Long term readers may have noticed that when I write about the London Fire Brigade I often indulge in some slight mocking. It's an attitude that is taught to you in training school and one that is continued by the 'old hands' of the service.

When you start in the ambulance service you find yourself asking why this is so, surely it can't just be because they often get to sleep all night while we get moaned at if we find ourselves blinking for longer than necessary?

After all, when dealing with an RTA, they are instrumental in turning a car into a convertible so we can safely get a patient out. Likewise, when something is on fire they are pretty good at throwing water at it.

The less charitable amongst us might also say that they are also experts at blocking off roads with a multitude of unnecessary appliances and flooding the streets with fire-fighters who then stand around and do nothing.

Maybe it follows that there is this derision because they work less than us, get paid more than us and for some reason end up on calendars and are drooled over by otherwise sensible young ladies.

So, jealousy really.

My crewmate and I were sent to a 'fire call' in a residential street - we arrived to find that the fire had already been put out, three fire trucks and about 12 fire-fighters had successfully dealt with an electrical fire that had caught a mattress alight. Our patient had been laying on the mattress at the time.

Surprisingly, for someone with very much reduced mobility, he'd managed to get himself out of the burning bed and into another room. Relatives had then called for the fire-fighters but by the time they arrived the fire had gone out itself causing minimal damage.

Our patient was more 'shook up' than seriously ill. He was a large fellow with a number of long-standing medical problems, including lung disease and the aforementioned mobility problems. As it was a foam mattress that had burned we decided to take the patient to hospital.

Meanwhile the dozen fire-fighters milled around chatting to the extended family of the patient, or stood on the pavement taking in the sun.

Then I heard the head fire-fighter (the one wearing a white helmet) suggest to the family that they could all stand for a cup of tea. As she left to start brewing he confided in me that it 'keeps them busy, and takes their mind off the fire', which is fair enough.

We soon got to carrying our large patient to the stairs where his installed stair-lift could do some of the hard work of getting him down from the upper floor of the house. It was a real struggle - the patient was large as well as heavy, and despite having leapt from his bed before he torched himself, now seemed largely unable to move.

So we puffed and we sweated and we strained - getting him downstairs and back onto our carry chair.

Then we had to move out of the way so that one of the women of the house could carry a tray full of tea out to the heroic fire-fighters that were chatting in their garden.

We left the house with every fire-fighter having their own cup of tea - can you guess what poor bastards didn't get a cup of tea? Yes, that's right, those of us actually doing some work.

Not that we would have accepted, we were looking after a patient after all, but it would have been nice to have been offered.

As I say, pure jealousy.

-----

It seems that whenever I'm not working I miss all the excitement. Actually, having been involved in a few riots in the past, I'm rather glad that I wasn't working - for one thing I don't think that my stab vest still fits me.

In the absence of an 'instant sobriety' pill, a pill or injection that would instantly sober someone up (like Naloxone does to opioid use), I'm wondering if we should go the other way...

You see, I find myself taking drunks into A&E on a regular basis, once there they are given a nice soft trolley to lay on, some poor nurse to clean them up and often some IV fluids to counter the dehydrating effect of alcohol. This means that any hangover is prevented, or lessened.

Like rats who receive a pellet every time they push a lever, these drunkards know that they can drink to excess and the 'emergency' services will babysit them and make sure that they are fine in the morning.

And then we wonder why alcohol related calls are climbing by 12% every year.

I have two solutions.

First - being unable to instantly sober someone up, we should work on a pill that enhances the effects of a hangover while making any use of analgesia ineffective. By making the hangover worse we would be teaching these little alcohol sodden rats that drinking to excess is bad. Send them home sober but vomiting, with a headache and with aching joints.

Secondly - there should be enacted, in legislation, a new policy where - if you are drunk and incapable, any ambulance called to you is allowed to go through your pockets and take any money for themselves (or the ambulance service benevolent fund if that crew is feeling particularly charitable). Not only will this inspire the rats to keep some degree of sobriety, enough to defend themselves from the grasping hands of the ambulance service, but it will also remove some of the money that would no doubt only go on to be spent on alcohol.

