I've reached that point in my blogging career where if an ambulance story is in the media I'm phoned up to provide comment.

So this BBC article about solo responders and the concerns about using them so extensively has already had me woken up by one newspaper.

I don't mind - after all it's something I've been shouting about on this blog for ages. Please remember though that I'm just a worker on the road, if you want real information you should talk to the LAS Press office 020 7921 5113 (and who are a bunch of top folks by the way).

Still it is nice to have something that I'm concerned about in the news. For more on this subject you may want to check out the following links.

A simple description of ORCON (The government target we are desperate to meet)

Why I think that splitting crewed ambulances to man solo responders is a bad idea for patient safety.

Where I describe the plan to increase solo responders and decrease double crewed ambulances. (I'm a lot less enamoured of the idea now than when I wrote this).

One concern for staff and patient safety that often isn't thought of.

Where I moan about some of the hoops we have to jump through to get our targets - but the comments section has more information.

My solution to the 'target' question that will actually benefit patient care.

To summarise things as I see them (and remember - these are my views alone, not those of my employer).

The government wants to measure the performance of ambulance trusts. The main way of doing this is to see how many of our 'high priority' calls we get to in under eight minutes. There are often more calls than there are ambulances, so solo responders effectively double your workforce with respect to reaching this target. Once a responder reaches a patient, the clock stops.

Solo responders can't safely transport patients. They also are unhappy to leave people at home because they are scared they will die. Solo responders therefore can spend a lot of time at scene waiting for a double crewed ambulance to arrive.

Sick people need to be in hospital - it is better to get there in nine minutes and be able to transport them than to get there in seven and have to wait half an hour for a proper 'truck'. The government does not agree.

The eight minute target is from research over 20 years old - and it only deals with cardiac arrest patients, not with 'high priority' calls. The department of health has no copies of the ORCON paper on record -although there is one in the British library. Modern research says that eight minutes is too long to get to a cardiac arrest.

Although our ORCON response percentage in London is roughly the same as has been every year, our cardiac arrest survival rate has more than tripled. Doesn't this show that other initiatives (which aren't tallied up by the government) are far more important?

Getting to patients quickly is never a bad idea, but in concentrating resources on solo responders at the expense of double-crewed ambulances I firmly believe negatively impacts patient care. Sick people need to be in hospital.

In London we are about to start running community responder posts - first-aiders from the public sent to calls. This is so deeply wrong that I can't get my head around it. Again I suspect that this is to help us meet these targets. It's not like we are in the wilds of Scotland where it physically takes you an hour to get from one place to another.

This is just the beginning of the discussion - the plan is to have all but the most serious calls (like confirmed cardiac arrest) attended to by just a solo responder, a double-crewed ambulance won't be sent - once the solo is on the scene they will make the decision as to the patient needing an ambulance to transport them, or if they need a GP, or can make their own way to hospital.

The simple solution is that we need more ambulances and more ambulance crews - but the government won't reach into their pocket and give us what we need, so instead the ambulance trusts have to make these difficult decisions.

It's not the ambulance trusts fault that we are heading down the solo responder route - it's purely the government's focus on this out-of-date target and lack of motivation to give us the funding we need to continue giving Londoners the care that they expect.

Oh and people call us for utter rubbish like veruccas - which is why we are under so much strain at the moment.

I'm hoping that this will run and run and might cause some form of change - unfortunately I suspect that this story will soon be ignored because of some celebrity drug 'sensation' or we find someone else who has faked their own death.

Remember I was telling you about the new function on our display terminals in the vehicles, the one that counst how long you have been at hospital? This is a picture that my crewmate took while I was away playing on the FRU the other day. It shows that she was waiting to hand over their patient for two hours.
It's been crazy the last few days - we leave the station at the start of our shift to attend to a patient who has been waiting for us to start work. Then we spend the rest of the day out, running from patient to patient. While doing my paperwork at hospital or on the way to a patient all I've heard is our dispatchers doing 'general broadcasts' to see if there are any ambulances available to attend to the 'many emergency calls across the sector'.
It's not even your usual winter pressures - I'm yet to see much of the traditional winter illnesses. It's not like there is a sudden increase in 'flu' cases, there hasn't been an outbreak of Norovirus. It's been the usual run of people with chest pains, old people collapsed, drunks, abdominal pains - all the usual stuff, just much more of it.
I was speaking to a hospital site manager the other day, she agreed that there isn't any apparent reason for the increase in people coming to hospital. It's the normal stuff, just more of it.
So we have been waiting at the hospitals, which have been filling up with patients - this means that patients have been waiting for ambulances.
Which was why an lovely old fella was waiting for an ambulance for an hour on the floor of a shop with a broken hip.
Then he had to wait for two hours on an ambulance trolley in order to be handed over to the hospital.
I can't see a solution to this - there will always be periods where more people need emergency healthcare. While I think that we should have more ambulances - this isn't a solution to these short term increases in demand.
Hopefully it'll be better in a few days.

