Last post I mentioned how we seem to be throwing resources at the 'non-emergency' side of our work, sometimes though it does work out in the patient's best interest.

Take Mavis for example, she gets a bit wobbly on her feet sometimes and had a fall - she picked herself up and got back into bed. When the first carer of the day arrived she found blood everywhere and Mavis with an inch long cut to the back of her head.

The carer called us and as soon as we arrived disappeared out the door.

Chatting with Mavis it was obvious that she didn't want to go to hospital, she'd lived in this flat all her life and didn't trust hospitals, or doctors. Fair enough really, they aren't my favourite places either.

So we called out our ECP, 'Emergency Care Practitioner' - a Paramedic who has been taught a few more things like how to close wounds or how to diagnose urinary infections. He turned up and after chatting with Mavis for a while started to clean the wound and glue it shut.

As Mavis is fairly mobile there was blood all over her flat, and when the cleaning carer arrived she sucked her teeth, said, "I don't do blood", and disappeared sharpish.

So while our ECP friend was washing Mavis' hair, I went around the flat with a damp cloth cleaning the blood while my crewmate pointed out the bits that I missed (we work well together like that).

With the wound cleaned and treated we left Mavis a very happy customer in her own home. Our ECP returned a few hours later to check up on Mavis, and she was still healthy and still happy with the treatment we gave her.

It is nice when we can avoid taking vulnerable people into hospital - it's a place full of nasty communicable diseases. And yes, I am fully aware that I may be contradicting what I wrote about in my last post - that we perhaps shouldn't be this overly accommodating to patients. But I just think that it highlights just how much this job, and healthcare in particular isn't so black and white sometimes.

The difference of course is that Mavis would have normally needed treatment in an A&E department, while the sore throat or verruca patient can normally survive without a trip to the hospital.

As I've mentioned many, many time before it would seem that the world of healthcare just stops once the sun goes down leaving just us ambulance folks and the A&E departments to deal with everything. The weekends are the same.

We had a perfect example earlier this week, while my regular crewmate was off watching the Foo Fighters at Wembley (lucky cow...) I was working with another EMT chasing around the Hackney area.

We were called by the district nurse service to attend to a woman who had been cannulated, but the cannula had come out.

Our patient was being treated for a long running infection, no-one really wanted her in hospital because it is really easy for her to catch another infection there, so she was being treated at home. A splendid idea.

She needed a small needle (cannula) in her vein so that she could be given antibiotics straight into the bloodstream, and the district nurse service came around twice a day to administer this.

Unfortunately this cannula had started to fail on the Saturday night. Unfortunately for the patient the service who inserts them in the community doesn't work on a weekend, or after the sun goes down. The district nurses couldn't resite it, they don't have that training in this area.

So they call an ambulance and expect us to put a cannula in the patient and leave them at home.

Unfortunately neither me or my guest-star crewmate are paramdics, so we aren't allowed to put in cannulas either (despite me doing it regularly in my previous life as a nurse). Meanwhile the patient really didn't want to go to hospital.

"How do you think I got this infection in the first place?", she said to me, and I couldn't really disagree with her.

The family were lovely, so it wasn't a hardship to go that extra mile for them. We called up our control and asked them to send us a paramedic who soon arrived. I was glad to see that it was one of my mates and I knew he'd be happy to do it.

However... Are we legally covered to cannulate someone and leave them at home, normally when we stick a needle in someone we take them to hospital. So my paramedic friend phoned up our control and asked for the 24 hour clinical advice desk.

He was on a break.

So we chatted to the family of the patient, not a great hardship as they were your classic, traditional, East-end family while we waited for the clinical advice desk to phone us back.

He did so and gave us the go-ahead to pop that needle in and leave the patient at home.

Which we did.

And the patient and her family were extremely grateful.

This is just one more example of how the ambulance service and the A&E departments pick up the slack for the other agencies that have decided not to work after dark, or on weekends, or on bank holidays.

Part of us being run ragged at night is due to people expecting treatment when they want it, when it is most convenient for them. When 80% of our jobs can be treated by GPs or walk in centres, why do these patients wait until most of these services have closed? Because it's most convenient for them. The health service then expects us accident and emergency services to pick up this slack.

