First up I would like to thank Dave for sending me the link to yesterdays post. It was bad form to forget to credit him - my only excuse is that I was laughing too much.

Another short post from myself today as I shall be mainly replacing my car battery (which should take minutes), and then I will be upgrading my Macbook's hard drive (which will probably be the work of hours and more than a little bit of swearing).

Also there is shopping. I need cow juice to put in my tea.

As I left you with something funny yesterday, I thought that today I would link to something much more thought provoking.

Three blogs from America, one a police officer, one a paramedic and one an ER nurse, collaborated on a call that they all shared. It shows how all these services work together to try and do the best for our patients and is powerful reading.

Start with the Police officer's entry.

Then the Paramedic.

And finally the Nurse.

While I'm out running around doing all those things us shift workers have to fit into odd days here and there I shall leave you with a wonderful discussion thread.

Blu-tones's adventures with Picolax and the bum clinic.

(And tomorrow I perform major surgery on my Macbook by trying to cram a 300Gb hard drive into it. Should be fun. But it might result in a bit of a delayed blogpost.)

There is a warden controlled place a little way down from our station and we find ourselves going there a fair bit. Unlike some of the so-called 'care' homes that we go to, this place is really nice, the wardens are great and they call us for all the right reasons.

Our patient was somewhere in her seventies and had just moved into the place, her 'paperwork' was still coming in from the various agencies that had arranged her placement here. She had a 'funny feeling' in her head from the night before and had vomited once in the morning.

As these were unusual symptoms the warden thought that it would be best for her to go to hospital and had called us. I couldn't disagree.

It was hard to get the patient to describe her symptoms to us as she was suffering from the early stages of alzheimers disease.

Her disease showed itself by her constant repeating of a few conversation topics. She kept telling me about the lino that she had jut bought. She told me that she was concerned about the women who keep knocking on her door (the wardens checking that she is alright), and that she sometimes gets panicked during the night.

Yet she was able to recite a long prayer word for word at me.

She was a really pleasant lady, one of the 'old East end' types, littering her talk with gentle, friendly cuss-words. Friendly and polite, telling me about her family that keep visiting her and fitting her new lino. Just the sort of old person that I like, and if you've read this blog for any time you'll know I have a soft spot for the old 'uns.

Normally when we see patients with alzheimers disease they are pretty far gone, often bed-bound, they cannot remember anything, they are incontinent and can spend the whole day crying. It's an awful, awful disease, and this pleasant lady was going to end up like this.

It's hard work to care for someone suffering from dementia, it was hard enough for me to listen to her circling conversation for twenty minutes.

Especially as when I looked at her I could see her future.

I came across a patient yesterday who had a really good idea, it was an idea that helped us, helped her and helped the hospital.

We had been looking for a job to last us until the end of our shift and had thought we had got it with a drunk in the street. It would have been fine if he'd let us take him to hospital, but unfortunately he woke up and wandered off home. So we were stuck with forty minutes until the end of the shift. We would have to hope for a nice quick and easy job - something like a two year old with a head injury.

(Two year olds with head injuries are easy jobs because the injury isn't severe, it's normally stopped bleeding, we don't have to do any serious observation taking and the mum or dad looks after the child while we essentially act like a taxi).

Of course, what we wish for is often very different to reality.

From our 'patch' we were sent to a train station in the middle of London. Miles away.

At least it was Sunday, so the traffic wouldn't be so bad.

Our patient was having an asthma attack, the first responder on the scene was asking for an ambulance as quickly as possible, so it was obviously something a bit serious.

I don't like people having asthma attacks - they can tend to go wrong very quickly. Also the patient is having a very hard time of it and it's never nice to see that. I heard a description of an asthma attack once as, "trying to run a marathon while breathing through a drinking straw", and that description has stuck with me for years.

So we got there as quickly as we could through unfamiliar streets to find *two* motorcycle responders there. They had been waiting a long twenty minutes for us.

