I look at my patient and consider my choices, either I act outside the policies that the LAS have set me in the best interests of my patient, or I follow the rules and provide sub-standard care.

What do you do?

Our patient is a fiercely independent woman - well into her eighties every morning she walks to the shops, has a potter around to buy her papers, has a chat to the shopkeepers and then returns home.

She'd had a fall because the strong wind that day had blown a door into her, one of our first responders was already there and had patched her up. We took her to the ambulance and completed the assessment. She had a cut like half of a 50p piece on her shin. Sometimes you can get quite nasty skin tears, but in this case it was more of a gouge, and therefore easier to fix up.

There was one problem, our patient didn't want to go to hospital and after she told us why, I cold only agree with her.

No problem, it would be a simple job to steristrip the wound closed, something our ECPs are well equipped to do.

Except there wasn't one working on this shift.

Now, as long time readers will be aware, I used to be an A&E nurse. Wound closure of this sort is something that I would do regularly when working in the minor injuries department. I could easily do ten such closures a day, all without supervision. Our doctors would tell me to clean, close and dress the wound and the choice of how to do this was down to me.

But with this lady, if I were to follow our policy, she'd be left with a cut that would be left open with little more than a bandage over it. This would not only cause scarring, but would also have a higher chance of becoming infected.

It just so happens that I carry some steristrips in my personal bag.

So, of course, I used my nursing knowledge and closed the wound using my steristrips. It is a low risk, high outcome intervention that I am competent in. At the end of the day I can justify taking this course of action to anyone who questions me, and more importantly, to myself. I can guarantee that I've done more wound closures of this sort than any of our ECPs.

Us ambulance staff work under guidelines rather than the more restrictive protocols these days and this means that we can do pretty much anything, just so long as we can justify it. While I've been been told that I shouldn't use my nursing skills (like cannulation) I can't see anyone having a problem with my course of action.

I sure that my patient was happy.

I've written before about our 'psychic computer' and the new policy of Active Area Cover (AAC), we've been told that it is to improve the public perception of the service and to better let us hit those rather pointless government targets.

If you remember (or reread the article) it involves a computer that was no doubt bought at considerable expense which predicts where calls are going to come from next Something that I firmly believe in a urban setting like London to be utter hokum.

But it would appear that it's not always being relied on, and instead those high up in management are making things up as they go along.

Consider the following two bits of evidence that I have collected personally over the last two days.

In the first episode, we were told to go on Active Area Cover on a street 0.2 miles distant from our station. As the policy lets us roam around within a radius of 0.5 miles I informed Control that we would therefore return to station and wait for a call there, incidentally allowing me to have my first cup of tea of the day. Our dispatcher agreed.

Then I suspect that someone had a word with her because she called us up less than 20 seconds later to move our AAC point much further away.

Surely if this is a science then the first AAC point would have been the best and it would mean that we shouldn't be moved seemingly on a whim just to keep us from the station.

The second episode was just as foolish. We are not supposed to be put on AAC within half an hour of the end of our shift. So I was surprised to be told to go out with just 12 minutes left in the window of opportunity. Well, I'm not allowed to refuse, so I asked where the psychic computer was telling me to go - for hasn't it scientifically predicted where the next call will be?

"Oh, go anywhere", I was told.

So with 42 minutes to go to the end of a twelve hour shift we were being told to go and drive around for twelve whole minutes.

I'm in the process of reading a book at the moment concerning American ambulance workers, and one part seems particularly apt - in it a supervisor is asked about how to manage ambulance staff and he replies that, as we are trained to gather evidence about a person's illness or injury in three minutes, we question everything. You can't just tell us that 'this is the way we are going to do things' and expect us to roll over and do it without some form of explanation or evidence.

A good example of this is the CPR guidelines that keep changing based on evidence - we have no problem in adapting our practice to use the latest evidence, and no-one questions it.

So here is the challenge - I know management read this blog. I want management to provide me with scientific, peer-reviewed evidence that Active Area Cover works in a high population density area. I don't want the marketing guff that the software company sends you - I want proper evidence. After all, isn't evidence what all modern medicine should be about.

I'd also like an assurance that the system is being used properly, and not to 'punish' crews. Is there an audit in place for example to see which manager sends which crews out?

Until I get that reassurance I will continue to suggest that the best thing for ambulance efficiency would be to buy the management in Control a load of cat toys, and let them play with catnip woollen mice rather than get bored and annoy road crews (and the poor dispatchers who have to phone us up and give us the bad news that we aren't allowed to remain on station).

On a more amusing note, two things which have lived up my shifts of late.

The first was when I asked a woman how many children she had given birth to and she answered, 'six or seven, I can't remember'.

The other was the GP who told a mother that the best way to get earwax out of her five year-old child's ear was to use eardrops and then root around with a cotton bud. Needless to say we were sent to the child after her ear started bleeding. As I've always been told that you shouldn't stick anything in your ear smaller than your finger, I suspect that this GP may have bought his GP certificate from a market stall.

Either that or the mother was mistaken - it happens sometimes.

Ergh - what a day...

