Two jobs, both of which revolve partly around the inability for my patients to keep their blood on the inside. I can go weeks without seeing a drop of blood, on this day there were two patients. One after the other.

Two patients - one who had just had her wisdom tooth removed, the other had his arm sliced open to the bone when caught between two lumps of machinery.

Both patients stressed out by their injuries, both trying to be brave and both being nice to me in their own particular way.

One patient bleeding at least half a litre of their blood over my ambulance, needing me to blue them into A&E

One patient, a few drops of blood at the scene, the dressing that was applied caught a small amount of blood.

She was sped into hospital after trying not to cough blood over me.

He took a more leisurely ride in where his arm would almost certainly require surgery.

Her problem would be solved by her bleeding stopping, the work of a few people.

His problem would be solved over months of work by a complete team of people.

Two patients - different but alike.

More from the Mail.

"I always carry a large pair of scissors. Issued so I can cut a patient's clothes if necessary, they're my one form of self-defence if I'm in real danger."

Yes. Apart from them not being sharp (because you don't want to cut a patient's flesh by accident). And not heavy (because they are cheap NHS plastic). But you can use them to rub against the back of someone's hands to get them to drop you.

My one form of self defense is running away really quickly, or not being there in the first place.

I hate being made to look like I'm aiming to stab people.

...And while I sit on station waiting to the floor of the ambulance to dry due to my last patient having some difficulty keeping their blood on the inside I have a chance to moan at the Daily Mail.

I'm in today's edition and they make it sound like the words are coming right from my mouth rahter than an accurate reporting.

The first paragraph is the worst, making it sound like I'm some sort or hero being surrounded by knife-wielding maniacs. Trust me, if that were the case I'd be driving away quicker than you can say, "Look at that sensible man driving away from the armed nutters".

After the hyperbole it settles down a little, but if you are a regular reader then you know that the words aren't my own - it is quite interesting to see how it's been written for the style of the paper, words like 'horrific', 'shocking' and 'pressure cooker'.

It's not a huge misrepresentation - but it does make it sound like East London is a war-zone rather than a place that can get a bit rowdy.

Still it *is* the Daily Mail, so what else did I expect when I chatted to the reporter earlier in the year.

You can read the full article here.

We have an internal monthly 'magazine' called LAS News, and to be honest it's fairly awful (sorry communications department). But in this month's issue there are two interesting tit-bits of connected news.

'Savings to be made to ease the financial pressure'

Savings of nearly £11.5 million will need to be found to balance the Service’s books this year. Increased costs – including £14 million for staff pay as a result of the introduction of Agenda for Change – means that the Service’s £219 million budget will not cover outgoings over the next 12 months.

As approximately 80 per cent of costs relate to staff, it is possible that some posts will no longer be funded. Although no decisions have been made on how many jobs and which areas of the organisation will be affected, some reductions on posts will be achieved through not recruiting to vacant posts.

It is also hoped that some savings will be able to be made through more cost-effective purchasing of resources such as uniforms, vehicles and fuel.

Which I read as we are in danger of going bankrupt due to changes forced on us by the government. It's also the first time I've known how large our budget is - £219 million pounds to run a 4,000 jobs a day 24 hour service and civil emergency planning service.

Which, if my 'back of the envelope calculations' are right (£219,000,000 / 365 days in the year / 4,000 calls a day) equals £150 per job. That is to pay everyone, get new vehicles, new stock, petrol, uniforms and so on and so forth. Around £30 of that £150 goes to my crewmate and I, of which our bank balances see around £10 each.

And then it looks like we are going to lose some posts - probably starting with the training department as we can't afford to hire new staff. Then some people will leave the job due to retirement and the total number of staff will decrease as they won't be replaced.

But I'm not budget minded, so it's a bit hard for me to comment on such things.

However...

'Boost for alternative patient treatments'

A payment of £38 is to be made to the Service for every patient who receives appropriate care that sees them not needing to be taken to an A&E department for treatment. In a bid to reduce inappropriate A&E admissions, London’s primary care trusts have set aside £800,000 this year as an incentive for the Service to provide alternative treatment for patients who do not need to go to hospital.

