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.

My crewmate and I were called to a nursing home not far from station. We'd already been warned that there was another ambulance crew on scene dealing with another patient.

We jokingly wondered if the nurses there were beating the patients up.

As we entered the home we were met at the front door by a member of staff (as any regular reader of this blog will realise, this is a rarity). It turned out to be the nursing home's manager. She led us towards the patient.

She also knew about the patient, even though he was only staying there for a week or so while his wife was in hospital herself. Again, a rarity.

As we stepped into the lift we met the other ambulance crew on their way out with their own patient - he told me that he'd had a look at our patient and that, while he had a cut to the head, he was otherwise fine. He also mentioned that it would be a shame to drag the patient out to the hospital.

Our patient was suffering from severe dementia and was described as 'a wanderer'. While wandering he'd had a simple trip and had hit his head against one of those bits of furniture that seem to dislike old people. He was currently sitting in a chair in one of the communal rooms, surrounded by another twenty or so deeply demented, and wandering, patients.

But here is the thing - the patients were all clean, their clothes were tidy and none of them were 'tied down*' to the chairs. There were also four nurses in the room engaging with the patients (even as one of them decided to have a root through our kit bag - and then started swearing at the nurse who told her that the bag didn't belong to her).

So it was obvious that this was one of those good nursing homes that I always believed was out there but seldom witness.

A bit like the Loch Ness Monster.

The cut to the patient's head was pretty typical - it had stopped bleeding and was a minor affair. To drag this demented patient out to the hospital would be rather cruel, so we decided to follow an 'alternative care pathway'.

"Alternative care pathway" is classic NHS gobbledegook jargon for 'the patient doesn't need to go to hospital'.

Instead we decided to call our Emergency Care Practitioner out to see the patient. The ECP is trained to deal with minor wounds and is on hand to see patients in their home. I knew who was working and like all the ECPs on our patch I think he's excellent and would be happy to have him look after my mum.

I have an advantage as, being an ex-A&E nurse, I'm pretty good at knowing what the hospital treatment would be. If the patient were to go to hospital the doctor there would treat him in exactly the same way as our ECP. Except that our ECP would do it better as it's easier to fire an ECP for doing something wrong than it is to fire a doctor.

We met the ECP later in the day. "You rotten sods", he told us, "I went to that patient - he was so confused he kept trying to hit me. Then he tried to bite me. I closed the wound with some glue, but nearly glued my glove to his head".

It all worked out in everyone's best interest - the patient wouldn't have to sit for hours in a loud and confusing A&E department getting scared out of his wits and being put in danger of injuring himself again. The hospital wouldn't have that extra patient to see. We were able to clear the scene quicker and were able to go to a more serious call after dealing with the patient - without the ECP we would have still been tied up with transporting him. The nursing home wouldn't have to send a nurse to accompany the patient, thereby reducing the care cover.

And the ECP got to lose a wrestling match with a frail 90 year old man - which is always good for the ego...

*Not literally tied down (although I'm sure that it does happen). But instead patients are hemmed in by trolleys, chairs or other bits of furniture in order to stop them wandering.

If this post makes even less sense than normal please accept my apologies - I've just come off a tiring nightshift and haven't had the chance to sleep yet. I just want to stumble around moaning "Brains... brains...."

Cleveland, USA.

Ambulances there seem to have the same problems as us in the UK. Like them we have a policy of "You call, we haul".

This video could have been made on one of my shifts.

Unfortunately our hospitals have to see patients in under four hours, so they will get seen, even at the expense of other sick patients.

(Tip of the hat to Dr Grumble)

Well there you go...

The NHS is in a fine state. Everything is fine. No need to panic. Look, we've saved money.

Fine.

Honest.

Everything is good.

You can all relax now.

Nighty-night.

*BEEP!*

We are spending too long at hospital.

*BEEP!*

In order to have ambulances that can reach calls in under eight minutes, we need to have ambulances 'Green up' (be available for another call) at hospital faster than they do at the moment.

*BEEP!*

There is a policy in place that if we spend longer than twenty minutes at hospital we are supposed to book in with Control and explain that there is a delay. Unfortunately It's nearly impossible to get your patient booked in at the hospital in under twenty minutes. So we don't do it - we only book a delay if we spend longer than forty minutes at hospital.

Otherwise we'll make our controllers go mental with our calling up after every job.

