Once again, patients are waiting for ambulances rather than ambulances waiting for patients.

What is interesting is the reported tone of the Derry Mayor (and I may just be paranoid here), when he says about finding out what the other ambulances in the area were doing,

"Were they on emergency services, were they on emergency duty, were they transferring people and stuff like that," he said.

"I think that is something that needs to be addressed."

Which sounds very much to me like he wants to know if they were on a break, skiving or otherwise not 'working'.

Or it could be very interesting to see if they were dealing with people who were demanding an ambulance for a wart they'd had for the last three weeks. But I doubt that this particular follow-up story would make national news.

So it would seem that I'll be taking an effective pay cut this year as inflation outraces my pay packet. Unison (which, for better or worse is the main ambulance union) as agreed to a below inflation pay rise, staggered over the year.

I don't belong to a union because I begrudge giving them my subscription dues when they agree to stuff like this, so I don't get a vote. Much like I didn't get a vote to decide this current Prime Minister.

Still, what do I expect when our Prime Minister has cosy little chats with the Milk-thief.

It's an incredibly cheery thought, as I get ready for a run of twelve hour night shifts this Friday, Saturday and Sunday that the government values me so much. I'll bear it in mind as I destroy my body through shift work and unhealthy eating that, in order to protect inflation, I have to suffer a reduction in my quality of life by getting paid less in real terms than I did last year. I'll think of this as my back starts to ache from being stuck in an ambulance for twelve hours straight, only getting exercise as I carry people younger than myself down several flights of stairs.

And then our Health minister comes out with garbage like this,

"What is important is that we build on this, involving the workforce in the key decisions about the future of the NHS as we modernise patient care. Involving staff in this way is the key to boosting morale."

I can picture him smirking inside as he spouts this bullshit.

It seems that more and more often I think about getting out of this job and instead do something more reasonable, like writing for a living or working with computers. Unfortunately my computing 'A' level dates back to the years of the 8086 processor, and while I'm fairly smart about computers, I have nothing formally useful on my CV. That and starting on the bottom of the ladder (again) is just too depressing to consider.

And if I'm depressed now, I can imagine how I'll feel after my run of nights...

Job offers to the usual email address.

At least one of the Lib Dems has had a reasonable idea. Nothing will come of it of course, but it is a nice idea that gets him some news coverage.

UPDATE : Mousethinks points out an even better way of looking at the problem. One that in my blaise acceptance of abuse I'd completely forgotten about.

First off go and read this. Some of the comments are pretty good as well.

The article has changed somewhat from when I first read it, but it still seems to place a large part of the blame on the ambulance service. The last section tends to stick in the mind, especially the paragraph that reads.

It had failed to meet response time targets and was branded "appalling" and "unacceptable" in a report by a committee of AMs in March this year.

If things are unchanged since I was a nurse on a Medical ward and a Care of the Elderly ward then I can explain exactly why patients are waiting on ambulances for A&E trolleys.

The routine for a patient who needs a trolley and then admission to the hospital goes something like this.

1. Patient calls 999, ambulance turns up, does clever medical stuff and drives them to hospital.
2. Ambulance gives patient to A&E department by putting them on an A&E trolley.
3. A&E department doctor sees the patient, does even cleverer medical stuff, and decides they need admitting.
4. A&E nurse calls the bed manager, bed manager finds the patient a bed on an appropriate ward.
5. A&E transfer the patient to the ward.
6. Patient gets treated on the ward and either goes home or, if unable to return home, is referred to the social workers who arrange a care home/warden controlled place/home care package.

So where is the most common delay? It's at step 6, and this trickles back all the way to step 2.

When a patient cannot return home (for example following a stroke) the social workers need to sort out who is going to fund the care home, they need physiotherapy reports, they need occupational therapy reports, they need to run 'Multidisciplinary team' meetings and they need to do all the other arcane and hidden things that they get paid to do.

Then there needs to be an available place at a care home that the patient and family are happy with. And this all takes time, and so the patient becomes a 'bed-blocker'.

(The record for me when I was a nurse was a patient staying on the ward unnecessarily for six months while funding was sorted out)

Even if the patient can return home but needs assistance, be that daily carers or just a stairlift installation, the delays are much the same.

If the ward beds are full there is no place for a new patient, so the patient stays in A&E taking up a trolley that could have been used by the next patient rolling in by ambulance.

Which means that the A&E department turns into a medical/surgical/psychiatric ward by knocking the wheels off some trolleys and hiring and expensive agency nurse to look after the patients for a few days.