It would also have the happy side effect of boosting my pay packet.

Please send the Nobel prize for medicine to the usual address.

'Male - behaving strangely, threatening self harm'.

"Would you like the police to attend?", asks Control.

For some reason I'm feeling brave this morning so I let them know that we can save the police some time and I'll take a look at the patient first.

It's a hostel, not one that we usually go to - as the owner leads us to the patient some other residents walk past us, they seem remarkably normal. I know that may seem judgemental but most of the hostels we go to are full of people with psychiatric problems and alcoholics. It's one of the perks of the job, we get to see all the nice places.

The landlord gives me the impression that he just wants our patient out of the hostel. For reasons best left unexplored it would seem that he prefers us tramping around his hostel than the police.

My patient opens the door to his room and looks at me. I look at him and realise that this person has serious mental health issues.

I'm sure that if you were to read this person's medical notes it would state 'flat affect', 'unable to maintain eye contact', 'meandering conversation', 'issues with self care' and 'threatening body language'.

For me, for any ambulance person, it's all laid out for me in that split second look.

He looks at me with confusion and with a grunt, invites me in.

He doesn't tell me much, he starts to talk then stops. He paces about like an animal in a too small cage. In and out of his room he paces, when he passes his door he rests his head on it for a moment.

From down the corridor two police officers arrive.

"I told Control we didn't need you", I say to one of the (by coincidence the good looking female one).

"We were only down the road", she says, "thought we'd come and check up on you, make sure you are all right".

The patient sees them, he's obviously had run-ins with them in the past.

"Who called them?", he says, "I've done nothing wrong".

Hoping to build some sort of rapport with the patient I ask if the police could leave - while their presence can often have a calming effect, for some people it's a red flag to a bull.

With a friendly wave the police disappear back down the corridor.

Now, of course, the patient doesn't want to come to hospital - I let him know that while I'm not allowed to kidnap people, he'd be better off coming to the hospital for a check up.

He refuses a few more times. So we leave.

The landlord looks most upset, he wants me to take the patient away as he is 'disturbing other guests', but as I've told the patient, I can't kidnap people and that if he wants the person forcibly removed he'd be better off with the police.

-----

I'm in the ambulance outside the hostel completing the paperwork when the landlord knocks on the window.

"He wants to go now", he says.

I wonder what the landlord has said to the patient, but who am I to judge, so I open the back doors to the ambulance and the patient gets on board.

It's a very short trip to the hospital and I take the patient into the majors area to hand him over to the receiving nurse. The nurse is one of the good ones.

I explain all what has happened, and about the patient's mental state - not self-harming but 'not right' either.

Sadly (thanks to the healthcare commission, about which I will write later) there isn't any place for our patient to go than out in the waiting room.

-----

We sit him out there and explain that a nurse will see him shortly, then go and book him in.

We watch our patient get up and walk out of the department to have a smoke. He walks back in with the lit cigarette and heads for the patient area.

I go to stop him - I explain politely that he can't smoke in the hospital, that it's not good to have naked flames near piped oxygen.

He bristles, squares up to me, stares me in the eyes.

"Arrest me".

I try again, polite but firm.

"Arrest me".

I signal one of the nurses, to let her know that this might get nasty. I can see the aggression in his eyes. I know that patients with schizophrenia aren't meant to be violent, but they still make up a sizeable proportion of people who have taken a swing at me.

Once more he squares up to me, daring me. his posture, his body language, his voice (the first time I've heard emotion in it) all have me wondering if I should be the one to make the first move.

But once that happens, there is no turning back - and I don't like fighting people.

"Arrest me".

I'm getting ready for him to take a swing at me when I hear a tiny voice behind me, "You can't smoke in here".

It's the triage nurse, all four foot of her.

Our patient looks down at her, up at me.

He drops the cigarette and crushes it with his foot. Then walks back out to the waiting room.

I leave the department wondering if this little nurse could come with me when we get our next potentially violent call.

He's old, not long for this world. A diagnosis of cancer after an otherwise healthy life. The doctors have told him that treatment won't be able to do anything.

