The daughter of a 77-year-old man who died two days after falling over said she may sue an ambulance trust.
Henry Purnell, of Great Yarmouth, had been drinking heavily before he fell.
He suffered a fractured skull and died in hospital from severe brain injuries two days later. An inquest jury has returned a verdict of accidental death.

No comment, or blogging today, as I'm off doing something wonderful - more on which later...

You know, I've been trying to think of a way to write about this for quite some time now (and the related subject of planning around it), but each time I've thought about how to write it I've always been scared that I'd come across as racist.

So here we go, lets give it a try and just write my impressions without putting any value judgements on it.

In my area we have a large amount of immigrants. For reasons that I presume are cultural many of these groups tend to start having children earlier than your 'native white' woman. They also tend towards having lots of children.

I tend to take more immigrant birthing women to hospital than 'native white' women. Is this just because 'native white' women tend to be financially better off and therefore own a car or have other transport?

Recently I've been finding that, on taking birthing women to hospital, they tend not to have any empty beds.

It doesn't end there.

Having lots of children places a strain on the ambulance service, the A&E departments and GP surgeries. When an infection starts spreading through the schools we get lots of calls to sick children.

If there are a lot of children in a house then all the children tend to get sick.

People who do not oppose immigration, and I count myself as a moderate member of this group, would say that if there are more people in the country then there are more people to work in the medical services industry.

Except that it doesn't work like that, I can count on the fingers of one hand the number of, for want of a better phrase, 'minority ethnic*' ambulance people. For some reason it's less of an issue for nursing staff and GPs.

(Heh, maybe 'minority ethnic' people aren't as daft as folk would make them out to be - what sane person would want my job?)

This lack of 'minority ethnic' ambulance people is at least partly because the government doesn't give us enough money to hire more people. I don't think that the LAS recruited anyone for an eighteen month period recently.

But there is no simple solution, can you really tell people to stop having quite so many children? The majority of the people I go to aren't that rich (otherwise they wouldn't live where they do), so taxation isn't the answer. Where does the money come from?**

So we muddle along. Myself? I can see us ambulance people delivering more babies at home as birthing mothers get turned away from midwife units (the second child I ever delivered was born at home because of this).

A while ago I took two 'native white' women to the midwives, both in labour, one after another. Both shared the same first name. Both were on a Methadone program. I mention this à propos of nothing.

Oh well, so it goes.

UPDATE:Just watching the local news, apparently in my area three out of every four births is to an immigrant mother, which reflects my experience.

*Because, if you are born in England you are a native Englander. But I understand that it's not as simple as that.

**The first person to comment, "By not fighting unwanted, improper and pointless wars" wins a cookie for stating the obvious.

Imagine being called to the third pub of the shift, like the other calls the patient is 'collapsed'. You arrive and the person is stinking drunk.

He's able to answer questions, an examination shows nothing serious. You tell him that you'll take him to hospital.

He refuses.

He becomes aggressive, swearing at you, flailing around to push you away.

You can't 'kidnap' him, even if you could there is no way to safely force him into your ambulance.

So you leave him with his friends, or the police arrest him. Then you spend the rest of the night worrying that there was something wrong with him and that you'll end up standing in a coroner's court.

That nightmare has just happened to an ambulance crew.

I have a problem with the sub-headline 'Paramedic refused to treat him'. It looks to me that they tried to treat him but that he refused.

99.99% of these jobs would turn out fine, the patient would sober up in the police cells, or back at home - unfortunately there is always the slight chance that alcohol is masking something more serious.

Obviously the report can't tell us everything that happened that night, and I wasn't there and anything I write about this situation is supposition. However I do have experience with calls very much like this one - a lot of experience.

I can see how the crew made the decisions that they did. I've made similar decisions myself.

Take for instance the report of being unconscious for ten minutes. Daily I come across people who don't know what 'unconscious' means, for some people sitting on the floor means 'unconscious'. For others groaning in pain is 'unconsciousness' and for some being dizzy means that they are 'unconscious'.

If the witnesses to an event have all been drinking and aren't medically trained, then you often take what they say with a pinch of salt.

If you are unconscious for ten minutes there is a good chance of you occluding your airway and dying, someone sitting there chatting to you is unlikely to have been unconscious. I'm not saying it never happens, it's just unlikely.

So I can't blame the crew for taking the history with a pinch of salt.

But in any case, they tried to take the patient to hospital (where he would probably be sat out in the waiting room to sober up where the headline would then be 'Nurses sat patient in waiting room to die'). It was only when the patient because abusive and aggressive that they stopped trying to get him into the ambulance.

So at what level of aggressiveness do you stop trying to force someone into your ambulance? When they tell you to 'fuck off'? When they threaten to hit you? When they take a swing at you? When they push you away? When they connect with a punch? When they connect with a second punch?

At what point do our bosses, and the courts, or the press, want us to ignore being abused?

When can we kidnap people? What powers should we have to force people to submit to treatment and transport? If someone doesn't want to go to hospital and they seem to understand what is happening then we have no power to drag them to hospital.

So it's not as if the crew didn't try to take him to hospital.

The question comes down to asking if the head injury this person suffered is what caused the aggression. Unfortunately we don't have portable CT scanners and the skill to read recent onset cerebral bleeds.

Also injuries of this sort after a fall of this type are very rare - I can't count the number of 'drunk - head injuries' that I've gone to (and yes, I try to take them all to hospital), but I can't remember any that went on to die.

So, it's not incompetence, it's not a lack of care, it's not a "oh, he's just another drunk, lets leave him". It's a combination of it being illegal to take someone to hospital who doesn't want to go, of not wanting to have a fight in the back of an ambulance, and of the unlikely odds of this being something serious.

So, based on the reporting, I look at what this crew did and I think that I probably wouldn't have done anything different.

Honestly, what would I do? Take him to hospital in police cuffs for apparently only a graze to the head?

What would you do, without the benefit of 20/20 hindsight?

I have sympathy for the patient, his friends and his relatives. I also have sympathy for the ambulance crew, no-one wants their patients to die.

But that is the risk we take whenever we don't take someone to hospital.

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.