Our patient was still receiving the nebuliser treatment that the two motorcycle responders had started. They told me that the patient's chest had nearly been silent when they had arrived. This is a sign of a very serious attack.

Our patient had obviously been in this situation before as she produced a neatly typed sheet of paper with all her details, her allergies, here previous medical history and the type of treatment options that worked best for her. It told me that she was a 'brittle asthmatic', which always makes me bluelight these patients to hospital when they are having an asthma attack. If you are having an asthma attack it can be difficult to talk - so all our patient had to do was hand over the sheet of paper to whoever was looking after her.

It was a good thing that she had that bit of paper because every time she removed the nebuliser mask from her face to talk her oxygen saturations (a measure of how well she is breathing) dropped rather quickly.

So we loaded her up and sped to the nearest hospital.

I wish that all our patients had such a bit of paper. Where I work there is often a language barrier, even heavy accents can make my life difficult, so a little sheet like that would make my life so much easier. Also I find myself going to patients who don't know what is wrong with them. All they know is that they take a 'little white pill in the morning and two brown pills in the evening". Of course, this is more a failing of the Primary healthcare provider in not making sure the patient is kept informed about their health.

More importantly imagine going to a 'collapse in the street' only to see a bit of paper stuck to their jacket saying, "I'm OK - I'm just drunk".

As a question to you all, utterly unrelated to this blogpost. How can I be tired after thirteen hours of sleep?

First off go and read this. Some of the comments are pretty good as well.

The article has changed somewhat from when I first read it, but it still seems to place a large part of the blame on the ambulance service. The last section tends to stick in the mind, especially the paragraph that reads.

It had failed to meet response time targets and was branded "appalling" and "unacceptable" in a report by a committee of AMs in March this year.

If things are unchanged since I was a nurse on a Medical ward and a Care of the Elderly ward then I can explain exactly why patients are waiting on ambulances for A&E trolleys.

The routine for a patient who needs a trolley and then admission to the hospital goes something like this.

1. Patient calls 999, ambulance turns up, does clever medical stuff and drives them to hospital.
2. Ambulance gives patient to A&E department by putting them on an A&E trolley.
3. A&E department doctor sees the patient, does even cleverer medical stuff, and decides they need admitting.
4. A&E nurse calls the bed manager, bed manager finds the patient a bed on an appropriate ward.
5. A&E transfer the patient to the ward.
6. Patient gets treated on the ward and either goes home or, if unable to return home, is referred to the social workers who arrange a care home/warden controlled place/home care package.

So where is the most common delay? It's at step 6, and this trickles back all the way to step 2.

When a patient cannot return home (for example following a stroke) the social workers need to sort out who is going to fund the care home, they need physiotherapy reports, they need occupational therapy reports, they need to run 'Multidisciplinary team' meetings and they need to do all the other arcane and hidden things that they get paid to do.

Then there needs to be an available place at a care home that the patient and family are happy with. And this all takes time, and so the patient becomes a 'bed-blocker'.

(The record for me when I was a nurse was a patient staying on the ward unnecessarily for six months while funding was sorted out)

Even if the patient can return home but needs assistance, be that daily carers or just a stairlift installation, the delays are much the same.

If the ward beds are full there is no place for a new patient, so the patient stays in A&E taking up a trolley that could have been used by the next patient rolling in by ambulance.

Which means that the A&E department turns into a medical/surgical/psychiatric ward by knocking the wheels off some trolleys and hiring and expensive agency nurse to look after the patients for a few days.

There are other delays, like ward nurses 'not being ready' for a patient even though they have an empty bed, or A&E departments being reluctant to accept new patients because it would impact on their four hour government target. But generally I would say that these are fairly minor and can be fixed by a Matron with a big stick. Or an angry A&E nurse threatening ward nurses with bloody murder...Ahem...