"I want treatment for my sore throat now", said the great unwashed public at 2 a.m. in the morning and phones 999 for an emergency ambulance. Then they moan when they have to wait at the A&E department while they deal with real emergency cases.

And so what happens? The ambulance services start reconfiguring to meet this demand for trivial work, we train and employ ECPs who do the GP scut-work, and we start converting the fleet to cars, all the better for taking the minor illnesses to hospital.

We aren't an accident and emergency service any more, we are the "coughs, colds, bumps and grazes" service, open 24 hours a day we will bring the hospital to your door - free of charge and no waiting needed. Meanwhile the seriously ill can go waiting because we are so busy dealing with your minor case at a time of your choosing.

"You really do get upset at crap carers", one of my station officers said to me.

We were sent to a young woman living in a group home. There are carers there as this woman has some severe mental health problems and there are a number of similar people living in this home.

Not that I would know as the carer opened the door and essentially pushed the patient at me.

All I could tell was that the patient was confused and uncommunicative. She reached out and took my hand and started walking towards the ambulance.

I explained to the carer that I'd settle her down in the back of the ambulance and then come back to get some information.

The patient sat in the ambulance, due to the way she was holding her head and breathing she was spraying spittle everywhere. The carer was nowhere to be seen.

I went back to the house and banged on the door.

"What happened?", I asked.

"She wanted me to call an ambulance", said the carer, "I don't know why".

"Did something happen?"

"Her eyes rolled back in her head".

"Did she shake at all?", I asked.

"Oh... Yes", said the carer, appearing a little dazed herself.

"What can you tell me about the patient's normal condition?", I continued.

"I don't really know her", she said. When I pressed her on how long our patient had been at the home she told me it was only "four or five months".

Shaking my head in disbelief that in a small house like this the carers took so little interest in the people living there that they knew nothing about them after four months I asked what medicines she takes.

"Two little white pills in the morning, and two purple ones at night".

I let the carer know that my psychic powers weren't that good and she'd have to be more specific than that. She couldn't.

The patient was unkempt, appeared to have someone else's underwear on and her hair hadn't been washed in some time. The 'carer' didn't know anything about her and refused to have anyone come to the hospital with the patient. By now the patient was starting to wander around the back of the ambulance and I wanted to get her to hospital.

On the way to hospital the patient kept standing up, so I had to hold her hand and get her to sit down again - I didn't want her falling over should my crewmate need to stop suddenly. While she was doing this she was unconsciously spraying spittle up my body, over my arms and in my face. She wouldn't keep an oxygen mask on, so I was getting covered.

By the time I got to the hospital I was fuming at the lack of care that this patient had been receiving from this 'care home', I was angry that no-one had travelled with her, I was angry that she had been 'dumped' on my with the carer not telling me anything about her and I was a little annoyed that I'd been covered in her drool.

Then I booked the patient in and discovered that she has 'open' tuberculosis, which means that I may be needing six months off work at some point in the future.

Again, this was a thing that the 'carer' had neglected to tell me.

So it was back to station for me for a long shower, followed by filling in paperwork for my risky exposure and a 'vulnerable adults' form to highlight what I considered neglect going on at that home. Someone higher up on the food chain than me will take on having a look at the home and seeing if my fears are justified.

As I reported it to my station officer he said to me, "You really do get upset at crap carers".

"Yes", I said, It's one of the few things that still fires my blood, that 'carers' can get away with doing such a shoddy job while I feel that us ambulance people are the only ones who still give a damn about people. I wish I met more people who were good carers.

A little time ago I met the private secretary for Ivan Lewis, the minister for social care - he told me that they don't have much to do with ambulances as we supposedly don't deal with that much social care. I put him right on that score, that around 80% of our jobs involve social care. This is what we see, this is what we deal with - we are that safety net that deals with everything when the other services throw up their hands and don't know what to do. When the sun goes down and everyone else goes home, we and the A&E departments must deal with everything and anything - and that is why we see the flaws in the system.