There are other delays, like ward nurses 'not being ready' for a patient even though they have an empty bed, or A&E departments being reluctant to accept new patients because it would impact on their four hour government target. But generally I would say that these are fairly minor and can be fixed by a Matron with a big stick. Or an angry A&E nurse threatening ward nurses with bloody murder...Ahem...

I think that when Mike Cassidy says, "We've experienced some difficulties, maybe one or two days every couple of weeks just when the system overheats a bit and when demand is extremely high for us.", he is highlighting that this is a cyclical thing, and perhaps people should look into why it is a cycle. Is it because in the hospital social workers and the like vanish at the weekend, leading to a Monday/Tuesday backlog of patients?

However - both the hospital trust and the ambulance service blame the number of 'inappropriate attenders', people who should have gone to their GP for their minor illness. 'Inappropriate attenders' don't block beds - they tend to slow down the transit of people through A&E, but as they seldom need trolleys to lie on they can't really be blamed for making ambulances wait with their patients for trolleys. What 'inappropriate attenders' do is make other minor injury people wait to be seen.

We can blame 'inappropriate attenders' for a lot, I know I do, but in this case their influence is tiny.

What is needed is more social workers, more care homes and more hospital beds with the nurses to staff them. There needs to be a way to move people who no longer need hospital treatment into appropriate placements much faster and there needs to be a streamlining of the discharge into care process.

But that requires money.

And I'm not the minister for health.

A big thanks to Dr Crippen for writing about what I was going to post about today. It means I can go back to sleep.

The short version is that there are some pillocks that don't want to have to look at the injured servicemen coming back from Iraq and Afghanistan.

It was drawn to my attention on one of the ambulance forums, partly because we have a fair number of ex-forces people in the ambulance service and partly because, while some of us may disagree with the purpose behind the wars, we do respect and honour the people on the ground actually doing the fighting for our political masters.

the other thing to post about is that, as you are probably aware, there is wide flooding around the UK at the moment. The British Red Cross have set up an appeal fund. If you have a spare couple of quid please head over there and donate to that or one of their other causes.

(...and now I head over to PC World to get something for my brother, then to Homebase to get a tonne of stone for my mother. Then I shall collapse back to sleep).

From TheyWorkForYou.

Sandra Gidley (Romsey, Liberal Democrat)

"To ask the Secretary of State for Health how many (a) male and (b) female teenagers were admitted to accident and emergency departments on grounds related to drunkenness in each month of (i) 2007 and (ii) the last five years, broken down by NHS trust; and what treatments they required, broken down by category."

Dawn Primarolo (Minister of State (Public Health), Department of Health)

"We do not collect data relating to alcohol-related attendances at accident and emergency departments." [Emphasis mine]

Tables have been placed in the Library which supply data for teenagers admitted to hospital [Emphasis mine] via accident and emergency with a primary diagnosis of T51 toxic effect of alcohol (i.e. more severe than general drunkenness and loss of inhibitions) for the last five years, broken down by gender and health care provider. The information provided in the tables does not include instances of the toxic effects of alcohol as secondary diagnosis."

---

From the BBC

"The introduction of 24-hour drinking laws may have trebled alcohol-related admissions to A&E departments in inner city areas at night, a study claims.
Researchers at London's St Thomas' Hospital compared overnight visits before and after the 2005 law change.
There were 80 alcohol-related visits in March 2005. This hit 250 in 2006, the Emergency Medicine Journal said. "

---

We 'code out' all our calls. There are two or three numbers to write down that represent what has happened to our patient. The first number is the 'type of injury' code. So (from memory) - Code 01 is 'Illness known', 02 is 'illness unknown', 03 is 'fall', 14 is 'assault' and so on.

Then comes the injury code. 01 is 'abdominal pain', 75 is 'minor head injury', 69 is 'vomiting', 23 is 'epileptic seizure'.

'62' is alcohol related.

The small problem is that where someone has two types of injury, for example they had a seizure due to alcoholism and cracked their head open, there are only two boxes to write numbers. For the fitting head injury mentioned that would be as 57/75 ('fitting - other cause', 'head injury - minor'). There would be no place to write down the '62' - alcohol related.

Couple that with the problem that the boxes are very small and easily forgotten and are therefore are occasionally not filled in and you have an obvious lack of data on how alcohol affects A&E attendance.

