Dr Crippen posts about the Princess Diana documentary and draws attention to the ideas of 'Stay and Play' or 'Scoop and run' in the ambulance service.

There is a discussion that has been going on for some time in medical research circles about the training of paramedics (and I would suppose also us lowly EMTs) and what we should be doing on the scene of an accident.

Let us imagine a young man with a stab wound to the chest - a nice 'trauma' job. Should the ambulance crew remain on scene for a long time, getting venous access (so that fluid can be given to prop up the patient's blood pressure), examining the wound to see where we think it goes (to determine the severity of the injury) and conducting a full physical examination by cutting off all their clothes (to make sure that there aren't injuries that have been missed). In America the crew would probably also immobilise the neck because the patient had fallen over*

Or.

Would it be better to load them into the back of the ambulance, do up the straps and rush them into hospital where there are doctors and surgeons and operating theatres?

It is complicated somewhat by the policies of the ambulance service. Unless there is a really good reason we have to record a full set of vital signs for every patient we pick up, that's blood pressure, pulse, oxygen level, rate at which they are breathing and blood sugar. We can also be expected to do 12-lead ECGs and measure the amount of carbon dioxide someone is breathing out.

So the option to just 'run' is fully out of the question - if the patient dies we would be up in front of the coroner and they would be asking awkward questions about our lack of vital signs.

So we have to stay on scene to check those signs. What else do we need to do?

Some stabbings are 'nothing' jobs, a little slice, or even a minor skin scrap have been reported to us as stabbings, if we were to 'blue light' these calls in we would be rightly laughed out of the hospital. So we need to do some form of assessment to determine the severity of the injury. To properly do this we would need to cut off the patient's clothing.

Gaining venous access would depend on the patient's vital signs and how close they are to the hospital - I am personally a big fan of 'scoop and run'. The place for a sick person isn't in the back of an ambulance.

But.

Here is where I consider myself lucky. I work in London, I'm never more than ten minutes away from hospital; if the patient is in the back of the ambulance then I can get them there really rather quickly (sometimes the trick is getting the patient into the ambulance, but that is a discussion for another time). I have that luxury of being a very short distance from a fully equipped hospital. If I were to work in the depths of Essex then I could be an hour away from hospital, then there is more of an need to stabilise the patient before transport (or doing such work while on the move).

Someone once mentioned LATER - Load And Treat En Route. Something that I've done myself with 'naughty' jobs - for instance heart attacks; if the ECG shows a heart attack then I'll get going and do the rest of my treatment on the way.

I don't know where Dr. Crippen works, but I would guess that if paramedics want to stay and play it'd be because he's a long way from a hospital. I may of course be wrong, I would guess that there are those ambulance types who see themselves as 'masters of trauma' and will fart around if it gives them something interesting to do - I don't know any myself.

Strangely enough, and tying it back into the death of Diana, we find ourselves 'staying and playing' when there is a doctor on scene (most often from HEMS). We all have stories of HEMS** turning up when really what we would like to do is 'scoop and run' with the patient. Of course they do come in handy when we have that delay getting the patient into the ambulance for example when they are entrapped in a car crash.

So while I don't think that Dr. Crippen is wrong in the treatment of trauma patients, I do think that he doesn't understand the mindset of your average ambulance staff. This may be a wild generalisation but we know we aren't doctors (even though the government is making us cover for doctors). We know where the limits of our education are, you won't see us trying to do things that we haven't been trained to do, and I'll tell you why - it's because we are scared of being sued. We like a nice easy job, pick someone up, drop them off at hospital, everyone is happy. We don't wear our pants on the outside, because we sure as hell aren't Superman.

I agree that the study and cover of 'traumatology' in this country is awful and I don't think that it will ever get any better.

Finally the good Dr. mentions his bad experience with paramedics - I've got to say that the last few disecting AAA patient's I've seen, all the ambulance crew present recognised it for what it was and blued the patient into hospital, doing the BP and such-like on the way. But if I may be cheeky I'll counter his bad paramedic experience with my own story of the A&E SHO who was convinced that the patient was having an asthma attack when every nurse in the department (me included) was shouting at him that the patient was having a disecting AAA.