Looking at my list of future blog-posts I think that this week will have the failure of the care system as a bit of a theme, not for any real reason, just because that's what I've been getting of late.

This is interesting,

The Scottish Ambulance Service has been given a month to bring forward plans to end the single-staffing of its emergency ambulances.

"I have made it clear to the Scottish Ambulance Service that it must take action to eliminate rostered single-manning," Ms Sturgeon told MSPs, making it clear the use of rapid response vehicles, designed to be manned by a single-paramedic, was also being looked at.

In London there is an increasing move to have solo responder RRVs going to calls (it helps with the eight minute target), in fact the move is to reduce the number of double manned ambulances and instead have many more solo cars.

In London a lot of the RRVs are manned staffed by ambulance technicians rather than paramedics, and ambulance techs don't have the same drugs available as paramedics.

When I was working on the RRV if I arrived at someone who was having a seizure there I couldn't give the drugs that a paramedic would use to stop the fit.

This plan, the 'front end' model, where a RRV is first sent to a job to decide if a double-crewed ambulance should be sent is due to be rolled out in London in the near future. This story would mean that at least one person in government is unhappy with this plan. Along with a lot of on-the-floor ambulance staff.

So I wonder if the Health secretary will be looking at other ambulance trusts?

Those of you who read my Twitter feed will have had a preview to today's post.

The night before last I was attacked at work. Thankfully my injuries were limited to bruises and scratches, however I have been incapacitated by muscle strain. Let me explain.

We were sent to a man who was unconscious in the street, we arrived a few seconds before the police to find him collapsed in the road. It was obvious that someone had given him a good beating as his face was like a split fruit. Big cuts, large lumps, swollen lip - whoever had hit him had really gone to town on his face.

He seemed mildly disorientated so we quickly got him on our trolley and into the back of the ambulance. We checked him out to make sure that he didn't have any stab wounds - it's a bit of a hazard round my way, especially considering not all stabbings get reported by the media.

The police tried to get some details off him, but he said he was in too much pain, so we told them that we would meet them down at the hospital where he might be a bit more cooperative.

His behaviour was a little 'off', he'd been drinking, but was possibly showing signs of concussion or maybe something more serious.

I got into the front of the ambulance and started towards hospital.

Within seconds the man was up and swinging his fists at my crewmate, slamming on the handbrake I ran round to the back of the ambulance and managed to restrain him.

His confusion seemed to have become more severe, he couldn't remember what had happened to him and he kept repeating the same questions. Every so often he would look at his hands, see the blood and start asking us why we had hit him.

He alternated between calm and very agitated, he kept refusing to go to hospital and kept fighting us to get out.

Here is were we get into the thorny issue of Consent and Capacity. I can't kidnap people off the street, not if they have Capacity (the understanding to refuse).

However in the case of someone who cannot understand the consequences of refusing treatment and may have life or limb threatening injuries then I can try to 'force' them to go to hospital. For example, someone hit by a car who has a serious brain injury causing them to fight us off may be dragged off to hospital as they don't have the Capacity to refuse.

Needless to say, it's not something that I like doing.

What we were worried about with this patient was that he had been beaten so hard that he had a bleed on his brain, it was this which could have been causing his strange behaviour and which could prove fatal. He wasn't able to understand the consequences of what was happening to him, nor of what would happen if he didn't have treatment - he was having trouble remembering his name let alone anything more complicated.

He needed to go to hospital and in our opinion he didn't have the Capacity to refuse.

Unfortunately the police had left the scene (they needed to in order to allow us to get to hospital) so there was no help there. Every so often he would try wrestling with us and he only got stronger. My crewmate called Control for urgent police assistance, normally they would come running to help, but for twenty minutes we were bounced around the inside of the ambulance as he tried to hurt us while we tried to not hurt him.

He also had the strength of an angry man, while we had to remain calm.

Don't get me wrong, if someone tries to assault me because they are drunk, obnoxious or just plain nasty then they will get reasonable force used on them and they'll be throw off my ambulance - but with someone who is apparently not in his right mind I can't exactly knee him in the testicles.