He's strong, he's looked after his family, moved them to this country. He's raised a son and a daughter.

They don't have much money, the house has souvenirs and memories. It's clean, fresh fruit on the table.

When I meet him he's angry. I recognise it in his tone of voice, in his body language. He gives one word answers, offers no explanations. Taking his history is like pulling teeth, one after another.

Before we go to hospital he wants to use the toilet, he wants to change his clothes.

He calls to his grown son, shouts at him. The pyjamas, not these pyjamas, those ones, the ones over there.

He's angry, he loses his temper - more shouting at his son.

His son sighs, I can see it annoying him. His father is shouting at him, but he's not doing anything wrong. He's doing what his father wants, but it's apparent;y not good enough.

I ask the man if he want's his wife to come to the hospital with him, he tells me no, that his son will come instead.

The wife shares a look with the son as he helps his father out the house and into the ambulance.

He'll be gone soon, the father. I want to tell the son that his father doesn't hate him, that when he is gone he'll miss him and that the anger isn't really directed at him.

I want to tell him that he should remember the good times, before his father became sick.

But it's not my place.

"Eighty-nine ear old female, stuck in the bath".

One of our 'regular' types of calls are to the elderly who have taken a tumble, normally while going to the toilet in the middle of the night, sometimes they just slip out of their bed. We turn up, we pick them up, dust them off, and go on our merry way with the patient's thanks ringing in our ears.

'Stuck in the bath', is not something we often do.

Let me explain how difficult it is for two ambulance staff to get someone out of the bath.

First, the bathroom is often tiny, and the bath is normally up against a wall. What this means is that our usual method of hoiking up someone can't be used. Normally we'd each take an arm and lift, but with the wall in the way you can only get under one arm.

Next the patient is wet and naked. This makes them embarrassed and slippery. Neither of which is conducive to an easy lift.

Finally we often have to lift them over the lip of the bath, which means lifting them higher than we normally would.

----

We arrive at the patient's house to find that she is well and truly stuck - she's using a lifting gizmo that she sits on, but this seems to have stopped working. She's also not the lightest person in the world.

Thankfully she has a very upbeat nature and, after getting a dressing gown on her, we start to attack the problem.

What we can sometimes do is a 'top and tail' (which will probably make any manual handling person cry out in horror), essentially one of us comes from behind the patient and lifts under their armpits while the other ambulance person lifts the patient's legs.

Unfortunately, because of the shape of the lifting device if we needed to put her down in a hurry (which can happen during a lift) she would find herself sitting on two rather pointy looking bits of metal.

I had a delve around the lifting device to see if I could fix it, but it was well and truly stuck.

Time for backup.

-----

We have a wonderful bit of kit called a Mangar Elk - essentially it's an inflatable cushion - you put the patient on it when it is deflated then pump it up. It expands and the patient comes up with it. I've used it in the past and it's been a real godsend.

Unfortunately we don't carry one on every vehicle, so we called for a station officer to fetch one from the ambulance station.

We waited for only a short while before the officer turned up, handed us the bag and gave a look that seemed to say 'I hope you folks know how to use this bit of kit'.

Thankfully I did, we would get our patient to rock from one side to the other so we could get the cushion under her, then inflate it and Bob would be your uncle.

The patient did as she asked and moved to one side.

And then her lifting device started to lift her up.

Click, click, click it went.

Up and up she went until she could swing her legs over the bath and, with a bit of assistance, get out of the bath.

The officer looked at us as if we had called him out for a joke.

-----

So we had a chat with the patient, a bit of a laugh and then went on our merry way. The officer taking the unused Mangar Elk back to the station.

At essence a simple job, but one that was a bit more complicated than normal.

There are a couple of reasons why the public like us - the biggest reason is that when they call us they are the centre of attention - they are sick and now two people have turned up and are giving them their undivided attention. We don't have more patients to look after, we don't have to run off to bed three to give someone a bedpan, we don't have to drop everything for a drugs round. Instead that person is focused on 100%, no distractions.