(Apologies for a hastily scrawled blogpost, but I'm extremely busy today)

*I may be wrong, this is just the impression that I get.

**Talk of the devil the noisy sods are circling my house at the moment.

"Fitting female".

The address was one of those tricky ones. Places in that area tend not to have door numbers on them and in the rough area of this address there is a homeless hostel (which has a lot of people fitting because they are alcoholic) next door to a disabled person day centre (where a fair number of their clients have epilepsy).

We had to take a guess as to which of the two places the call came from - we guessed wrong because as soon as we walked into the hostel the man behind the desk looked very confused and in broken English asked us why we were there. To give them their due they do normally know when one of their lodgers has taken a bit sick, as they are normally the ones who phone us.

So we walked to the large house next door where some of the local disabled people have a day centre. We were met by a member of staff who led us to a young woman laying on the floor. In the corner of the room was a woman 'dancing' with a wheelchair bound patient.

One of the day centre staff told us what had happened - the patient had suffered a short fit, and as part of their care protocol they were to call an ambulance.

I tried talking to our patient but she wasn't saying much. I asked if she understood English and they told me that she spoke it perfectly they also told me that she wasn't deaf and that she was normally quite chatty. I tried talking to her again and there was still no answer.

I sent my crewmate to fetch the trolley-bed, it was tricky to get it in but it would serve us better than the carry chair. Meanwhile I checked the patient out a bit more to make sure that she wasn't hurt and got a bit more of a background from the staff.

In a strange coincidence the staff who was talking to me was an ex-patient of mine, I'd taken him to hospital when he had a heart attack at work. Nice to see that some of my patients do get better...

As soon as the trolley was brought up to her my patient sat upright and told me that she 'wasn't going to go on one of them' and that she would much prefer to walk into the ambulance. So after struggling with the trolley to get it into the centre we had to struggle to put it back on the ambulance.

Our patient and a carer walked onto the ambulance and, after a few more checks, were soon on the way to hospital.

I'm a friendly chap and will quite happily talk to my patients - so I started getting her medical history - Epilepsy was pretty easy to get out of her, but how do you ask someone what their particular mental 'disability' is? I always feel that it's like calling someone stupid, or insane. I'm also never quite sure of which politically correct term is flavour of the month.

In the end we settled on 'learning disabilities' and then settled back to chat about all sorts of things, including her telling me that doctors keep asking her if she has a boyfriend, something that she finds rather rude. We chat about other things of course, like her going to college and about the other people in her family.

Eventually we reach hospital and leave her and her carer there so that she can wait for her mother to come and pick her up and take her home.

At the end of the day I don't think that she really had a seizure - her recovery was too quick and she was too eager to go to hospital. I'm guessing that she really just fancied a day at home rather than at the centre. But who am I to judge, unless I see the fit myself I don't know if it has been faked or not. No ambulance person ever lost their job taking a willing person to hospital.

And I had a nice chat as well.

I often moan* about GPs mostly it's when I go to a really sick patient who is sitting out in the waiting room. On more occasions than I can count I've been called to someone who looks like they are having a heart attack and the GP is nowhere to be seen - instead they are dealing with a nasty case of nappy rash.

I understand that GPs are under time pressures, but sometimes the care that people who are actually sick receive makes me spit feathers.

So when I meet a GP who knows what they are doing I feel like shouting it from the rooftops.

I was sent (miles out of my area, but that is nothing unusual) to a person having an allergic reaction in a GP surgery. I've got to admit that I fully expected to walk in and see the patient sitting in the waiting room clutching a letter from the GP, a GP that is hiding somewhere.

But no.

Instead the GP had recognised a fairly severe systemic allergic reaction. He'd laid the patient down, was giving oxygen and, by the time we had arrived, had given two drugs via injection and put an intravenous line in. Because of the GP's actions the patient's allergy was resolving nicely.

And the GP was incredibly polite to my crewmate, the first responder and myself. I've got to say that I was mightily impressed with the actions and attitude of this GP. The GP had also made some suggestions as to what had caused this new allergic reaction and had all the patient's notes printed out for us.

The only thing about this that is a shame is that I find it so surprising and unusual to come across such a good GP. I'm always aware that I only tend to go to the bad GPs and that the area in which I work probably isn't high on the wish-list of jobs for GPs who can interview well elsewhere.