There is a reason why so many of us who work in emergency healthcare hate Mondays, it's because they are one of the busiest times for us. Us ambulance types are run ragged, the A&E department is packed solid with few people moving up to the wards and I would imagine that GPs get a lot of 'emergency' appointment requests.

The reasons for this are many, and I may miss one as I'm writing this while my brain is still recovering from this particular twelve hour shift.

It's mostly to do with the weekend. Hospitals tend not to discharge many patients on the weekend as a lot of the 'non-essential' roles tend to keep office hours and aren't available during the weekend. Assessments for going home aren't done and there is often only one doctor team on call for for each of the specialities. Therefore one team is unlikely to discharge another team's patient.

So, over the weekend the patient's stack up in the wards and the nurses there are so busy trying to discharge them they are too busy to accept new patients from A&E.

This means A&E trolley waits go up which spills over into us ambulance staff waiting for a trolley to put our patient on, which means that ambulances can do less jobs in a shift.

From our end of things, we have three main types of patients, those who couldn't see a GP over the weekend and are now so ill they have to go to hospital, the patients that are finally seen by the GP who then sends them into hospital and the people who don't want to go to work or school or who didn't want to waste their weekend, but now they are off work, don't mind wasting that time.

So, Mondays are terrible and the sheer number of people going to the hospital tends to leak over into Tuesday.

We did do something unusual yesterday - we went to a little old lady who'd fallen out of bed, as she wasn't seriously hurt and didn't want to go to hospital we put her in her wheelchair and told her to call us if anything changed.

Seven hours later, to the minute we were back at her place because she'd fallen out of her wheelchair. This time she agreed to go to hospital as she'd skinned her arm.

What was quite sweet was that she was worried that we'd moan at her for calling us back. As I tell many of our patients, 'I'd rather be picking you up off the floor of this nice warm, clean and dry house than wrestling with some drunk by the side of the road in the rain".

And I'm serious about that.

I've just had a week off*

I was coming off my first set of night shifts in some time, I've been burning my annual leave allowance to avoid doing them and it's been a right trauma trying to reset my body-clock back to day shifts.

Winter is approaching, and with it my Seasonal Affective Disorder. During this week off I've been unable to be motivated about anything - I've been sleeping between nine and eleven hours a day and I've been alternating between not eating and binge eating. There are other symptoms, but you don't want to read me moaning.

So I've dusted down my SAD light and checked that the bulb still works - time to start blasting myself in the face with it.

I hate this time of year.

The problem is that you have to be careful not to let it affect your work - it's incredibly easy to start snapping at people, and that way leads to written complaints and warnings from those above me in the LAS pecking order.

It's been said that over half the complaints against our service are due to 'attitude', so as the nights draw in I try and be a bit more mindful of what I say and do and of the way I present myself.

Of course it doesn't always work; take the drunk who was asleep in the street. We were getting run ragged and this was the third person of the night who'd decided that going home wasn't for him, instead he'd just kip down in the middle of the pavement.

Be aware that it's only around seven in the evening.

So we parked next to him and I deployed the 'diagnostic boot'**. Essentially it's not a good idea to kneel down next to someone who is drunk, you never know if they are going to take a swing at you. If the person doesn't wake up to me shouting at them, I gently kick the sole of their shoe with my boot, not with the purpose of hurting them, but just to shake them awake.

Sure enough he woke up and I introduced myself and asked if he was alright.

'Fuck off!'

I informed him that he couldn't sleep on the pavement, someone might trip over him.

'Fuck off!'

I let him know that if he kept sleeping here we, or our colleagues, would keep being called to him as a 'unconscious male, caller refusing to approach'.

'Fuck off!'

I asked him if he would like to go to hospital, it was less than 200 yards away.

'Fuck off!', he then spat a gobbet of drool at me.

'No', I replied through gritted teeth, 'You don't get to tell me to "fuck off" four times and then spit at me. If you don't 'fuck off' yourself I'll get the police down here to have you nicked. And they are a lot less pleasant than me - but I would guess you know that already'.

At this he got up and wandered home.

I am, after all, only human and I don't get paid to have drunks swearing and spitting at me.

The trick, is to not lose my temper when it's a cold and dark February evening and turn the 'diagnostic boot' into the 'your head is a football, you annoying twerp boot'.

Fingers crossed.

*I'm typing this while manning ORG's stall at the Green Party conference. I really like being able to write things in advance - comes in handy for the twelve hour stretches.

** Before I start getting emails of complaint, I was told to do this at our 'self defence' course. I didn't have the heart to tell the course leader that we'd all been doing this for years.

Obviously I am superb at everything that I turn my hand to. To believe otherwise would mark you out as a fool.

So when the Open Rights Group asked for volunteers to star in a promotional video it would have been dreadful not to give them the benefit of my Oscar wining acting style.

So here I am.

Who's Watching Who? from Dean Whitbread on Vimeo.

(What you should perhaps keep in mind is that I was asked to 'ham it up')

For those with lower bandwidth you can also watch this on Youtube.

