This is the second attempt at this, the first one vanished into the ether and was, I think, a lot better than this post.

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.