Peter Canning has written another excellent post, this time about fractured hips.

We get a fair few fractured hips (or #NOF for 'fractured neck of femur), most common among the elderly, it's one of those things that I feel that we as an ambulance service don't deal with as well as we should.

Apparently the thought is that this isn't a 'medical emergency', but explain that to 'Doris' when she has been lying on a hard floor for six hours with a broken bone causing excruciating pain.

Part of the problem is how we prioritise calls, using much the same computer triage system as Peter mentions these calls often come out as one of the lowest, or 'green' categories.

This means that they have to wait while our limited resources deal with 'Red' and 'Amber' calls - an example of a recent 'Red' call for me would be the man in his twenties suffering from a hangover.

So Doris continues to get pressure injuries from the floor because every move is agony.

'Green' calls don't need to be attended to on a 'blue light and siren' response unless they are in a public place (because people waiting for an ambulance in view of the public is obviously a clinical risk...ahem).

Personally as soon as I see that there is an elderly person on the floor I'll respond on blue lights, call me old fashioned but I think that leaving old people on the floor, sometimes in their own urine (for many fall after getting out of bed at night to visit the toilet), is just not the right thing to do.

Of course, I also think that a blue light response to a hangover is a bit excessive, but then we do tend to over-prioritise most calls.

Peter talks about the lack of painkillers being given to these patients, like his service we also have Morphine to give and, I would suspect that some paramedics are a little reluctant to give such 'strong' analgesia to a frail patient - but I have no experience or evidence of this.

My pet Paramedic and I are more than happy to dose up little old ladies with some high grade narcotics...

(No prizes for guessing the Prodigy song that runs through our heads when we do this)

When I was a nurse we set up a pathway for #NOF, we would x-ray, give fluids and analgesia, refer to the surgeons and book the orthopaedic bed all in one go - it was designed to get these patients, vulnerable to pressure sores, off the hard A&E trolley as quickly as possible. All of which boosts their chance of survival.

Yet, in the ambulance service we leave them on the floor.

It's one of the things that I've mentioned before - that the government grades us on how quickly we get to calls, but it doesn't grade us on the relief of pain, or the appropriateness of our telephone triage system.

Perhaps that needs to change.

It's been a fair few days since I last blogged, it's probably the longest that I've gone without blogging ever since I started.

It's because of this that I'm a bad boyfriend.

Sometimes, especially when the days are short, I lose all my energy. That isn't all, I also just want to shut myself down, hide myself away and ignore the world. When I'm forced to leave my house I find myself wishing for the sudden painful death of the people around me purely because they are annoying me.

My body shows it's tension in my neck a jaw, so I sit in pain from a stiff neck and jaw muscles. My crewmate knows this well, so 'would you like some chewing gum?' is her coded way of showing that she has spotted my growing anger. Chewing gum, you see, helps with loosening the jaw.

The lack of energy for anything besides moaning means that my writing 'muse', such as it is, disappears off on holiday - I hope it's sunny there.

I find myself 'self-medicating', this is why I find myself playing computer games, the simplicity of pointing and clicking fosters a rhythm in my brain that I equate with the sorts of effects I used to get when I was indulging in meditation.

And this is why I'm a bad boyfriend, because I can suddenly become no fun to be around - and you can guess what the above effects have on my sex-drive.

So this is why I don't have a girlfriend, or why I can't keep one - because at some point I just stop liking them, like I stop liking the rest of humanity, and that's that...

I'll slip in and out of this state of mind between now and Spring, I have more reason than most to hate Christmas.

So if I vanish for a few days, hopefully I'm alright - it's just that I've not got the energy to put finger to keyboard. I've a few things lined up to write about, but it's all about getting in the right frame of mind for it.

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Pondering - 'Sheriff Fatman' by Carter USM is very much a product of it's time - if it were written now I wonder what the lyrics would be? Listen to it here.