So - every person who we go to, and don't take to hospital means we 'earn' £38. Which is a fair chunk of the £150 that I mention above. To be able to claim the full £800,000 we just need to leave 21,000 patients at home (sorry - refer to alternative care pathways), which is 57 patients a day. Out of 4,000 calls this means we only have to refer a shade over 1% of patients.

This is easy - I refer far more than this number and I'm a 'nervous nelly' when it comes to leaving people at home. So it's not really an incentive if we are doing it already is it?

Now for the complicated part - We supposedly refer 32% of patients via our telephone advice service, or they are attended to by an ambulance crew but not transported (data from the same story), yet we are looking to double the amount of telephone advice staff. I have no problem with this if it means that more people are given appropriate advice and an ambulance isn't sent. But, given our budget pressures mentioned in the first story, where are these staff going to come from?

Off the road? If we are going to less calls then we need less ambulances don't we?

Yet I still hear Controllers on the radio asking for any free ambulances to attend to emergency calls because we are all busy.

I don't know - I'm just a bloke with a big yellow van; I'll leave it up to people brighter than me to work out if I'm missing something obvious. As always if someone from management wants to email me corrections I'm more than happy to print it.

(Apart from the magazine being poo - I'm sticking by that. Also the internal website makes my eyes bleed and is completely unfit for purpose).

Police could do more to protect ambulance crews in certain situations, a new report has claimed.

In one example crews were forced to break into a house to rescue an elderly woman when police were not present.

I'd rather they didn't, I really rather enjoy the odd chance to kick down a door to save someone - it makes me look all heroic to passers-by.

(It's also good stress relief).

On a more serious note though, I have noticed that us ambulance folk are being used to cover manning* shortfalls in the police. On more than one occasion over the last three days I've been sent to 'Assault - possibly people hurt, no police units to send', because of the way the text is formatted we know that it has come straight from the Police control room.

Some crews will refuse to go to such situations, thinking quite rightly that the assailant may still be in the area, so they will wait for the police to attend in order to make sure that they are safe. Myself and quite a few others tend to 'feel out' the job before asking for the police. '20 Eastern Europeans fighting each other with machetes in the street" is a bit different to "man kicked in testicles by girlfriend"...

So we roll up to the address to find no-one particularly injured, certainly no-one who needs any hospital treatment. Then we get raised eyebrows as they were expecting the police to arrive, not two blokes in green carrying bandages. Then they try to involve us in the petty domestic dispute that started the fight - something talked about of Copperfield's or the Inspector's blogs.

I understand why Police Control do this - they have no units to send and they know that we go to everything (just like themselves) - but it's not really a good use of our resources. We still have sick people waiting for ambulances and yet we are going to places where there is no confirmation that someone needs medical treatment.

So we attend the 'scratches' and the 'Chinese burns' and the 'light bruising', fill out our paperwork and are unavailable for up to an hour. And you can't blame the patients because they wanted the police.

On the flip side, something that I'm more than happy to run on because it's my job is people who call the police in a panic for a medical emergency. Strangely enough the last two seriously sick children I've been to have presented like this, the parent called the police and shouted down the phone that their child was dying. So we arrive around the same time as the police.

So what is the solution? How about the Home Office paying for an ambulance crew to be on secondment with the police, even one ambulance person in an FRU. Then they can go to such calls with the police and they decide if the person needs to attend hospital, or can be treated at home or via GP. If the patient needs an ambulance then they can be used to take them to hospital, or in the case of an FRU, can call for another ambulance. It would be cheaper than increasing the total number of ambulance crews and police in order to meet demand - something that they are loathe to do.

I know the LAS can't afford it (more on which in a later post), so it would need the Department of Justice helping out the Department of Health. Or is that sort of thing not allowed?

*Sorry - resourcing, not 'manning'. I didn't mean to be sexist.

In an alternate dimension...

I find myself standing in front of the Coroner.

She says to me, "Did you consider that the patient who died may not have been competent to refuse transport? He was after all hypoglycaemic and septic. Why did you leave him at home instead of taking him to hospital?"