Twenty minutes we wrestled with him while waiting for the police - we didn't want to move because otherwise the police wouldn't be able to find us to help - but after all this time it seemed that we weren't going to get the help that we had urgently called for. By now the sweat was dripping down my body, I was covered in his blood and he'd managed to get a few good scratches and punches in. Thankfully my glasses were intact.

I managed to restrain him enough for my crewmate to drive us to hospital. There was a bit of a stand-off at one point where he kept threatening me, but I managed to keep him controlled.

Unfortunately as my crewmate opened the doors to the ambulance he managed to break past me as by now I was exhausted, sore and feeling sick from the exertion. He burst through the doors and ran down the road after waving goodbye and shouting 'sorry for hurting you'.

I wasn't going to chase him, to be honest I don't think I had the energy in me to chase him even if I'd wanted to.

The police officers at the hospital came over to see what were happening and after telling them they offered to arrest him. I've read enough police blogs to realise that if they did arrest him it'd be a load of paperwork and wasted time for the CPS only to decide no further action because my patient probably wasn't in his right mind.

We spoke to an officer who suggested a ten minute cup of tea, before seeing the expression on my face and realising that sending us home for the last few hours of our shift was for the best. So we returned to the station, filled in the relevant paperwork cleaned up the warzone that was the back of our ambulance, wiping the blood off the walls and cupboards and fixing the chair that had been battered in the struggle.

Then home.

And so I sit here typing this, in pain not because of any great injury - but because my entire body aches from twenty minutes of extreme exercise, I'm walking like a cripple and the grip has gone from my hands. I suppose that I'm just reaping the consequences of not having the chance to do regular exercise. I'm hoping that he didn't have anything nasty in his blood. And I'm off work for a bit due to my inability to walk like a normal person.

£10 per hour after tax doesn't seem enough for this sort of work.

For those concerned about the patient, I believe that another ambulance and police team-up managed to get him to hospital - the further results of which I don't know about.

As for the police not attending our urgent request for help... I spoke to our Control and she told me that she used both the Scotland Yard line and the dedicated line and on both occasions she thinks the phone was picked up by the cleaner rather than someone who actually knew how to answer a phone and dispatch police officers. I believe the phrase she used was 'some civilian numpty' - I think that a complaint from our Control has already gone in to the police.

As I've mentioned many times in the past us in the ambulance service, and our colleagues working in A&E are often used as a 'safety net' by other medical professionals, whether that is by the nursing home nurse who is concerned by a patient being 'off their food', or the GP who doesn't wish to come out an see a housebound patient.

Obviously there are a lot of people who don't use us as such, but it does seem increasingly common.

Here is an example, we were sent to a severely mentally and physically disabled young woman because she was suffering from thrush. She had been sent home from the day centre and her family had made a sensible decision to phone the GP surgery. This young woman has some complex problems and so she is better served being seen by someone who knows her and her medical history.

The GP had refused to visit, telling the family that 'I'm not examining her' and had told them that they should call an ambulance to have her taken to the local A&E.

We had arrived to find her, not distressed but obviously suffering from the infection, sitting naked on the bedroom floor. Her older sister was playing with her. Both myself and the family were reluctant to take her to A&E, it's an unusual setting full of strange noises, bright lights and strong smells. It's also not the right place to be dealing with a medical condition that is neither an accident or emergency. All in all it would be an immensely distressing experience for her. She'd been there before and had hated it her family told me.

We discussed with the family our best plan of action, they agreed with us that our Control should try the GP and see if they could come out to see the patient, we were aided in this because by this time most of the regular GPs would have changed shifts so we would be talking to a different doctor. The family agreed to this and after our Control spoke to the GP the doctor agreed to come and visit.

It must have been fine as I didn't see her in the A&E department during the duration of the shift.

I don't like leaving people at hospital, it's often the path of least resistance to load up the ambulance and drive them in. But sometimes it really is in the patient's best interest to stay at home and this was a classic example of this and in those cases I'm willing to take that job-threatening risk.

A quick listing of things that might not warrant a full blogpost, but have been clogging up my 'I really must post about this' file.

Adrian Sudbury is dying, in his final weeks of life he is petitioning the government to improve education about bone marrow donation, as there are still a lot of myths about the process - if you live in the UK please do sign his petition. It's a bit of common sense legislation that works in other countries.