I think that when Mike Cassidy says, "We've experienced some difficulties, maybe one or two days every couple of weeks just when the system overheats a bit and when demand is extremely high for us.", he is highlighting that this is a cyclical thing, and perhaps people should look into why it is a cycle. Is it because in the hospital social workers and the like vanish at the weekend, leading to a Monday/Tuesday backlog of patients?

However - both the hospital trust and the ambulance service blame the number of 'inappropriate attenders', people who should have gone to their GP for their minor illness. 'Inappropriate attenders' don't block beds - they tend to slow down the transit of people through A&E, but as they seldom need trolleys to lie on they can't really be blamed for making ambulances wait with their patients for trolleys. What 'inappropriate attenders' do is make other minor injury people wait to be seen.

We can blame 'inappropriate attenders' for a lot, I know I do, but in this case their influence is tiny.

What is needed is more social workers, more care homes and more hospital beds with the nurses to staff them. There needs to be a way to move people who no longer need hospital treatment into appropriate placements much faster and there needs to be a streamlining of the discharge into care process.

But that requires money.

And I'm not the minister for health.

A couple of people asked me in the comments about having only one cup of tea during the shift. This desire for tea is not limited to the ambulance service (See the recent post from the excellent Inspector Gadget).

Here is how it works...

Due to the European Working Time Directive us ambulance people have, under law, the entitlement for a marked out 'rest break'.

Except that sometimes we don't.

Sticking to twelve hour shifts, because otherwise it gets complicated, we should have one forty-five minute rest break. Thirty minutes of this break is unpaid and is uninterruptible. The final fifteen minutes can be interrupted, and if it is interrupted then we get £10 compensation.

We should only get interrupted for 'life-threatening' calls.

We must be given our rest break in a 'window' stretching from four hours into our shift and the break must be completed two hours before the end of the shift.

Now the interesting thing about all this, and the bit that I don't understand, is that all this is kind of optional.

On many shifts we don't get a break, and so are allowed to go home half an hour early (and claim £10). This means that we are working for eleven and a half hours without a break. On a busy day this means that the opportunities for a cup of tea are limited. It might also mean that the LAS is breaking the law - but this is just my layman view.

Why don't we get a break? Because it's too busy, because people want ambulances for the tiniest little thing and because there just aren't enough ambulances on the road to cope.

This is further complicated in that many ambulance people don't want to have a break - an extra £10 a shift makes a fair bit of difference to our pay packet and you can come out an extra £150-200 better off at the end of a month because of it. So you will find some crews trying to avoid being put on a break.

Things are made even more complicated when the Press suddenly realised that us ambulance people require the odd cup of tea and so the newspapers were rife with 'My Mum Died While Paramedics Drank Tea' type stories. One is even mentioned in the recent Trust Report where the reporter seemed to think that a broken down ambulance is 'on a break'. I went into this aspect of having a rest break in more detail previously.

But all this wouldn't matter except that technology has stuffed up your ambulance crew on the street.

It used to be said that if you couldn't find a cup of tea or a bite to eat then you weren't much of an ambulance crew. Hospitals have kettles, there are lots of chips shops in London and if you are desperate then you could even risk the hospital canteen.

However, with satellite tracking and an increasing number of calls (without an increasing number of ambulances), there is more pressure to make ready at hospital after dropping off a patient. Where we may have had time for a quick brew from the nurse's staffroom we are now receiving terse messages from Control asking what the delay is.

Not that I think these messages come from our Dispatchers - I always imagine some officer with epaulettes wide enough to hold all that 'scrambled egg' wandering around with a cup of tea, looking over the Dispatcher's shoulders pointedly asking why a crew is spending longer than half an hour at hospital...

Likewise, the location tracking on our vehicles means that we can no longer sneak down to 'George's chip shop' for saveloy and chips without being asked to 'update your status and location'.

(And people wonder why ambulance staff are often fat and die young...)

So we end up without breaks, or risk being disciplined for sneaking off for a drink and a bite to eat. This is why we like the dirty or bleeding patient, it means we have to return to station to clean out the ambulance and this gives us a chance for a cup of tea. It's why an incompetent assault that requires paperwork to be filled in is almost something to look forward to.