EDITED: To make it clear that I don't have a girlfriend, and this is just one reason why - I realised that I was getting across the completely wrong message. Blame the hormones...

It's not because she's young.

It's not that she's seriously ill

It's not that I don't know what it is that's made her helpless.

It's not that the only reason that she is standing is because her husband is struggling to hold her up.

It's not when she goes into a seizure and becomes incontinent.

It's not me being covered in her urine as I help her husband lower her to the floor on the crowded landing.

It's not the possibility that she could die from this illness or be permanently disabled.

It's not the way she looks at me with utter terror in her eyes.

None of those things kept me awake tonight.

It's the sound of her four young children behind me, wailing in fear as they realise that their mother isn't playing a game.

We ambulance people are finding ourselves called to the Barkantine centre quite a bit these days. Amongst other things it is a birthing centre.

It's really rather nice actually - it's clean and airy, the rooms are large and have all the amenities like an en-suite bathroom, birthing pool, televisions and big bouncy inflatable balls (I have no idea, the midwife who taught us how to catch a baby never told us what that could be used for).

The staff are lovely, when I have seen them dealing with medical situations their clinical skills have been good, they also seem very happy at their job, something that is a rarity in some of the hospitals I visit, and yet I find it incredibly important. Their bedside manner has also seemed excellent, again something that I've found lacking with some staff in some hospitals.

So, why do I find myself going to such a paragon of 'how things should be done'.

Well, we are used as a a transport service when things start to go a bit wrong.

To be fair, from the policies that they have they do tend to err on the side of caution. For example if the labour is progressing too slowly we will get called to transport the mother to the Royal London Hospital Maternity department (and that department is quite a change from the Barkantine I can tell you), the Barkantine midwife will travel with them.

A little while ago I took a mother and baby to the hospital because the baby was a little strange and needed some medical attention that the Barkantine couldn't provide. Hopefully nothing too serious, but my knowledge of neonatal medicine is rather thin.

So, while it is indeed a superb place to give birth, I have just one small problem with the Barkantine - it's not in a hospital.

While they only accept patients with no expected complications, such things can always occur which is when we are needed, and while I don't begrudge them using us as a transport service, because we do this for other hospitals, it does seem to be a bit wasteful of resources.

I'd also hate to see something bad happen to a mother or child because of a delay brought about by the wait for an ambulance and the following transport through the streets of London.

The Barkantine is excellent, it's just in the wrong place - it should be in a hospital, with access to theatres and a SCBU, Consultants and 'Crash teams'. These options should not be twenty minutes away by blue light transport and dependant on there being an ambulance nearby that isn't dealing with yet another drunk.

So, when the new Royal London Hospital is built, can we transplant the Barkantine to the roof there please?

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I'm working Friday, Saturday, Sunday nights - so don't expect an answer soon to any comments or emails.

Jacqui Smith says public demand means people will be able to pre-register for an ID card within the next few months.
The cards will be available for all from 2012 but she said: "I regularly have people coming up to me and saying they don't want to wait that long."

The fuck!?

"Please Jacqui - let me pay you £30 or more so that you can store my data on a huge database that will almost certainly not go missing (unlike many, many other cases of dataloss) all so that you can catch those nasty, nasty terrorists. I'm more than happy to have £50.1 billion of my tax money going into this scheme rather than into, I dunno, the NHS".

When is it we can get to vote this shower of fools out of government?

Here is my statement of intent :

I refuse to carry any national ID card that is based around a national database and would rather go to prison than submit to this attack on my privacy and security. They will have to get my biometric data* by force and I will shred any ID card of this type that I am sent.

I would rather emigrate (And I love London and the UK) than be forced into this scheme of waste and evil. I will vote for any political party that guarantees scrapping this white elephant.

*Which is still hideously flawed and throws up too many false positives and negatives. To be fully informed please visit No 2 ID.

Seasonal Affective Disorder - You know it's getting bad when you look at the blank, white page of your blogging software and your mind just shuts down.

