I'm going to do something a little different this week. I'm going to 'theme' the week around both the difficulties and the pleasures of working in a multicultural area. This is partly because there are various bits in the news about race at the moment and I have various thoughts churning around in my head, setting them out here will help me deal with them.

We were looking for the last job of the day, something simple that would leave us close to our home base. The job which came down our vehicle's terminal wasn't ideal, but it wasn't awful either.

"36 year old female, assaulted. Currently in police station".

It wasn't ideal because she would be going to a non-local hospital, but it wasn't too far from our station. We'd be getting paid overtime to drive back.

Our patient was sitting in the front of the police station talking to one of their civilian support workers. With her were two of her neighbours. All three came from the Indian subcontinent. Our patient didn't speak any English at all, the neighbours were translating as was the civilian support worker.

Out patient physically had a small injury - nothing too awful, it would be sorted out by a quick visit to hospital.

We set about getting a history of what had happened to her via the different translators.

Our patient (36 years old) was married to a sixty-year old man. She had been assaulted by him and by her daughter.

Except the neighbours told us that the daughter wasn't her daughter - she was the sixty year old man's other wife.

She is aged thirteen.

The neighbours had basically rescued our patient and brought her to the police station in order to get this state of affairs out in the open - the assault had been the final straw for them.

Our patient kept crying, partly because of what had happened, but also because she thought that the police, and us, would beat her up.

There are some weird (compared to how I was brought up) power dynamics in some of the communities around our area - young girls marrying men very much older than themselves is just one of them. This is the first one I have come across where the other wife has been under the legal age.

But then I wonder - in this community families live in large groups, perhaps I've taken more than one under-age wife to hospital. If they are described to me as a 'daughter' or 'sister', how am I to know? I've got so used to seeing lots of people packed into one bedroom that I don't think about it anymore. Is there a huge amount of child abuse going on that I have no way of knowing about?

I used to think that these large families were a good thing - the community would look after their own elderly population, I'e often been very impressed with the round the clock care that large families can give. But perhaps there is a dark side to this.

Two bits of good news. Well, one bit of good news and one bit of astoundingly brilliant news.

Firstly, remember the man who had a cardiac arrest and had immediate CPR by the St John ambulance fellow?

He's only gone and kept living, now he's sitting up and chatting with people and should be discharged soon.

A real success story.

And now for the astoundingly excellent news.

I have my travel mug back.

'W00t!' as I believe the young people say.

I think that I have the 'curse of the observer' at the moment. We dropped our first patient off at the hospital (a 36 year old female with a two day history of a cough and a headache. No, she hasn't taken any of her own painkillers), and have come away with a student nurse.

She is training to be a paediatric nurse and since picking her up we have traversed the length of our patch without a single call. We have even made it back to our station (unusual in itself) and have been put on a rest break. Which is why I'm typing this now as I won't have time to write anything tonight.

The 'Curse of the observer' takes two forms. The most common is that *nothing* happens all shift, or the calls that you do get are so utterly simple that it does the observer no good at all. The other, much rarer, form of the curse is where everything goes wrong - large patients who you can't move, people run over by trains and sick people seeming dropping out of the sky.

I'm guessing that we get the... peaceful type of the curse*

Today, just for fun, I'll be asking everyone who is in pain if they have taken any of their own painkillers - and if not I'll ask them why. Lets just imagine that it's the world's worst piece of research.

*People in the NHS never use the 'Q' word, it is seen as tempting fate, so a shift is 'peacful' or 'controlled', never 'Q***t'.

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.