I was spoken to by a reporter from 'The People' newspaper in order to get my comments on the winter pressures. I explained that, as an organisation, we have a pretty good process in place to deal with the demand. As pressure increases we do various things to increase the number of ambulances on the road. Overtime also becomes available - which is nice for us poorly paid people.
The strange thing is that the day after the People article (by Tom Carlin) is published, an very similar article is front page news in the Daily Express. This article is by Mark Reynolds, and contains the same quotes (and a fair bit of the same sentences). Except that they misattribute comments from a nurse as comments from me.

Isn't this plagarism? Or just the 'echo chamber' that blogs are often accused of being.

Have a look and decide for yourself -
Original article in The People.
Second article in the Daily Express. (The comments to that article are both scary and hilarious)

Finally - I managed to persuade my brother to buy himself a Macbook Pro (better than my Macbook, the swine! The next person to say that teachers are paid rubbish will get a severe talking to from me). It was a right struggle to get him to open his wallet - but he's now really rather glad that he did. It especially made an impact as to how easy it was to set the Mac up with his home network as opposed to the swearing I was doing trying to get his Vista machine to work.

Does anyone have any 'killer apps' that they would like to suggest? He's impressed with the ease of Handbrake and iSquint to get video ready for his iPhone. I've already got him admitting that Quicksilver is 'greased loveliness' and he has Delicious library installed but I'd love to hear what other people are using.

Lets talk about something nice for a change.

The LAS, not only doing well against nasty infectious diseases in the backs of ambulances, are also doing pretty well in the fight against people dying from cardiac arrest.

The latest figures for the cardiac arrest survival rate are out and we are doing really rather quite well.

In 2001-2002 of the people having a cardiac arrest, only 5% survived to be discharged from hospital.

in 2005-2006 it was 10.9%

Last year the survival chance is up to 15.8% - more than a three-fold increase from 2001-2002.

We must be doing something right. I would suspect that it's partly down to the change in the resuscitation guidelines. We've moved from the old (and very easy) five chest compressions at a time, to a much more knackering, but also much more effective 30 chest compressions at a time. Also our people who answer the 999 calls are moving towards giving people who call ambulances for cardiac arrests better instructions how to start CPR - we are currently in the middle of a research project based around improving these instructions.

The LAS has also been working in putting public access defibrillators in place in addition to training staff, such as rail and tube workers, in their use.

This is funded, not by the government, but by lottery money...

It's good to see us doing something right, just because it is right - even though the government doesn't 'mark us' on it.

There is only one slight downside to this - and it's because of the simplistic way in which the press reports things. The cardiac arrest survival rate is calculated using the Utstein* method. This means (very simplistically) that it is only the people who realistically have a chance of surviving that are counted. Poor old Doris whose heart stopped two days ago doesn't get counted. This is unfortunate in that this reporting still gives some family members a heightened expectation of their relative surviving - in which case it is up to the crew's people-skills to explain what has occurred.

*The cardiac arrest survival figure is calculated using the Utstein method, which takes into account the number of patients discharged alive from hospital who had resuscitation attempted following a cardiac arrest of presumed cardiac aetiology, and who also had their arrest witnessed by a bystander and an initial cardiac rhythm of ventricular fibrillation or ventricular tachycardia (From the LAS release).

Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?

(OK, nerd episode over).

I've been spurred into writing this post for two reasons - the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.

To recap - the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.

The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.

In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.

People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.

Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, "the place for a sick patient isn't the back of an ambulance". Nor is it in their own home waiting for an ambulance to turn up.

So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.