It's also why, when someone misses the vomit bowl and pukes all over the floor of the ambulance, I can honestly tell them not to worry about it with a big smile on my face.

It can be very hard to stop, even when it would be in the best interests of the patient.

We were called to a new care home that has just opened in the area. Our patient was a man in his late seventies who's heart had stopped.

Our ambulance arrived at the same time as the FRU and we were met by the patient's grandson at the door to the home. We bundled into the lift carrying half the contents of our ambulance and asked the son what had happened.

He told us that our patient was bedbound following a stroke and was unable to eat - so his food was given to him through a tube into his belly. His family had been visiting when he had stopped talking, they called for a carer who had called us.

I often moan about care homes, but in this case the carer was doing excellent CPR on the patient*, there was a large number of the patient's family standing in the room watching.

The first thing that we did was to connect our defibrillator to the patient's chest to see what his heart was doing and to see if if would need a shock to 'restart' it. We looked at the screen and were met with a flatline. People tend not to come back from this type of heart rhythm.

We have a policy in the ambulance service that - if after 20 minutes or so of CPR and drug treatment there is not positive result we can terminate the resuscitation attempt and recognise that the patient has died. Looking at each other we decided that this would probably be the best course of action.

So we started to resuscitate the patient, I was pumping on his chest, my crewmate was trying to secure an airway and the FRU was getting access into a vein so that we could give the patient drugs like adrenaline and atropine.

While doing this I was talking to the family, explaining that it was incredibly unlikely that the patient was going to survive (not the patient to them, to them he was their father, their brother, their granddad). They asked why I wasn't 'shocking his heart' and I explained why it wasn't possible. I told them that they could make a choice, that we could attempt to resuscitate him here in his home - doing all the same things that a hospital would do, or that we could try to get him into hospital, but that due to the distance we were from the ambulance it would be bad for the patient and that the hospital would do exactly the same things that we were doing.

The family asked me a few questions and then they decided that we should remain here and that once we were sure that there was no chance of survival to stop resuscitation.

And then the patient got a pulse back.

Our hearts sank, there was no way that the patient was going to recover - the drugs that we had been giving him had restarted the heart, but this was just a chemical reaction. What this meant was that we would have to take the patient to hospital, and that the family might feel some hope despite there being no chance of survival.

But our protocols say that if we get a pulse we should run to hospital.

His heart stopped at least four more times and each time we got a pulse back with adrenaline and CPR. We got him to the hospital and as we wheeled him through the doors of the hospital his heart stopped again. We explained that we had been resuscitating him for an hour while we stabilised him as best we could and transferred him to the hospital.

I was almost apologising to the consultant as I explained that we had no choice in the decision to keep resuscitating the patient, or to bring him to hospital, or to provide the family with false hope.

I went to the relatives room to explain what the doctors were doing, and to let them know that it was an almost hopeless case - the family told me that they were prepared for his death, and that they were grateful for everything that we had done.

Ten minutes later the doctors at the hospital declared the patient dead.

It always makes me sad to resuscitate people when we know that it isn't going to do any good - I wonder if there is enough brain activitie to feel the pain of us pounding up and down on their chest, to know that we are pulling them about to get them onto a trolley, to be aware of the sirens as we weave through the traffic.

I wonder if it would not be better to accept that some people cannot be saved and that it is their natural end.

Some time ago we moved from written policies for treatment to 'guidelines' - the onus for a patient's care would be placed on us, we would have to decide what was in the patient's best interest, but the policy of terminating a resuscitation is still in effect.

I know that we have these policies in place to protect the patient, and to protect us from being sued, but I wonder if there will ever come a time where we might have more flexibility in deciding the end of someone's life.

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On a completely unrelated note, DG hits the nail on the head once more - and writes something that I should have written ages ago.

*Yes, I am writing a letter of thanks for someone knowing how to do their job.

Update:Edited for grammar.