'Jeremy Clarkson has been criticised for claiming he drove at 186mph on a public road, by a father whose son died when a speeding car crashed into his vehicle...
...When asked about driving the supercar, Clarkson, who lives in Chipping Norton, said: "I got a great speeding ticket. I think it was 186 in the Limehouse Link.'

I love Top Gear and I have no problem with the presenters doing daft things on the telly, but 186 m.p.h. through the Limehouse link tunnel is utterly moronic. If this is true (and let's face it, he was probably willy-waving) then I'd suggest that this was 'dangerous driving' and perhaps worthy of a driving ban. The Limehouse link tunnel is in my patch and I remember, before the speed cameras were fitted, having fatal R.T.A's there seemingly every other week.

Boing Boing recently had a post on a 'Right to Die' card. I hope that Salford council have liaised with the emergency services because if someone waved a bit of card at me while I was about to start doing CPR on a recently dead person it wouldn't mean a thing to me. Our rules for not starting resuscitation on a patient are strict for a reason - to prevent mistakes that could quite literally cause someone to lose their life.

Saying that, there may well be a point in my life when I have DNR (Do Not Resuscitate) tattooed on my chest.

In a related story here is a tale of a movement to recognise that sometimes it's best not to be over aggressive with the treatment of disease. We can't all live forever, but for some people it seems like a goal to aim for regardless of the consequences of the treatment.

I'm not too sure how it would translate in the NHS - dealing with decisions in a privatised health service raises some very different questions than in the socialised medicine of the UK. How much does treatment cost factor into things? Would a poor person choose to die rather than saddle their relatives with debt for instance?

But ultimately, if you are hoping for a dignified death keep your fingers crossed because it so seldom happens, it's definitely not the 'important life journey' that certain groups would have you believe.

'Incidents of violence and aggression against drivers of one-person rapid response ambulance vehicles are not recorded separately by the Scottish Ambulance Service'

Shame, because that's exactly the sort of information we should have before moving ahead with the 'Front end model', that has a lot more ambulance staff on solo responder cars - and therefore probably at increased risk of being seriously hurt. One day a solo responder will be killed and I can predict that the service involved will say, "lessons have been learned".

By the way, I adore They Work For You watchlists...

A good idea to use 'Telehealth' to keep an eye on our ageing population. One of the trial areas is on my patch. Unfortunately the report itself is written in a really childish fashion. I suppose that it's alright to insult the elderly, here's hoping they do the same to those rascally Jews next...

Peter Canning writes about something that all us folks in the emergency services occasionally worry about. Recently one of our FRU drivers was involved in a crash (thankfully no-one was seriously hurt) and only the other month some... person drove into the back of our ambulance while we were on lights and sirens. Under pressure to hit the ORCON targets some people are going to drive too fast to get to a job (which is probably just someone with an ingrowing toenail anyway). Thankfully our managers are too smart to tell us to drive faster as I think they know exactly what answer they would get...

Here is another fear that us ambulance types have - being falsely accused of sexual misconduct. You will notice that his ambulance service took the brave step of supporting him by firing him even after he was found not guilty in a court of law. Unfortunately it wouldn't surprise me if the UK services didn't take a similar tack. I hope that Mr. Howes has some good luck with his arbitration.

I know that this is something that I'm very scared off - it only takes one drunk, drugged or mentally unstable patient making an accusation to have you suddenly out of a job.

It's one of the many reasons why I like having a female crewmate.

Some nice news now. Inspector Gadget will have a book out soon. His is a top blog and I wish him all the best with it. He is on my list of 'fellow bloggers who I'd like to buy a pint, but are likely to want to remain anonymous'.

On Thursday I'll be entering all the information from my 'holiday wiki' into Google Earth and making some decisions on where I'm going and what I'll be doing, feel free to edit it until then. Afterwards I'll have to make a decision what to do with it, the smart money is on me tidying it up and leaving it as a permanent resource.

I think that's everything - lots of these came from people sending me links, something I'm always happy to receive so do keep sending them to me at the usual address.