My solution is to have more targets.

But targets which will have an impact on patient care.

Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.

Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?

Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.

How about improving the measurement and treatment of pain - its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.

How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.

Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.

How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.

Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.

Finally, how about a 'staff satisfaction' target - a happy workforce is a more effective workforce.

Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.

We could even keep the ORCON target, but give it a more reasonable weighting of importance.

This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.

There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.

Right - how do I get to be Minister In Charge of Sensible Ideas for Ambulances?

I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.

Ambulances may be spreading infections such as MRSA because they are not being cleaned properly, union leaders warn.

...At the other end of the scale London Ambulance Service has introduced on-site cleaners who work throughout the night to routinely deep clean the fleet. They also restock ambulances with fresh kit, freeing up paramedics for seeing patients. Effectively, crews bring in a dirty vehicle and leave with a cleaned one, Unison said.

It is pretty good in London to be completely honest. The 'Make-ready' crews do clean the ambulances and they do have an attempt at stocking the ambulances. Except when there isn't the spare kit on the station, in which case they don't run around to other stations to try and find the equipment, that's up to us.

We are also still supposed to check the ambulances, but this rarely happens (unless you come into work early) as our call rate is so high.

There are also random swabs of ambulances where we see if there is anything growing on an ambulance that shouldn't be there. So far the results have been very good.

It's especially good considering that the Make-ready people get paid minimum wage and work hours like 1am-5am.

Where it is somewhat let down is that due to the desire to have us rapidly 'turn around' at hospital, unless there is specific soiling of the ambulance (blood, vomit, or for me last night, large amounts of spittle) we don't have the time to clean down the trollies with detergent.

Nor do we have enough blankets to have each patient have their own separate one - again they only tend to get changed if there is visible soiling or if the patient is known to be carrying a communicable disease.

But on the whole I think that we do a pretty good job with the resources that we have - we could do better, but that would mean that the government would have to give us more money. Something that they are loathe to do.

An investigation has been launched after an ambulance took 22 minutes to reach a dying pensioner.
Ernie Rutkiewicz, 82, from Glasgow, choked on his dinner last Thursday and died in Glasgow Royal Infirmary.

The crew which attended could not be assigned to the emergency any earlier as they were on a meal break.

Under rules, ambulance crews are entitled to a half-hour break during their shift and cannot be disturbed during that period.

The meal break rule was introduced in Scotland as part of a UK-wide initiative called Agenda for Change, which affects NHS pay and conditions.

This is a sad story and I feel very sorry for the patient and his family.

Once more it is meal breaks that are 'to blame' for someone dying rather than there being a lack of ambulances to cover for the legally mandated rest breaks. The ambulance crew involved would not have even known about the call. For all intents and purposes during a rest break the crew are not being paid and are therefore not on duty.

(And it's a 'rest break', not a 'meal break', there is nothing making the employer provide an ability to eat food).

However, the last time I saw a story like this, the newspaper involved claimed that two ambulance crews were on a rest break - when actually their vehicles were broken and they were off the road waiting for them to be fixed.

I've just done four twelve hour shifts, I've only had one rest break on all those shifts. Most folks work eight hour days and would expect a break at some point.

My next set of shifts is eight hours long, and they are an absolute doddle considering our 'normal' shifts are twelve hours long.

I wonder if the investigation into this particular case will ask what other ambulances were doing? Were they covering GP who refuses to see patients? Were they rushing through the streets to a drunkard in the street? Were they going to someone who wanted an excuse to knock off work early? Where they running to someone who'd taken too much heroin? Were they trying to find a hoaxed call? Were they going to someone who just wasn't home?

It's too easy to suggest that the reason this man died was because of rest breaks as opposed to the much more complicated mixture of a lack of ambulances, too many inappropriate calls and that we are doing everyone else's job these days.

But that is less likely to 'sell' the news.

While I sleep - a round up of some stories that have been sitting in my brainpan. Some of these were sent to me by readers, do keep up he good work. Please excuse any random kneejerkage - I'm drunk on lack of sleep.

The Healthcare Commission judged LAS as 'good' for both its use of resources and its services - a better rating than any other service in England.

First off, well done to the LAS for being the 'Best in the Country' - this really deserves a blogpost of it's own, but I thought I'd mention it here in case I forgot.