Still - it is nice to see someone else out there doing a decent job in a crappy system.
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*And the first person to go 'oh really...' in a sarcastic manner gets a damn good thumping.

Just some link-dumps really for the moment as I'm rather stupidly busy with many things. I'm also in a rather amazing amount of pain after clearcutting half of my garden - breathing is painful, let alone actual movement.

These ambulance links were sent in my readers, and I do appreciate them.

First up, a paramedic is jailed for stealing from a dead patient. As Vic (who sent me the email) said - who'd give up their job and pension for that.

Adam sends me this news from Japan - that they will be telling people with minor injuries to make their own way to hospital. We have something similar in the LAS, the Telephone Advice Service which tries to persuade people to use 'alternative pathways' - Like asking people who are dialling 999 for verrucas if they wouldn't rather see their GP. I'm not too sure about telling nosebleeds to make their own way though, I've seen more than enough people nearly die because of serious nosebleeds to consider this safe.

Quixote also sends news of what the office of an American senator really thinks of first responders. Oh dear. Still, I would suppose that similar documents are floating around the UK government as well.

Finally - Would you like to see me use my zero media experience in interviewing someone? If so you can see my interview with artist Emma Vieceli from here or via youtube. I've learned a lot about video work during that day...

1) It's a good idea if the interviewer isn't in shot - because the encouraging body language is just a distraction.

2) Check that the tape hasn't been accidentally rewound between interviews (as I lost three interviews that way and am trying to work out what to do about them)

3) Some people are very hard to interview.

4) My brother is actually a rather good cameraman.

My photos from the event are up on my Flickr account - there is a distinct lack of young manga girls because I refuse to take pictures of school age girls in flimsy uniforms.

It's been an absolute age since I last went to someone in the process of being sectioned.

For those of you not well versed in English law as it pertains to mental illness a 'section' refers to a part of the Mental Health Act 1983. Most often it is used to describe admitting someone for mental health assessment against their will. The section that I most often come across is the police using Section 136 which enables them to remove to hospital the naked man running down the street screaming that he is off to kill the aliens who are putting thoughts in his head.

Don't laugh, it's happened.

But on this day we were sent to two 'Section Two' cases, people with a mental illness who are a danger to themselves or others. These are often a bit of a circus to be honest, you have a social worker (and probably their backup), two doctors (and sometimes their drivers) a stack of police (normally around six, it case it all 'kicks off') and an ambulance crew. There is a lot of hanging around on street corners waiting for these various people to arrive. You also have all the neighbourhood turning off their 'Jeremy Kyle Show' and instead putting chairs out in front of their houses to better watch the show.

Not good if the patient is distressed already. But then, that Bedlam spirit of gaining entertainment from the mentally ill has never really gone away.

I have no idea why you need an ambulance to take a physically well person to hospital. There are two ways that a Section two job goes - either the patient agrees to go to hospital (and can therefore travel in a car) or they refuse, in which case the safest place for them to be is in the back of a police van. I have no idea why it needs an ambulance to take this patient to hospital at the cost of £400+ in addition to removing an ambulance from frontline duties. While we are doing this we could have been dealing with the mental health patient who can't wait for an appointment. If the patient decides to get violent you find yourself struggling in the back of a van with loads of equipment that can be broken or used as weaponry.

But, at the end of the day, it's often an easy job - even if we are just being used as a very expensive taxi.

At both jobs the patients decided to come into hospital of their own accord, which is nicer for everyone. At the first job the Social Worker in control said, "Oh - I'm glad we didn't have to wait for you" to me and then wandered off - no-one thought that it would be helpful to tell the taxi driver anything about the patient.

At the second job we didn't even get that - the patient walked out, the Social Worker managed to string the words. "He he is - I'm driving back on my own" together and then vanished. Under a Section Two we aren't supposed to transport without an escort, so a police officer was pressed into service. Again the patient was fine the whole way, but it did seem that the receiving ward had forgotten that he was coming in that day.

I love to see that whole 'synergy between healthcare professionals in a multi-disciplinary, multi-pathway in an ethnically aware process' thing happening.