Of course, when they hit hospital they take their place behind all the other 'generally unwell for two weeks' patients that found the idea of a GP appointment just too much effort. Certainly more effort than dialling 999.

And really, it was your choice to wait four hours for treatment in A&E rather than get a GP appointment, so don't blame me for taking you out to the waiting room to burn some hours with the multitudes who think the same as you.

This, in my eyes, was common knowledge - however a recent article by Professor Richard Ashcroft has shown another reason why us ambulance types rock your world.

Patients and families seeking help on how to live with long-term conditions such as autism do not always get the clear advice they seek.

Any diagnosis of a serious medical condition or impairment is hard to take in at first.

What you need after that is reliable information, and co-ordinated clinical care and social support.

Co-ordination is not what you get.

'Hints and clues'

Professionals are trained to be "non-directive" when they advise or counsel parents.

n my work, I teach current future doctors and lawyers about medical ethics and law. I teach them about informed consent.

I think empowering patients to make decisions in the light of their own values and interests is really important.

But I don't think "non-directiveness" achieves this.

Essentially, nurses and doctors are told to be 'non-directive', to not tell people what to do as that would be seen as taking away the other person's independence and right to self determination. That to be 'prescriptive' is some sort of abuse of the power relationship that folk in uniform have over the general public.

When I was training to be a nurse I suggested that perhaps we should be directive, as after all we hopefully have the full facts of a person's illness and the skills to deal with it.

I was told by my lecturer that by saying that I was acting like a Serbian war criminal. A badge I wear with bizarre pride.

That's something that us traditionally educated ambulance staff have never been told (I have a horrible suspicion that this is not the case for the new training regime) - in our training we are told that we are to take control of a situation as everyone else will be looking to us for direction (normally followed by a few unkind words about brickheads, dripstands, Trumpton, our firefighting colleagues).

No - what we do is direct. We turn up and make the chaos into calm, the fear into peace and the uncertain become certain. We tell people what to do, we tell them what we are going to do and we can often explain what the hospital is going to do. People surrender into our loving embrace and feel better because we are there to help and the other people present can abrogate responsibility to us.

That is what we do, and people are happy for us to do it.

More on the last post - a new memo has appeared on the notice board that boils down to 'if you have swineflu, the advice is to not come in to work, it will be counted as an absence' - which to be fair is only reasonable. After all the coughing pig death virus is a fairly mild flu - and we don't have special circumstances for normal 'flu.

-----

The job was sent to us as 'man - bitten by dog two days ago' which figures high on the 'rolling your eyes' scale, but not too high on the 'completely unexpected' chart. What was unusual was that in the special instructions part of the dispatch notes was that the patient needed to police to look after his dog.

When a job like this comes down the wire it is only traditional to share the news with any other ambulance personnel within earshot. It's a game of one-upmanship that we play with each other, seeing who can get the most ridiculous call.

"Hold up", one of my station mates says, "what address is that?"

I tell him.

"You'd better take the police along with you, I was listening to them talking about that patient yesterday - he's apparently violent".

I could see that he wasn't joking.

As the job was obviously not going to be anything too serious we decided to ask for the police to arrive, after all the patient had asked for the police himself to look after his dog.

We were waiting only a few minutes before two response officers and a dog handler arrived. The dog handler got the kit out of his car - a loop on a stick and a fire extinguisher.

Fully prepared we approached the front door and rang the bell.

"Come on in", said the man who opened the door - a man with obvious alcoholism and mental health problems*.

We entered to be greeted by what is perhaps the most energetic dog I've ever met.

This dog, that apparently needed the police to look after, ran over to my crewmate looked her square in the eye and rolled over to have his belly rubbed.

My crewmate and I are both dog lovers and when we get to a job where a dog is loose whoever isn't dealing with the patient is normally found playing with the dog.

And that is what happened - while I tried to persuade the patient that, no, his finger wasn't going to drop off, my crewmate sat playing with the dog while the police, seeing that we were fine, disappeared off to their next job.

A bit of a waste of all those resources, but what can you do except shrug and keep going?

-----

*Don't ask - after a while you start to develop an 'eye' for such things.