There are some vague figures mentioned in parliament. But these are only for people admitted to hospital - not for that much more common breed of people who are treated and discharged or are allowed to sober up and make their own way home. Or for those that attend, are violent and are thrown out.

So the St Thomas' Hospital study is incredibly important, and should be going on nationwide. During nightshifts alcohol probably accounts for 40-60% of my work, half that during dayshifts. Yet it would seem that no-one is recording or studying the numbers and types of people using the NHS for this reason.

Again from the BBC

"Both the Department of Health and the Department of Culture, Media and Sport, which was behind the legislation [to increase licensing hours], were dismissive of the findings, noting that the study only related to one hospital in one particular month."

So why isn't there a more widespread counting of the number of alcohol related attendance? Something done all year in all hospitals, something involving ambulance service trusts. Just a simple tickbox asking if we considered alcohol the cause of the injury or illness.

If it were recorded and studied, might it not make a difference in how we provision care, fund hospitals, amend licensing laws and tax alcohol?

Or is that why it's not done?

Because this sort of thing happens.

And because I noticed it because Rachel 'twittered' it.

(Yes - I'm paying a bit more attention to my other blog now - there may be reasons behind this...)

After a long stretch of work (including the sheer and bloody horror that is getting in to work at 6am), I finally have a few days off. I have a feeling of utter joy at the huge stack of laundry that stares at me whenever I enter my bedroom. Maybe if you all buy my second book¹

I also find myself laughing at the ineptitude of the terrorists of today. Burning a car is a local pastime for the children around my area, and they aren't daft enough to set themselves on fire. As for the London car bombs - I could make a better bomb. It seems that if they are really al-Qeada, then that bunch of stone-age wannabes are really scraping the bottom of the barrel.²

I'm not scared of terrorism, no-one I work with is scared of terrorism³. We recognise that the chance of dying in a terrorist attack is much, much smaller than the numerous other causes of death and injury that we face everyday.⁴ What makes us more nervous is considering what the British government might do in response to these pitiful attacks.

---

The other thing that has been in the news is another cluster of stabbings in London. It was only a few nights ago that I found someone in what I like to call a 'pre-stabbed' state.

Seventeen years old, he'd come home from 'hanging around' in another part of town. While standing around on a street corner some men in a car had pulled up, grabbed him and beaten him up. No reason for this attack was given. He had a few minor injuries - a head wound that could be glued together, some grazing to his arms that could do with a clean up and a nose that was swollen.

The police arrived at the house moments after we got there, as he wasn't seriously injured I told the police that they could get their interview done before we took the boy to hospital.

Of course, it wouldn't be as simple as that - he started off by claiming that he didn't know where he had been 'hanging out'. He also didn't know who he had been with, what type of car the assailants had been driving, what they had looked like or even his friend's home address or phone number. He wasn't going to tell the police anything.

All of this was given in a terrible Jafaken accent (the accent du jour around these parts, always hilarious to us emergency workers).

My local knowledge let us know where the assault took place, it's just down the road from where I live, and I know the 'kids' do so love to stand on that particular corner eating their chips and play chicken with the traffic.

But that was all he would say, the police understandably decided not to waste any more time with him. So our patient and his mum walked onto the back of the ambulance and we headed off to hospital. While in the back his mum told me how he was always getting beaten up, that she had tried to stop him going out and meeting up with the wrong sort of people. She'd enrolled him in college and recognised that he was walking a thin line. He'd already been convicted of a minor crime and she was obviously concerned that he may end up in more serious trouble.

So I gave him my lecture about the people who we pick up having been stabbed - how they are mostly people like him. That they hang around in gangs, that they indulge in minor crime and that they tend not to listen to their mums. I told him how you lose all your macho attitude when you have half a dozen stab-wounds in you. It's an attempt, no matter how pointless, to try and scare them into turning their backs on that kind of life.

¹ Yes, there should be a sequel; this blogpost also took an hour longer to write than it should because I was trying to find a way to write superscript elements in Ecto without having to handcode them in the HTML view. Then I realised that the Rich text view won't show it anyway. Now I'm having a nice cup of tea.

² I'm of the strong belief that we should mock terrorists, we shouldn't call people 'suicide bombers', instead they should be referred to as 'Brainwashed morons who blow themselves up because of superstitious fairy tales from the middle ages'. The pleasure of being an atheist...

³ Most of us can remember living under the IRA for a start. I long for the days of 'Special Black' rather than 'Critical'.

⁴ Look at my driving for instance...