I reply, "Well our honour - I couldn't be sure. He knew what day it was, where he was and who was the prime minister. What I wasn't sure about was that he knew what would happen if he was left at home. *I* wasn't sure to be completely honest, there was something about him that I didn't like the look of, but I couldn't put my finger on it. I figured that he needed a doctor to give a full bill of health - not me."

"So", she asks me, "Don't you have capacity for consent tool for determining such things?"

"Yes Ma'am - but it's only really a guidance, it doesn't give us a checklist for things that we *feel* about a patient. It's very much a grey area and needs my judgement".

"So, in your judgement", she continues to ask, "Did you think that he was competent to refuse treatment?"

"I don't know - maybe he was 10% impaired - would that stand up in a court of law? I'm sure I could have filled in the competency either way, able to give consent, or not able to give consent. Either would have been a fudge".

"And what do your guidelines say about people unable to give consent?"

"That I should use reasonable means to get the person to attend hospital - or get the police to assist me".

"And why didn't that happen? Why did you leave him to die when you had such concerns about his health and some concern about his capacity to refuse treatment". The coroner was asking me a lot of awkward questions.

"Well your honour - there are a lot of people out there who would rather err on the side of caution when it comes to consent. They would have us believe that everything is black and white and that we should always give people the benefit of the doubt when it comes to consent. After all it is only a matter of degree between telling a little white lie to someone to heading down the slippery slope of secret arrests in the night for people with communicable diseases".

"So you left him at home."

I gulped nervously, "Yes Ma'am".

"To die?", she raised an eyebrow.

"Well, I wasn't sure..."

"But he died didn't he?"

"Yes your honour".

"You are a prat."

I couldn't really argue with her, "Yes your honour - and I can't sleep at night".

The coroner was unsympathetic, "Have you lost your job?"

"Yes your honour - the family complained and I was dropped like a hot potato. If I'd taken him into hospital then the family could complain and I'd have lost my job that way. But at least I'd be able to sleep at night."

"And the patient would be alive?"

"Is that important your honour?"

---

Wow.

I go away for a few hours and return to comments either congratulating me, or saying that I should lose my job. (Because if there is one thing London needs right now is one less ambulance staff). Still its interesting to read people's thoughts.

Part of it though is that my use of the word 'fudged' was a bit ambiguous...

To be clear, the capacity for consent assessment could have gone either way, I could have had an officer and a few police down to try and persuade the patient (something I would have done if my bluff hadn't worked, I was *that* worried about him).

I wrote the last post partly to highlight that it's not always black and white as to what we should do in any situation. At 11pm on a Saturday night there are very few people around to help out. There is no psychiatrist to turn to in order to sort out a formal competency hearing. There is no form full of boxes to tick that take into account my 'feeling' of a situation - that feeing that you get which cant' be expressed in an examination box two inches deep.

You have to make decisions that will let you sleep at night - which often nicely tie up with decisions that are in the patient's best interests. You have only a limited amount of time to make those decisions.

Would it have been better to wait around for the patient to collapse again and then wheel him out while unconscious? Wouldn't that have been against his earlier wishes? Or did he not really believe that he would collapse again.

At the end of the day, the balance of probabilities is that he didn't know that he could become fatally ill - I wasn't sure that he would become ill again. So if I performed a formal capacity to refuse check (and when I get back to work I'll scan one in and show you the form), and it could have gone either way. Truly a grey area.

So I persuaded a patient by telling a vague mistruth - I can't 'medically arrest' him, but the police (along with a few hours of paperwork and mobile phone use) would be able to. He got the treatment that he needed, and he got it a lot quicker than he would have if I'd gone down the 'proper' route - which may not have worked anyway. The 'medical arrest' part was also just a small part of my attempts to persuade the patient to attend hospital.

At no point did I think that he wanted to die.

Here is the thing - If I go to someone who has taken an overdose that will be fatal without treatment, and they refuse hospital, know that they will die and are not confused - then I can't 'kidnap' them. If they are in a public place then the police can place them under a Section 136 and we can force them to hospital.

