...And today's winner for 'Most inappropriate use of an ambulance despite repeated mass media warnings' goes to the normally healthy man suffering from a cold for the past three days who picked up a phone, dialled '999' and asked for an ambulance, in order to get it to transport him to his GP for an appointment.

After the crew 'had a word' he decided that a taxi might be a better bet.

Rumours that if the taxi crashed en route the crew would be be suspended for not conveying the patient are, of course, unfounded.

David Nicholson (Chief Executive NHS)

"The ambulance service is not close to breaking point. It's tough, there is pressure on them, but I think they are responding fantastically well. Staff are absolutely responding to provide a fantastic service to our patients"

Peter Bradley (Chief of the London Ambulance Service)

"The increase that has come this winter has been far more dramatic than normal. It has been the most difficult ten days I have seen in the last ten years. It is absolutely horrendous. Hospitals are full and A&E departments are struggling. We have got ambulances having to wait longer to offload patients and that is causing difficulties."

Who do you think has the better idea of the state of the ambulance service at the moment? I know who my money is on and it's not on Nicholson.

On Monday the London ambulance service went to REAP 4. The REAP system runs from REAP 1 (no problems with the service) to REAP 5 (the sort of problems you get after all the power stations blow up and there are plague rats running on the streets of London).

We have never been at REAP 4, and if you ask the road crews in London they would probably say that we should have been at REAP 4 a couple of months ago.

From the official London Ambulance website

"Ambulance staff responded to 20,939 emergency incidents across the capital in the seven days up to last Sunday (14 December) – an increase of nearly eight per cent on the average of the previous four weeks. The pressure has been compounded by high percentages of calls initially treated as being Category A (immediately life threatening), and delays caused to staff at hospitals while waiting to hand over patients.
As a result of these ongoing issues, the Service today raised the declared pressure level at which it is operating from ‘severe pressure’ to ‘critical’ – the first time that it has reached this level since the capacity levels were introduced in late 2005."

The national news has been full of this story and there has been constant coverage that the 999 service is to be used for only 'genuine' emergencies...

...and obviously it has worked because five out of my nine calls today were to simple chest infections that could have been treated at home, seen a GP, or just sit and wait for it to go on it's own. None of them were sick enough to need an ambulance - but they called and we responded. I suspect it will be a similar story tomorrow.

We also had two hoax calls.

But I'm preaching to the choir.

It doesn't help that we had an outbreak of Norovirus at one of our local nursing homes, something that has led to a local hospital opening an isolation ward in order to safely cope with the influx. I'll tell you the full story of that night in a later posting.

Today, like many others of late, there were multiple calls being held waiting for ambulances - some of these calls would have been covered were it not for people picking up a phone and using the same number you dial if someone has dropped dead in front of you for their case of a 'nasty cough for the past three days'.

There are too many patients, 80% of whom don't require an ambulance, and not enough ambulances.

What doesn't help is that the politicians are ignoring the problem and trying to pretend that it hasn't all gone to the dogs. The politicians are being dishonest (yet again) and so, it would seem, are the executives of the NHS. Rather than admit a problem and make some sort of plan to improve it they lie and spin and lie some more. Just notice how they call a massive (30%) increase in calls a 'pressure' rather than a bloody disaster that we have seen coming from twelve months away - it's not like Winter just sneaks up on us does it?

And on Friday it's 'office piss-up' day.

Bloody great.

The only good thing about today has been a group of us stretcher monkeys getting a good result from a cardiac arrest. If this post reads a little weird it's because I haven't slept a wink in the last 36 hours and have just completed a 12 hour shift. At least the hallucinations haven't started yet...

Rather busy at the moment (more on which later), so I've just got time to throw you a link to a section of the new London Ambulance website (which I happen to think is quite a good site, much better than the old one).

It's about drinking too much, and the accompanying video sums up some of my night shifts pretty accurately.

The wife looks at my me and my crewmate as we lift the chair with her husband in it onto the back of the ambulance.

"You both must be very strong", she says.

I reply with a joke, normally about how my crewmate, half the size of me, is actually the stronger of the two of us.

-----

But what I want to say is that the lifting is the easy part, the real strength is needed with the things we see and the patients that we deal with.

It's the strength that you need when you have picked up the fourth severely demented patient in a row, they curl up on our trolley having been unable to move for many years, their arms and legs contracted into the foetal position. Their bodies are skin and bone, as we pick them up their joints creak and crack and they shriek in our ears, long nails dig into our arms.

It's the strength that you need when driving the ambulance and you hear them start to cry in the back, your crewmate holds their hand and tries to reassure them but they can't get through. Instead all you can hear is the sobbing and the noises that are left them now that language has gone. they can't tell you if they are in pain or are scared - instead all they can do is moan, and cry and scream.

It's when you walk into a nursing home full of the demented elderly. Stuck on the walls outside the doors to their room are photographs from their prime. Happy mothers holding their children, proud men standing to attention in military uniform. Sepia memories from the past, what they were, not what they are. You open the door and the person in the photographs is lying on urine sodden sheets, legs heavily bandaged from ulcers that will never heal, with hands constantly grasping for something imaginary that floats just out of reach. The person that they were is gone, all that is left is the shell, no expression behind the face that smiled all those years ago for the photo outside the door.