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So lets tell you about the future of the NHS, and how it's going to drive me crazy.

On my patch we have a hospital. This hospital has two buildings, one is the traditional hospital that all UK residents know and love, corridors, wards, doctors, porters, nurses, radiologists and others walking around. Slightly grubby, dodgy café, doctors running clinics.

The other building, 400 yards down the road is shiny and new. It is 'nurse led', there are posh coffee bars, the floors and walls are clean. Not much in the way of wards, but this building is only supposed to be used for day-case surgery. Nurses run the clinics and there is a sculpture outside. This is the future of the NHS, a pre-polyclinic polyclinic.

Which is why I'm surprised to find myself responding to a standard 'chest pain' inside this building.

The patient is there to see one of the nurse clinics, she develops a bit of chest pain and the first thing that the nurse in charge does is dial 999 for an ambulance.

I get there second as one of our FRUs was parked within sight of it. As I enter the room, not only have they moved the patient (resulting in us having to do a bit of searching) but there is a bit of a flap going on.

You se, a doctor has been called and he is panicking. He's shouting orders to the FRU, orders which could be extremely dangerous (for the medics in the audience he wants us to give GTN/NTG before checking a blood pressure). Our patient is sitting quite happily in her wheelchair watching our FRU take quiet control of the situation.

This is an absolute 'meat and potatoes' call for us, we deal with this sort of thing day in and day out - just by observing the patient and listening to her we suspect that it isn't her heart that is causing the pain.

But the doctor is screaming about getting 'crash carts' into the room and the nurses are running backwards and forwards like headless chickens. A manager from the other site arrives looking flustered - they confide in me that they turned up because they were worried about what these staff 'were up to'.

After a little more kerfuffle we wheel the patient down to the ambulance, do an ECG (which is normal) and transport her the very short distance to the A&E department where, after some more ECGs and blood tests, is diagnosed with indigestion.

I'm reminded of my nursing days when I saw a GP doing the world's worst CPR on a woman who had pretended to faint - I would have thought her trying to fight him off may have given him a clue that it wasn't a cardiac arrest.

This isn't a post about daft doctors and silly nurses though, after all if I were called upon to anaesthetise someone I'd certainly make a pig's ear of it. We do have our own area of expertise and I can't expect everyone to be as expert in the emergency treatment of chest pain as myself.

But.

This was a 'nothing' call, even without the benefit of hindsight - but as it was seen as an 'emergency', the best thing that the staff could think of was to call and ambulance and then a 'crash doctor' (and heaven alone knows why he was the only one to turn up, perhaps that's all they have staffing the crash team).

This points to there being a distinct lack of planning around what happens when something unusual happens, I'd dread to think what would happen if the patient had suffered a full cardiac arrest - they would have been little better off than collapsing in the street.

So, this is the future - you go to the nice, clean, artistically designed hospital for a minor treatment - but if you have a serious complication or something untoward happens the first thing they'll do is call for two blokes in a clapped out van.

Maybe it's just cheaper to 'outsource' emergency care to the ambulance service, maybe the next big thing for the NHS will be ambulances being called to deal with in-hospital cardiac arrests because then you won't need to pay for a full 'Crash team'.

I'm hopeful that somewhere in the planning for this 'healthcare centre' a manager getting paid a serious multiple of my pay-packet didn't think, 'well, if there is an emergency we can save money by just calling for an ambulance'.

I hope.

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Almost completely unrelated - my mum went to her hospital a few days ago and was told by a doctor that she should 'drink lots of water so that she doesn't catch diabetes', at which point she walked out in disgust. The same doctor recommended physiotherapy for something that would only be made worse by it. So its not just me that sees this sort of thing.

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Even more unrelated - does anyone know a good (or want to set up a) heavy RP guild on Warhammer:Age of Reckoning Ellyrion EU server? Edited to say *Obviously* for the side of Order...