A union has taken legal advice after ambulance managers posted details of the salaries of call centre staff on the internet.
Ray Salmon, of Unison, said the details posted on the internet included staff members' length of service, their grade, how much they earned, their date of birth, personnel number and what redundancy payment they would receive.

But then WMAS do something a little bit naughty - if you read the article the irony is rather rich, as other staff have been disciplined for releasing information in the public interest. (Begin Snark Mode) Also of some surprise is the sight of a Unison rep for the ambulance service doing something (End Snark Mode).

A woman who won the title Nurse of the Year from a magazine is to leave the NHS because she is fed up with cuts and reforms.

"what I see as a waste of resources is when I'm sitting in a big meeting, and as a clinician I am the cheapest person there at £35,000 a year, and decisions are still being put off to another meeting."

She's a better person than me, if I were paid £35,000 to sit in meetings I'd probably put up with it. I can't blame her, banging your head against a brick wall wears a bit thin after a while.

Individuals can no longer be held responsible for obesity so government must act to stop Britain "sleepwalking" into a crisis, a report has concluded.

I'm getting rather brassed off at the growing lack of personal responsibility. "It's not my fault that I'm a heroin addict", "It's not my fault that I'm an alcoholic", "It's not my fault that I kept eating after I stopped being able to see my feet". Apparently the government are force-feeding people like pâté de foie gras geese. Maybe people would like rationing brought back?

Heroin and cocaine addicts on the government's treatment programme are being given drugs as a reward for clean urine samples, the BBC has learned.

The National Treatment Agency (NTA), which runs the £500m-a-year scheme, admits the practice is "unethical".

Here we go again. I think that there are better treatment options than hooking someone on Methadone instead of Heroin. This seems an awful, awful practice - the pressure of bribery coupled with the pleasure of being able to get high again, just on a government mandated supply. Is it any wonder that people remain on Methadone for years and years? I'm with Theodore Dalrymple and Mao Zedong on this one.

Nearly 13,000 nurses across Finland are threatening to resign next month in a pay row, trade union officials say.

I don't think that much will come of this, I'd suspect that the union would blink first. Would that we had an ambulance union with that much power in the UK to balance the 'reforms' that the government is forcing on the NHS. Instead we have a union whose idea of representing us is to roll over and agree to everything - including an agreement that new members of staff are allowed to be treated like crap. Of course if we did strike the government would just privatise us all.

Bloggers are now finding themselves prey to censorship from repressive governments as much as journalists in traditional media, a report says.

At least I'm unlikely to find myself imprisoned because of my blogging. There is always someone worse off than yourself.

The BBC's online services will be made available free of charge at thousands of wi-fi hotspots around the UK.

The corporation has agreed a deal with wi-fi firm The Cloud, which operates 7,500 hotspots around the country.

I love the BBC, but this is just wrong. Signing up with a private company in order to provide content that I've already paid for with my TV license just isn't cricket. This is also I suspect a way in which the BBC is trying to get around the regulators ruling that people who don't run Windows should be allowed access to iPlayer functionality. Unfortunately, in the same breath they contradict themselves.

From September 7th.

"The BBC Trust has committed to making sure the BBC would meet calls for non-Windows versions of the iPlayer "as soon as possible" said the government statement."

Then October 15th.

Ashley Highfield... "We need to get the streaming service up and look at the ratio of consumption between the services and then we need to look long and hard at whether we build a download service for Mac and Linux. It comes down to cost per person and reach at the end of the day". He added: "We are not ruling it out. But we are not committing to it at this stage."

'Committed' to 'not committed' in the space of five weeks - I guess that the media world is fast paced indeed.

And yesterday, another turn around.

Are the people at the BBC (who still have jobs) feeling dizzy yet?

Essentially it all comes down to DRM - if the BBC were brave enough to offer content without DRM then platform agnosticism would be a trivial problem. But unfortunately someone somewhere has decreed that all content should expire after 30 days. Just like my old VHS recordings from 20 years ago. Because we all know how home taping has killed the entertainment industry.

The people that I know at the BBC are forward thinking, brilliant people. Unfortunately it seems that their management are holding them back. Give these sorts of people some power and you'd easily have your efficiency improvements. I have real sympathy for those on the shopfloor who are going to lose their jobs.