*BEEP!*

You see, you have to get the patient off the back of the ambulance - this sometimes involves hunting around for the increasingly rare 'Hospitalis Wheelchairus', the common hospital wheelchair. Then you wheel them into the department where you need to wait for a nurse to take a handover of the patient off of you.

*BEEP!*

It's in the interest of the hospital to delay this handover for as long as possible, so as to make it easier to make their four hour breach target. Sometimes there are three ambulance crews in front of you waiting to handover their patients.

*BEEP!*

Sometimes the hospital just has a culture of not taking ambulance handovers until they have been waiting for twenty minutes in any case.

*BEEP!*

Then you have to get the patient onto the trolley (or more likely wheel them out to the waiting room while trying to explain exactly why the nurse doesn't believe that they are going to die).

*BEEP!*

Then one of us heads to the reception area to book in the patient, while the other returns the trolley/wheelchair and makes the ambulance ready for the next patient. It is rare that the ambulance trolley gets a clean - it takes too long to dry.

We do try and wash our hands between patients though.

*BEEP!*

The crew in the reception then books the patient into the hospital - sometimes there is a queue of walking wounded waiting to book in - sometimes they are more ill than the patient you have just brought in, so you let them book in first.

*BEEP!*

Then you head back to the ambulance where you fill in your documentation in a way that will cover your arse should the patient suddenly drop dead and you find yourself up before the Coroner's Court. There are boxes to tick and findings to write. Times to be entered and obs to be recorded.

*BEEP!*

Then you hit the 'Ready for another call' button and get sent somewhere else for some fool with a poorly elbow.

*BEEP!*

This takes as a minimum around thirty minutes - note that I haven't included going to the toilet, grabbing a cup of tea or eating a bag of crisps. With an uncomplicated walking patient, with no delays on handover and a reception that is poised ready to take your handover this takes a minimum of around eighteen minutes.

I know, I've timed it.

*BEEP!*

In an effort to 'speed us up', and to remind us that we should be making Control's life more difficult by booking a delay after every job, some bright spark has installed a new programme on our vehicle based computer terminals.

*BEEP!*

After two minutes at hospital a big friendly black screen appears on the terminal. Then a big friendly timer appears that says...

If you are, god forbid, at hospital for longer than twenty minutes it goes

Also after you have been at hospital for more than twenty minutes it starts going...

*BEEP!*

Every minute it goes...

*BEEP!*

While you are trying to do your paperwork, in the manner that is expected of you.

*BEEP!*

It's like Chinese water torture.

*BEEP!*

Oh, and the number starts flashing in a friendly red and white manner.

All in an effort to get you to make available those few minutes quicker.

Now, I understand that there are ambulance crews out there who take way too long at hospital. These cause more work for those of us who get on with the job. But surely if you are concerned about those people (and management know who they are because everything we do is logged) then you pull them into the office and have a quiet word with them.

What you don't do, at least if you want a happy workforce, is to force them to endure psychological torture. Or to punish everyone for the crimes of the few (although it seems that this is the tactic that Nazis in war films use...)

It's all in a bid for increasing the calls we get to in eight minutes (and I've moaned enough about how it is clinically unimportant for such a target).

There is a rumour that in the new year we will be banned from booking our patients in at reception. The nursing staff will have to do this (because, you know, they have so much free time). This surprises me as I can remember when it was tried about six years ago and was a horrible failure as paperwork kept going missing and patients were left for hours without seeing anyone.

I'll still be booking my patients in because of a little thing called 'duty of care'.

But, you know, eight minutes is all that matters.

Anyway, 'nerd determinism' has won out and there is a simple way to stop the *BLEEP!* from sounding that isn't in the slightest bit damaging to the equipment on the ambulance.

I'll continue to have two mouthfuls of coke between jobs, and will make available as soon as I can (if only because I find it really dull to sit at hospital). My patients come first, not the eight minute target.

(It's a shame, for once, that only Mozilla browsers still support the *blink* tag...)

Just a post to dump some of the links that have been sitting in my Inbox (and were probably forgotten while I was hovering of death's door the week before last).

First up is from Trusted Places (recently the Times 'website of the week') - I've mentioned them here before, they are a website that lets you submit your own reviews of your favourite places. It's run by some really lovely people, and they are currently running a competition.

Just write a review and you have the chance to win a rather posh looking hamper.*

*Disclaimer - they are sending me a hamper, but for previous support, not for mentioning this link.

The Open Rights Group, of which I am a proud member, have just published their two year review - it shows what they have been up to for the past two years. They are good folks and fight on important battles. If you live in the UK and use the internet then you should be donating to them. I do, and I'm poor.