I'm not prejudiced, my dislike of social workers is based on experience - if I meet some who are good at their job and polite to me then I may amend my position.

I'm still waiting though...

Ah, the glory of taking three days off to do absolutely nothing that I don't want to do. I mean, everyone else has a bank holiday, why shouldn't I...

Now, of course, I have a huge list of things to do. But first an ambulance story...

I could have sworn that I've already told this one, but I couldn't find it anywhere. If this is a repeat then just blame my crappy memory.

I've mentioned it before that if I have the chance to climb something or to climb through a window then I will - so when we got a job described as 'Child fell off seven foot tall fence', I was hoping that he was on the other side.

It was a good job he fell on the other side - he had a softer landing. I say softer, instead of landing on concrete he'd landed in a bush of nettles.

Climbing over the fence was no problem, landing on the other side was a little trickier as my knees are getting old.

The story that we had from the large number of friends that were present was that our patient had been chased by a 'big dog', and in order to get out of the way the boy had scaled the fence and fell over the other side.

We didn't believe him for a second. He'd been with friends (who smirked somewhat as he told his story) and the garden that he landed in belonged to a derelict house, the windows and door sealed with metal plates. I'm sure that I'm not the only person reading this who used to play on disused land.

The dog, obviously, was nowhere to be found.

I suggested that I could call the police to let them know that an aggressive dog was on the loose - the friends let me know that it wouldn't be necessary.

The trouble of course was that our patient was on the other side of a seven foot tall fence. He'd also injured his ankle and I suspected a fracture.

Did I mention that it was dark and we were surrounded by a dozen teenagers? As well as the fence which we would have to lift the patient over.

Actually his friends were as good as gold, they would help me out by holding torches and mobile phone lights on the patient and by keeping him occupied while I got his leg into a splint.

After I'd assessed him I noticed that he was wearing female socks (pink and sparkly). I find that sometimes the best form of distraction therapy is to mildly mock the patient. I asked him if he usually wore womens socks. Bless his friends as they tried to cover for him by telling me that they were the latest fashion.

His mother arrived on the other side of the fence and let us all know that he was wearing her socks because he didn't have a clean pair of his own. She then shouted over to (jokingly) ask if he was wearing a pair of her knickers as well.

We explained to the mother what had happened and she was really sensible and unworrying. Reminded me a bit of my mum actually - you hurt yourself, you obviously aren't dead or missing any important bits of your anatomy and so are fair game for those magic words, "I told you so...".

To get our patient out we called out Trumpton The London Fire Service and they lashed some ladders together each side of the fence and one fireman came over to help me. I'd strapped our patient into our scoop and we would use that to get him out. Lets just say that lifting him to waist height was no problem. The 'jerk and lift' above our heads was a different matter (for me at least).

But after a bit of lifting and grunting (again, mainly on my part) we soon had our patient and his mother in the ambulance. Some further assessment and we were off to hospital where it turned out that the patient had only sprained his ankle rather than broken it.

A 'fun' job, no-one seriously injured but a bit of thinking needed on our part, a fun patient and a sensible mother. Could hardly ask for anything more.

I'm tired, my feet are sore and I have a lot to do before some friends come over to visit later this evening. However, because of some annual leave that I took I have a full 13 days off.

This makes me happy.

I shall be trying to get some relaxation on, do some writing, start prepping the sequel to 'Blood, Sweat and Tea', maybe attack my garden with napalm, tidy my house and catch up on some books that I need to read.

So really I'll be busier than I am when I'm at work...

Thankfully I have a few blogpost ideas jotted down, so there will still be regular updates here and, because I will have time to actually compose them rather than scribbling* them down, they may even be more readable than normal.

There are also a few event type things I'm going to be going to - including getting paid to talk about blogging. How easy money is that?

The only sad thing is that my travel mug at work (used for that essential 6:30am cup of tea) has disappeared - I don't know who'd want it as it is kept in a manky state for exactly this reason. Now the action figure version of myself will have to come with a different accessory. Something like a 'realistic pool of vomit' or a 'Life size "Vehicle incident" form - yes, he's reversed the ambulance into something again!'.

I have a Team Leader looking for it, such is my celebrity pull.

*Ahem*.

*What is the typing equivalent of 'scribbling?