There is a common, but weird, syndrome that I come across on a regular basis, in this case the specific presentation meant that I got a cup of tea.

For some reason the patient feels an overwhelming urge to pretend to be unconscious. Normally this is precipitated by an emotional response - often an argument. This syndrome is more common in women, but has been known to strike men.

I will often arrive and the relatives, who are worried by this 'collapse', will often neglect to tell me that there was some form of disagreement previous to the sudden striking of the illness.

In this case the woman was laying on the bed and our FRU had been on scene long enough to determine that she wasn't physically ill and the that collapse was a response to some emotional cue. The woman was also being treated for depression.

We agreed that it would be best for her to attend the hospital and that an assessment by a psychiatrist would be helpful. So we then stood the patient up to move her downstairs.

Then she punched me in the chest and started pulling her hair out.

Us and the family restrained her and we arranged the police to attend. The police are helpful in a situation like this because people tend to calm down a little when there are police officers around. This combination of the emergency services managed to persuade the patient to peacefully come to the hospital.

The police asked me if I wanted to make a complaint against the woman - something that I would consider a waste of their time, so I refused.

But it did mean that I would have to fill out the required ambulance paperwork, partly to record an 'assault', partly to highlight the address for the safety of other ambulance crews.

But most importantly it meant that I could get a quick cup of tea at the station while filling out the paperwork - the only cup I had for that particular twelve hour shift.

Yesterday's post and other posts in the past have had readers asking me why we tend not to 'challenge' people who we think are misusing the ambulance service. In yesterday's case it was the family who had a mildly ill child and then followed the ambulance in a people carrier.

By some stroke of luck there has recently been released the main reason why us roadcrews tend to shut up and get on with it.

Take a look at this pdf of the LAS Trust Board report from July this year. Take a look at the complaints made about behaviour starting at page 92 all the way down to page 99.

These are complaints about behaviour and attitude, not the clinical treatment given.

Some examples -

Complainant feels patient needed the attention of the A&E department was advised instead to attend the practice nurse. The complaint also states that the nurse was given a 'misleading assessment of the severity of the patients wound when she agreed to treat her.'

(Patient wants to go to hospital, we should do that rather than direct them to a more relevant care pathway').

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Complainant unhappy that driver of LAS vehicle seems to be sitting in vehicle at the end of road all the time with engine running and reading newspaper. Complainant concerned that this is unnecessary pollution.

(We sit on standby in a effort to reach sick people quicker - Vehicle heating/air conditioning needs the engine running).

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Complainant/Patient is blind. Injured his foot so neighbour called LAS. Crew arrived and treated patient. Female crew member was concerned about his living conditions and so stayed a bit longer after treatment. Complainant feels very offended by this and says he asked her to leave repeatedly and is very angry that she refused.

(Trying to make sure that someone has the support that they need?)

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“Complainant unhappy with attitude of ambulance man. Was on the phone with ambulance man after ex-wife had to be taken to hospital. Complainant needed to know what was going on as his daughters were at the scene but ambulance man was very abrupt and refused to give out any information and eventually hung up on complainant. Complainant also asked for name of ambulance person which he refused to give out. Ex-wife told complainant that when in the ambulance the ambulance man told her that he would report the complainant for asking for his name.”

(I'm thinking that there is a little thing called patient confidentiality, complainant is ex-husband)

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“Ambulance was parked in the middle of the road, when complainant asked for them to move it because his daughter had an exam and he was taking her to school, the female member of staff said she didn't care about the exam. Complainant finds this very rude.”

(We park in the middle of the road if there is no parking elsewhere and we need to see to a sick patient - not for fun. I could have had a similar complaint myself once upon a time.).

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“Linked to LAS 0300/04 and 0195/06. Complainant states that "JS and S" at (an LAS ambulance station)y have been humiliating her and her son and the local shop keepers. She also states that they have ordered goods for £500 on her account for Littlewoods catalogue.” (It should be noted that staff records reveal that no staff answering to the description

(Erm...)

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As you can see some people are quick to complain, or just don't understand the job that we do. Remember that I was complained against for saying that a patient hits like a girl after he assaulted me - and the complaint was fully investigated. I wonder if that is in a Trust report somewhere...

So for a quiet life it seems that the easiest thing to do is to relax, not stress out, and take them to the A&E department and let them sit there for 3 hours and 59 minutes*. It's not the right thing to do, but it is the thing that will mean I get to keep working.

You can find other reports here and can even attend the Trust board meetings.

Thanks to 'Wiggy' for pointing out this report.

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*Stolen from this.

After a month off work it was a bit strange to get back behind the wheel of an ambulance, there is always a moment when I feel uncomfortable at work, like trying to squeeze yourself into a pair of jeans you have become too fat for. After a job or two this feeling disappears and you get back into the habit of work.

Obviously the first thing that you do after a long time off is to find out the gossip - nothing too interesting (no pregnancies, crashes or other soap opera goodness). Although I did get to hear about this sad job from one of the crews who attended.

The first job of the shift caused the return of that familiar friend of mine, lower back pain. A woman had fallen over and hurt her ankle, unable to walk her husband had carried her up four flights of narrow, twisting stairs. Then he'd called us and expected us to carry her back downstairs. I did nearly suggest that as he had put her there he could bring her back downstairs, but that would have been unprofessional and so the carry chair came out...

Nice enough people, but a bit daft.

Then a seventy seven year old man who was a bit ill - high temperature, low blood sugar, dizzy and a pulse of around 140. We 'blued' him into hospital just to be on the safe side. Once more a very pleasant man to chat to.