Then one takes hold of your hand and looks up at you with bright blue eyes and asks if you are their dad, long since dust.

And your heart breaks.

I don't know how much longer I can do this.

Mostly linking to other people this week because these particular sets of night shifts are knocking me silly.

A couple of days ago I wrote about some attitudes towards homeless folks - there is another group of patients that engender a similar response, that of the heroin overdose.

Peter Canning writes (another) excellent post about the use of Narcan in opiate overdoses. I've got to admit that I've been guilty of 'punishing' overdoses in the past when I was a bitter and twisted A&E nurse, although in part that was in collusion with the A&E doctors.

Now I've taken a much more relaxed attitude to heroin overdoses, a nice slow administration of Narcan while I breathe for them with my ambu-bag, a chilled out little job with the overdose waking gently and peacefully. If you can maintain the patient's airway for them, and keep them well ventilated then there is no rush for the Narcan at all.

Makes life better for the patient, and better for the ambulance crew. Because who really needs to be the person put into instant drug withdrawal, or be the person who gets punched because they put someone else into instant withdrawal.

And if, as a crew, you are nice and relaxed then the patient's fellow junkies tend to be nice and relaxed as well - and I like nice and relaxed.

I don't know Fred (or at least I don't think that I do). But I hope that he's well and that his local management don't hassle him for being sick.

Now I'm off to sleep as I have had no food, drink or rest since starting last night's shift.

It's cold and dark, and for the next few days I'm working nightshifts, this will either result in a 'sense of humour failure'* on my part or I'll suddenly find myself sobbing in the corner of the room. Place your bets on what it'll be...

With it getting cold it becomes 'Homeless season' for the ambulance service. People who are normally happy** sleeping rough, drinking the day away on a park bench and having a nap wherever they can suddenly realise that it gets a bit chilly and that their normal lifestyle is a bit... uncomfortable.

So, as a service, or at least in my part of the world, we find ourselves being called to more homeless folk than is normal, at the risk of sounding politically incorrect let me just define 'homeless' for the purposes of this article as those people who are long-term homeless, normally due to alcoholism (caused in some part by the lack of 'wet' hostels for them) or the mentally ill (caused in some part by Thatcher). I'm not referring to the homeless who seek to improve their condition, but instead the outliers who either refuse help or who cannot keep the rules that are expected of them.

An example of how things change with the weather - in the last cold snap I was queuing up to hand over my homeless patient, also queuing up were another three ambulances with patients similar to mine. One was incontinent while waiting and another had been incontinent in the ambulance. Actually incontinent is perhaps the wrong word, one of the men whipped out his 'member' and urinated up the wall of the department.

Welcome to the world of healthcare.

But, you know, the homeless are people as well and they deserve as much care and consideration as anyone else, even if their sole contribution to society seems to be limited to turning cider into urine.

My patient, for example, told me that he had been vomiting blood - something that can be the sign of something serious, especially in the alcoholic patient. I listened to his history in the back of the ambulance, took his vitals and started my paperwork. I looked him up and down and wrote 'Patient complaining of vomited blood, no evidence seen'.

I stopped and looked at what I'd just written.

There wasn't any sign of blood or vomit on the man's clothing so what I had written was factually true. What stopped me was wondering if I would have written such a thing if I'd picked this patient up from a clean house? If he hadn't been an alcoholic?

I'd treated him with respect, I'd done all the same things that I would have done for anyone else complaining of the same thing, but still I'd written those words on my report form.

I may as well have written 'patient says he vomited blood but I don't believe him'.

So we took him to hospital. When we got there I started handing over to the nurse, as soon as I mentioned the vomiting of blood she turned round and asked me, "Was there any evidence of this?".

This isn't a 'harsh' nurse, she's pretty good actually - caring and considerate and definitely hardworking, yet she'd also asked me the same thing that I'd written down on my paperwork without thinking.

The patient went out to the waiting room.

I wonder if he would have been put out into the waiting room if he hadn't been homeless.

It's not a criticism of the nurse, trolleys are in short supply in the A&E department and the handover nurse has to make decisions between who gets to stay in the main department to be seen soon and those who can go out in the waiting room. While the various professional organisations that look after nursing and ambulance people would have us treat every word that comes forth from the patient's mouth as complete truth, there comes a time when you start to watch for people trying to 'trick' you for whatever reason they have.

It might be the junkie looking for narcotics, it might be the person playing up their illness in an effort to get seen sooner or it might be the person who lies about not being able to get an appointment at the GP as the reason for dialling 999.

One of the 'classics' is the patient who tries to convince you that their pain score is 'ten out of ten', and as the NMC*** say, 'pain is what the patient says it is', which is hard to believe when the source of their pain is a tiny shaving cut...

While I can normally tell a lie, I'm more than happy to give the benefit of the doubt to a patient, regardless of their background. I'd rather give analgesia to a junkie than withhold relief from someone in genuine pain.

Which is why I wondered why I wrote 'no evidence seen' on my report form.

*Sense of humour failure is a term that some people use to indicate losing their temper. I may well be using it in a similar way...

**'Happy' is perhaps the wrong word here.

***Who live in happy fairy land it would seem and when I was a nurse seemed to publish a lot of twaddle about any old rubbish. They may have got better. I doubt it though. They'd be very unhappy about me calling everyone either 'Luv' or 'Mate' for instance.