And if anyone is at the Green Party Conference, I shall be manning the ORG stall there. I may also threaten some bunnies with death and cooking if they don't all join immediately.

That should work.

I look at the screen and see the words, "Patient in labour", it's 4 a.m. in the morning and I huff at the thought of going out to another 'Maternataxi'.

My crewmate groans and tells me that while the patient lives in our patch the maternity department that she is going to is way outside our area to a hospital that we don't like much.

'She doesn't speak English', says my crewmate, 'oh, and she's fifteen'.

'No wonder her maternity department is in Essex', I joke.

We get there and her parents meet us at the door, they are babbling away in their native tongue and they basically push us, and the patient, into the ambulance. Her mother comes with her - all the time shouting the only word in English that they seem to know - "Quick!"

'Quick! Quick! Quick!' they shout at us, they aren't interested in us doing anything, you know, medical, so I grit my teeth and we drive them to the hospital.

I'm fuming. I'm sure that it doesn't help that this is the last of our very busy nightshifts, that it's silly o'clock in the morning, that our professionalism is being ignored for our ability to drive a free taxi and that we are being forced to go out of our area when all we really want to do is local jobs so that we can get off shift on time.

At some point my crewmate leans through the dividing door of the ambulance and lets me know that this is the third baby our patient is having and that the father of the baby is her cousin.

Again I mutter something about Essex*

We drop her off at the hospital, I neither expect or receive a 'thank you'. The midwives at this hospital were lovely and we returned to the ambulance to try and race back to our own area.

It was only after I'd had seven hours sleep at the end of my shift that I start to wonder about this call.

I wonder about our patient getting pregnant for the first time when she is twelve. I wonder about her cousin, I wonder how old he is, and how old he was when he first started what can only be described as child abuse. I wonder about the isolation that our patient would feel in being unable to speak the native language of the country in which she lives. I wonder about why the social services allow this child to remain in a situation where she has seemingly become a baby factory.

The pregnancy is all above board, the maternity notes are genuine, the history is good and action has probably been taken. But somehow the father of the child isn't in prison, isn't on the sex offenders register. Is it because he is a child as well?

I think about the fate of our patient, this child. I've heard things about Romanian gypsy families, that they marry their child while they are still children. Some private ceremony, unsanctioned by the state or by law, yet occurs without much fuss because to do otherwise might lead to accusations of racism**.

So now I'm angry again - I'm angry that a fifteen year old girl has been raped at least three times presumably with her family's consent. I'm angry because it would seem that nothing is being done about it and I'm angry that this isn't an isolated incident.

I think that this delayed anger is the more positive sort.

*I can make these jokes, I spent my childhood growing up in Essex. The fecundity of the women of Essex is the reason why I was a virgin until I left the area.

**Yes, I know it's the Daily Hate Mail, but it seems like reasonably factual reporting.

First off, thanks to everyone who left a comment in the last post - at some point once I've had some sleep I'll be looking at al of them.

Many, many moons ago when I was a lot more enthusiastic for the job that I do I wrote a post called 'What's in your pockets' - in it I detailed the things that I carried around with me. I thought that, with four more years of experience it might be interesting to see how things have changed.

Shirt Pocket - Right - Personal phone No1, 3G USB modem, Optrex eyedrops (to keep my eyes working on nightshifts).

Shirt Pocket - Left - Pen, pair of scissors, pentorch that is bright enough to sear flesh, lighter (I don't smoke, but you never know when you need to set something on fire)

Upper Right Trouser Pocket - Car keys, door keys, Swiss army knife, Wallet.

Upper Left Trouser Pocket - iPhone, cloth for cleaning glasses.

Lower Right Trouser Pocket - Gloves, bandage dressing, torch bright enough to burn skin and to play the 'Go towards the light, all your loved ones are waiting for you...' game with sleeping drunks.

Lower Left Trouser Pocket - Normally nothing, occasionally my stethoscope.

Everywhere else - Nothing, I don't put anything in my back pockets and as I don't wear my stab vest (except when it's very cold) there is nothing there either. I no longer have anything hanging from my belt as it would only dig into my overflowing gut.

Amongst the other things that missing which I used to carry are my service provided emergency phone (I used it once, it'd would have been quicker to dial 999 on my own phone), the drug cheat sheet (I rarely need to give drugs as I rarely go to anyone who needs them, for those patients who do need drugs I've memorised the information).
I no longer have a security card for the Royal London hospital, as it was stolen along with my car and has never been replaced (despite my hassling people), I don't need a key to the oxygen cylinders because they have changed the tops of them to be openable by hand (a change for the better).
I don't need a Pocket PC as I have an iPhone and in my personal bag I have a netbook computer (which is what the 3G modem is for should I ever get the chance to use it) it is also for this reason I no longer have a paper diary. And I no longer carry mints because I rarely eat a kebab any more.
I also don't carry as many gloves because I seldom wear them, I can often get through a whole shift without needing to touch a patient any further than I need to to take a pulse.

So I've slimmed down the stuff that I carry by quite a bit, although I seem to have picked up another phone somehow...

So, your turn now - tell me what is in your pockets when you go to work.