If they are in their own home then we are to leave them to die.

Then we will get a complaint from the family and we lose our jobs, are up before the coroner and most importantly have to try to live with what we have allowed to happen. And for most ambulance services you are guilty until proved innocent.

I'm a liberal type of person, but I also know that I have more experience of illness than 'civilians' - that puts me in the position of having more insight than a lot of my patients. Persuading someone to come into hospital to see someone with more knowledge than me seems pretty benign. I'm not going to strap someone down to get them to hospital. I'm not going to roam the streets and drug people and drag them off to be experimented on. I'm not going to drive around squirting fire extinguishers into smokers faces because it's 'for their own good'.

What I will be doing is the best I can for people - so that I can sleep at night knowing that I helped them out.

...Until I read comments that make me ill with worry that I'm some sort of monster who shouldn't be allowed near children or something - seems I'm a sensitive soul after all. And that is nothing compared to the abuse that I get on the job.

---

This post was written after a few pints. I hope it doesn't read like a horrible mess when I look at it in the morning. I still think that calls for me to lose my job are a shade on the harsh side though - although if I wasn't an ambulance worker I would have a longer lifespan, relationships that might work, better health and possibly a job that pays me a lot more than £10 an hour.

Actually... anyone want to hire me?

My brother goes into hospital tomorrow to have some teeth chiselled out of his jaw under a general anaesthetic - so I'll be unreachable for much of the day. Please continue to argue in the comments box.

We opened the side door to the ambulance and started getting our bags out. Our patient was young and unconscious, probably a diabetic, but you can never be too sure so it was time to take most of our equipment into the hostel.

One of the staff of the hostel led us to the patient - it is perhaps worrying that he knew more about the patient and their medical history than many of the nursing homes we go into. The patient had only arrived earlier that day.

The staff had found him semi-conscious and rambling, they had called us straight away and by the time we arrived the patient was deeply unconscious. He was so cold and sweaty he put me in mind of horses when they work up a lather. Our gloved hands kept slipping off his skin.

First things first - he was 'snoring' which is the sign of an airway about to block, a simple tilt of the head solved that and while my crewmate checked his blood sugar I started him on some oxygen.

The check of his blood sugar showed that it was so low it was outside the measuring range of our equipment. He wasn't too far from dying.

We have two main ways of dealing with an unconscious diabetic with low blood sugar, we can give them an injection into their muscle that frees up some sugar from the patient's liver. This is slow and only works if the patient has sugar stored in their liver. The other way of treating this is to put a needle into their vein and administer 10% dextrose - essentially sugar water straight into the blood stream.

Our problem was that he didn't have 'good' veins. They were invisible and deep.

So we gave him the injection into his muscle while we searched for a vein. If we couldn't get a needle in then we would need to 'scoop and run' which would mean moving someone with poor airway control - never much fun.

We managed to get a needle into him, more through luck than design, and we started pouring in the sugar water.

His blood sugar came back up, but he was still deeply unconscious. This is not good.

We knew that he was on opioid painkillers - perhaps he had overdosed? I went down to the ambulance to get the drug that reverses such overdoses.

It was probably then that I left the ambulance unlocked...

We gave him some of the reversal agent. With an overdose the patient will often sit bolt upright and go into instant withdrawal - this didn't happen but the patient did slowly come round. It seems that he was just taking his time recovering from the low blood sugar.

We sat and chatted for a while, he didn't want to go to hospital.

...But there was something about him that I didn't like the look of. I don't know if it was because his sugar had been so low, it might have been because he had been so slow to respond to the sugar we had forced into his veins, it might have been something else that I was picking up on...

I didn't think that it would be a good idea to leave him at home, he needed to be looked at by people more skilled than I.

So we argued the toss back and forth, I would plead, he would refuse. I would explain why he needed to go to hospital, he refused. I let him know how close to death he had been, he refused. I told him that if his blood sugar dropped again then he would die, he refused.

So I lied to him.