Next call was someone who'd been assaulted by "four crazy girls", a broken bottle slashed across his forearm leading to a cut so deep that we could see what I took to be his extensor digitorum tendon. While it looked intact to me (but remember, I'm no orthopaedic surgeon) he was unable to extend his fingers. Hopefully it was just that he was too scared to extend his fingers, but there could be a possibility that he would be needing some surgery to regain the function of his hand.

Then off to another cut hand. Our patient was a woman whose husband tried moving back into the joint owned house six months after being divorced. Understandably an argument occurred and he threw a glass photo frame at her causing a small cut. Our patient was sitting outside the house and the ex-husband had locked himself inside. The police were called, and we got to watch as they used a ram to bash down the door and present the ex-husband with some shiny new bracelets. Then they took him off or a ride in the back of a police van.

A few other simple jobs including a elderly woman who gets frightened and calls us out. This call probably being related to both of her neighbours being away for the day.

Then a one month old child with a cough all day. Parents decided that now would be a good time to call an ambulance - meanwhile the father and other child followed up behind us in his people carrier. It's not that I have to 'work' that annoys me about these calls - it's just that it might be taking an ambulance away from someone that really needs us.

Then our last job was to a nursing home and a patient with breathing difficulties. The usual mix of staff who could barely speak English, a patient with pressure sores and a general lack of care. Then as we were leaving to go to hospital an additional ambulance turned up for another patient in the same home. I made a joke about clearing out all the patients in order to have a party, but the carer who came with us didn't understand.

(Actually I don't think he understood much...)

So a nice gentle return to work with patients who were on the whole nice enough to deal with, only four of them needing to be carried.

And this afternoon I get to do it again.

I'm still happy to be back though.

(I am not going to comment on this - except to say that I have never been arrested picking up prostitutes, and that massaging my ego will get you everywhere).

...Actually it was one day's drinking and three days of catching up on the telly that I'd recorded, but the "three days" thing is a line from one of my favourite songs.

So three days of rest and recovery from the holiday, and as I sit and type this I'm three short hours from heading back to work. Then I have some writing to do for a few people and then I suspect I'll have to start work on the sequel to 'Blood, Sweat and Tea'.

I was giving some thought about the sequel, about making at least a third of it original content by looking back at my time as an A&E nurse. Then I got an email from an A&E doctor who has written a book about working in an A&E department. This meant I was going to have to trawl through this obviously inferior manuscript so that I wouldn't be accused of pinching his ideas.

Except that the swine has written a really good book.

I would say that if you like my writing, you'll like this - 'Dr Nick' explains what happens after I wave goodbye to my patients at the hospital, he also writes well on the politics that are screwing up the NHS. Funny and touching, while cynical he does also have a soft spot for the same sorts of patients that I like.

I can highly recommend this book - I enjoyed it, even though for me it's a busman's holiday.

It's also cheap.

It's 2am local time and I'm getting ready to leave the hotel at 3:30 to head to the airport. I haven't slept in the hope that I'll sleep on the plane. It's two flights totalling around 18 hours in the air. I'm 6'1" and flying economy.

Flying is not fun for me.

Especially if they show that bloody 'Spiderman 3' film again.

I land (insert my usual disclaimers about becoming a smear across the Atlantic should the plane drop out of the sky) around 4pm on Thursday.

Then I shall scuttle, or more likely crawl, home and attempt to recuperate in time for returning to work on Monday.

If you want to contact me then Friday might be your best bet.

What is kind of strange is that before the holiday I divided my life up into things that had to be done 'before holiday' and things that could be safely delegated to 'after holiday' - and I'm kind of looking forward to getting my teeth into some of that 'after holiday' work.

Bloody lovely.

There were some interesting responses to my last post about the treatment of a minor collision victim by firefighters. The general thought was that they immobilised the patient to prevent being sued by overzealous lawyers. In addition I was told that only doctors were able to remove the immobilisation collars, that the ambulance staff wouldn't touch the collars.

This makes me incredibly angry.

At what point did we stop performing good medical treatment and instead treat everyone as if they are angling to make money off of us.

The placing of a C-Spine collar is something that should only be done where there is a clinical need for it. We are trained to decide if there is a risk of a C-spine injury. We shouldn't be putting collars on just because we might get sued. Once we start doing that there is an argument that we should just follow written protocols. If we are doing that then we are be going to lose our skills and this will impact the care of our patients.

If I place a C-spine collar on someone it is because I have a reasonable suspicion that they have a neck injury - if I have this suspicion then the patient will be cut out of their car and placed on a hard backboard.

If I have someone cut out of their car and put onto a hard backboard (which can cause injuries itself) for no good reason then there could be the case for me to be sued for unnecessary treatment. And for ordering the destruction of the patient's car.

One more case of damned if you do and damned if you don't.

But unlike some of the dilemmas we have in this job (and there are plenty of them) we have the training to rule out serious neck injury. We shouldn't be doing this treatment unless it is needed.

Whenever I treat, or don't treat a patient I am thinking constantly of what benefit this has for the patient. I am always able to justify my treatment of a patient, whether to the patient, to the hospital staff or to a judge, magistrate or coroner. This isn't 'defensive medicine' this is 'good medicine'.

I try to keep up to date on the current research, and for those of us who don't, we also have medical bulletins from our management explaining the correct way to do things.

This isn't even counting the research that is initiated by the LAS.

We aren't stupid and we shouldn't be doing treatments 'just because', we should be confident in our use of evidence based medicine. We should also be confident enough to correctly document our treatment so that we can justify our decisions to anyone.

To do anything else turns us into taxi drivers.