(You can click through to Flickr to see the notes that I've added to my notes)

Just some notes that I made before going on Radio 5 Live to talk about this story.

Donal MacIntyre devoted part of his radio programme to it (and you can download and listen to it here, I don't know how long it will last).

So I got on the radio and said a few words (here for a few days - the section starts 1:03 in and again I suspect it only lasts a few days and won't let nasty foreign types listen to it).

But I didn't get a chance to say as much as I wanted to. But I have an audience here - so here goes...

Sadly we don't tend to flag addresses for people who are just verbally abusive to us, as I said in the radio segment, I'm working next Friday, Saturday and Sunday nights and I fully expect to be sworn at on every one of those shifts. If I were to fill in forms for that sort of abuse I'd never get any work done. Instead we fill in the forms for those people who have either physically abused us, or have acted in such a way that there is a high chance of them physically abusing people in the future.

We fill out the form, explaining why we are flagging it as a dangerous address and then fax it off to Control (using the hospital fax machine, our station doesn't have anything so high tech as a fax machine...)

So the dangerous addresses are flagged by people who have actually been there. And trust me, if someone dies as a result of a delay by us waiting for the police, the person initially flagging the address will get some serious questions asked.

The flagged address system is a warning system, it informs and compliments our 'at scene' risk assessment. Sometimes we ignore it, sometimes we wait for the police. It all depends on the situation. If someone is reported as not breathing then we'll probably go in, if they are calling because someone in the house is drunk then we are more likely to wait for the police. An example of when it was right to enter the address is this one, while in this example it was right for me to wait outside for police assistance.

It's that sort of risk assessment that we make all the time, often without consciously thinking about it.

The address is reviewed every six months, taken off the register if there have been no further reports, at least that is how it was explained to me.

So why are people violent towards us? Obviously drink and drugs play a huge part, mostly drink. But I think that there is a more subtle thing in action here.

When I wear my uniform people do as I say, they don't see me as a slightly overweight bloke - they see me as a figure of authority, that I know what I'm doing and that it is in that person's best interests to do as I suggest. Conversely, the uniform dehumanises me - it makes me a 'thing' rather than a person and it's much easier to hit someone if you think about them as just being a 'uniform' rather than a living, thinking, feeling human being.

A lot of arguments are started because of the raised expectations of people to be looked after by the state, they don't want to wait for their treatment and they want an instant cure - this is why I would suggest that actual violence against staff is higher in A&E departments, although they do have security guards posted there now.

The dangers for ambulance staff have only increased - there are more solo responders now, and they go into situations where the police would turn up mob-handed. While solo's aren't supposed to be sent to assault cases on their own, I know that I attended a fair share of such things - often waiting ages for a proper ambulance to arrive. I remember one stabbing I was sent on and it took forty minutes for the ambulance to arrive. I'm just glad that the assailant didn't return to finish off the job he'd started.

The other huge danger is Call Connect.

Due to "call connect", the government's new way of measuring the "success" of ambulance trusts, we are finding ourselves going into houses without any idea of the possible dangers. Once we are out of the ambulance, there is no way for control to contact the crew.

The new 'Airwave' radios have been delayed, so there is still no way for Control to contact us once we are out of the ambulance. We are often sent calls that just give the address.

An example,

I'm sent a call to a house I'm just driving up to - no further information is given. If I'd got out of the vehicle then I would have been met by a house full of drunks, one of whom had been cutting herself open with a kitchen knife and was arguing with the other occupants. Thankfully I don't give a damn about the government's ORCON target so I waited until more information came down - then waited for the police. If I hadn't done that there was a good chance that I wouldn't be here today writing this post.

To be honest, I would be very surprised if an ambulance person isn't killed in service before the end of next year.

Edited to add that I found the Unison's comments in the original BBC story particularly unhelpful, seeming to care more for the people who hit us than the members of their own union, then realising that there was a fence that they had to go and sit on.