I told him that if he didn't come to hospital under his own free will then I would place him under 'medical arrest' and that if he didn't come with me to the hospital I would get the police to help me remove him. I was holding my breath that he wouldn't call my bluff - luckily he didn't.

This is really naughty.

I'm sure I could 'fudge' a capacity check, say that he was confused and take him in under that, but it would be a stretch and almost certainly untrue. I wasn't going to be able to physically drag him out (and that would be crossing a line I wasn't willing to cross). Instead I had to bend the truth, and I do feel bad about doing it. I don't do it for all patients, but there was something about this man that made me want him in hospital.

We took him into hospital.

Later that night we saw him again - he was barely conscious in the resuscitation room. His blood sugar had plummeted again and he was septic and really rather sick. His temperature had obviously been disguised by his cold sweat as an effect of his low blood sugar.

I glad the hostel staff had found him, I'm glad that our treatment had worked, I'm glad my bluff had worked.

I'm not glad I had to bluff him though but I'd like to think that if he recovers he'd forgive me.

I could get into trouble for writing about this, but I think that it is important that people learn the truth about what we have to deal with, and how we sometimes have to bend the rules in the best interests of our patients. If that makes me a fascist... well then I'm a fascist.

I'm going to try and write this without swearing - honest.

Our first job was the now traditional 'drunken Eastern European', this time he was on a bus. He had a cut to the bridge of his nose and no ability to speak English. He had that immensely annoying way of pawing at us with his big blood-soaked hands. I think that he was trying to argue with us, it certainly sounded like it but you can never be sure with Russian (or Lithuanian, or whatever he was speaking). On more than one occasion we thought that we would have to get the police.

It's actually incorrect to say that he didn't speak any English, he could say "Eeeennglissshhh" and stick his middle finger up at us.

It would have been nice to leave him where we found him, but we'd only keep getting called back to him.

So far, so good - a slight annoyance, but nothing out of the usual.

Out next job however was a young man who was really rather close to dying (and will be the focus of a later blogpost), it took us a while on scene to basically save his life during which I was running back and forth to the ambulance.

When we loaded him in to go to the hospital I realised that in my rush I must have left the ambulance unlocked.

Some filthy thieving scumbag had stolen the Sat-nav screen and my crewmate's bag.

I informed Control and spent the next five minutes fuming as I drove the ambulance to the hospital. We were met by one of our managers who made sure that we were alright and sent us off for a replacement vehicle and a much-needed cup of tea.

Dear thief,

Us ambulance folk work long 12 hour shifts in all weathers, at all times of the day. Because of working shifts our health and relationships suffer, our social life is a nightmare. I take home £10 ($20) for every hour that I work, whether that is two in the afternoon or three in the morning. We do a job that has us verbally abused, assaulted and spat at. We go into the worst parts of town and treat the lowest scum of humanity with dignity and respect. We put ourselves at risk of catching serious diseases like HIV, hepatitis and TB from rich and poor alike. We get used by the police to go to domestic assaults when there are no police units to send. We serve the community, always there when we are called, even if it is for the most minor of things, like the patient who had a 'Chinese burn'. This is what we do - when you hurt we help, when you are dying we provide comfort. We do all this and like oxygen, we are always there.

And this is how you repay us.

By stealing something that is of no use to you, by stealing the medical books that we use to treat you. By seeing that we are in a house treating someone and thinking not 'I hope the person they are seeing to are alright', but rather, 'They won't be back for a while I wonder what I can nick from that ambulance'.

Because of shift work I'm cutting my lifespan, I already have illnesses that are work related. When you get stabbed, I'll be the person to come and make sure that you don't die.

And this is what that sacrifice of every ambulance person is for? For worthless scum bastards like you?

Your actions have taken an ambulance off the road, in the morning there will be one less ambulance to go to people - maybe it will be your mother who is ill and will have to wait longer for the ambulance, maybe it will be someone who you don't know. Either way you have made our job that much more difficult and put peoples lives at risk.

I wish I knew who you were - I'd fight you to get our kit back.

And then, with no doubt, another ambulance would treat you.

-Tom Reynolds.