Unless of course you want to see corrupt e-voting and more corporations taking away your rights.

Seriously worth every donation.

There is a newish police blog up - and he has just posted about his experience with the LAS. I have similar feelings when I'm trying to sit on an aggressive patient and they screech round the corner. The comments are good as well.

All emails have been answered - if you were expecting an answer from me and haven't got it - I'd send that email again.

Patients can be tricky little buggers sometimes - they like to trip you up.

We were sent to a middle-aged woman experiencing difficulty in breathing. We arrived and I did my usual examination and history taking.

Here is what I learnt.

• She had difficulty in breathing.
• She had a cough.
• She had a fast pulse.
• She was coughing up a bit of frothy white sputum.
• Her lungs sounded clear, no sign of infection.
• She'd recently had a long haul flight.
• She was a smoker.
• She wasn't on the contraceptive pill.
• She didn't have a high temperature.
• She had a pain in her chest that wasn't made worse by her breathing.
• She had a fairly low oxygen saturation.
• She had deep 'S' waves in lead I.

All of which made me think that there was a possibility that she could be having a pulmonary embolism - this is a life-threatening emergency and needs rapid treatment at a hospital.

So we carried her downstairs, did an ECG (where we discovered the deep S waves - something that is one third of the changes that occur in a pulmonary embolism), and 'blue lighted' her into hospital.

After some investigation she was found to have a kidney stone.

A kidney stone?

Now, I've seen a lot of kidney stones in my time. None of them ever presented like this. With a kidney stone you get abdominal pain, back pain, you tend to writhe around on the trolley. You don't have a cough, chest pain, reduced oxygen levels and an altered ECG. There was nothing, absolutely nothing, about her condition that suggested a kidney stone.

But it just shows you how easily you can be 'tricked' by the examination and history of the patient. It's why I have a fairly low benchmark before I 'blue light' a patient to hospital. Even if it's just something that my subconscious has picked up I'll 'blue' them in - I can always find a justification to the hospital as to why I've done so.

"Treat for the worst, hope for the best", it's how I get to sleep at night without worrying that I've let someone die because I haven't treated them seriously.

I'm sure everyone who works in healthcare has a similar story about how an atypical patient presentation has tripped them up. Feel free to tell me about it in the comments.

Four days off work - that I shall spend answering emails and doing writing type work. I swear, this blogging/writing lack is like having a second job. This is a problem as I am naturally lazy. So if you are expecting a reply to an email and don't get it today, then your best bet would be to send your email again as it's disappeared into the ether.

Thanks for all the comments on my last post. I don't think that my father disappearing really did affect me in any way - pretty much as soon as he left we treated the whole thing as a joke.

One day I should tell you about my half-uncle, my only other male relative (besides my brother) who is also an amusing pillock...

Right...To work!

It's coming up to that time of year again. That time of year when 'granny dumping' starts, where everyone has 'flu', when people with sickle cell disease start getting crises.

It's also that time of year where I move one step closer to the grave. It's nearly my birthday.

For some reason I'm thinking about my dad this year. He left us when I was about fourteen years old, he'd gone to live with his other wife (although he still hasn't remembered to divorce my mum yet...). He's got other children who are probably grown up themselves now. I don't know, I haven't heard from him in over twenty years.

Fuck. Until now I hadn't counted.

That's more than twenty years since I had a birthday card from him, more than twenty years since I last saw him, and more than twenty years he's gotten away with being a bigamist.

His sole contribution to me being the person that I am today is around 10cc of genetic material.

So why am I thinking about him now? It's because of a joke that I made to my mum about wondering if I'd get a birthday card this year. I have no idea where that joke came from.

It's not like I think of him much - the last I heard was that he lived someone on my patch, but I've never seen him. For all I know he might be dead. He's actually become a bit of a running joke, the men in our family are all a bit... well... wrong. And, yes, I include myself in that assessment.

He's like a mouth ulcer - I keep probing it to see if it still hurts. It doesn't hurt, it's been too long for that. I don't even think that it hurt when he left - by then I'd realised the sort of person he was. Even before I knew that he'd another family somewhere, a family he took to Florida while we barely had the money to eat.

I'd like to see him. Just the once.

Just to tell him what he missed out on by forgetting about his sons. One became a successful teacher. The other one became me - and you know about me.

So this year, when my year count goes up by one, I'll think of him.

And I'll think, "Fuck him".

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.