Continued from yesterday's post

All I can see is the back of her head, some blood and the shattered windscreen. All I can feel is her head, neck and shoulders and yet something tells me that she is slipping into unconsciousness.

Cramped up in the back of the low roof van a firefighter appears beside me, he's trying to remove the metal plate that separates the two sections of the van and I have to wriggle to the side to let him see how securely it is fixed. He tells me it's going to take some time before the roof can come off.

I shout through to the FRU and ask him if my patient is still conscious.

"It don't look it", comes back the reply, he's busy getting some venous access while stretched across the passenger seat.

This means it's decision time - do we wait until the roof is cut off in order to fully protect the neck and spine, or do we just manhandle her out as smoothly as possible because of the real risk of her losing her airway and choking to death. Also, if there is a serious head injury then they may need their skull drilled and waiting for the roof to come off may take longer than this patient has.

It's all about potentials - potential neck injury (that if we aggravate could stop her breathing) versus a potential airway problem versus the potential need to be in hospital for neurosurgery before her brain squeezes, like toothpaste from a tube, out the bottom of her skull.

Then that familiar flash of imagination - me standing before the Coroner, explaining my actions and my reasoning.

"Sod it!", I say to the FRU, "We need to get her out now, we can't wait for the roof".

The spinal board is squeezed under her buttocks, then as carefully as possible we rotate her out and lay her flat on the board and then onto the trolley-bed. Securing her we move her to the ambulance.

She's now deeply unconscious.

Cutting off her clothes we make a quick check of the basics - the airway is still open, so we can manage that using the tools we have on the ambulance, she's still breathing - which is always handy, the slightly worrying thing is that her pulse is starting to drop although the blood pressure is remaining stable. A dropping pulse can mean a serious head injury.

The next question leaps to my mind, do we wait for the HEMS doctors to turn up, or do we make a run for the hospital.

"HEMS are eight or nine minutes away", my crewmate tells me, radio mike in hand. It would seem that she is reading my mind.

"OK, we'll go", I say, I know my mates driving - in nine minutes we'll be at the hospital. I go to secure the back doors of the ambulance and see the HEMS car pull up.

Stay and play a bit then.

The doctor jumps on board - as always polite and professional and starts to assess the patient. The doctor thinks that they should sedate the patient and intubate in order to protect the airway and I don't disagree - she'd need to be intubated before surgery anyway and this way the airway is definitely secure for the transport to hospital.

As they always do, they take the patient off the back of the ambulance so that they have more room. I know it's not the same thing but I feel pride for my crewmate who manages to intubate both in the back of the vehicle and when the patient is stuck under a wardrobe.

The doctor first wants to wrap the patient in bubble wrap to keep them warm - I bite my tongue at the thought that the back of my ambulance is perfectly warm, and besides what happened to therapeutic hypothermia? But HEMS are fully informed on the latest trauma research so I am more than happy to let them do what they want. The responsibility isn't on me anymore, it's on the HEMS doctor and I'm sure that they have also got the same 'Coroner's court' vision in the back of their mind that I have.

But I really should ask them about it the next chance I get.

Just as the doctor is about to intubate the patient she starts to come around. Suddenly she is no longer unconscious, but awake, alert and orientated.

That's good, but again, this can be the sign of a serious head injury.

"OK", says the doctor, "let's go without sedating them".

We load the patient back up onto my ambulance, change over the monitoring machinery (for the third time) and make our run to the hospital, the doctor in the back of the truck making notes while I make sure that our patient doesn't move around too much on the trolley-bed. Our patient's consciousness drops and rises during the trip.

The trip takes eight minutes - I swear that my crewmate channels Stirling Moss and I trust her driving completely (except for her reversing, but that's another matter).

Into the resuscitation room and the HEMS doctor hands over to the staff there, our patient is awake again and so the hospital doctors can get a better history from the patient. I go out to the ambulance and start the long process of documenting everything while my crewmate cleans up the back.

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There is no closure to this story.

I'd love to be able to tell you how the patient got on but I never knew her name, so I can't ask the reception staff to pull their A&E notes so I can have a look at what the CT scan showed. I don't see HEMS often enough to ask them about the progress of our patient, when I next see them they will have seen countless other seriously ill patients. The police probably won't ask me for a statement on the accident in question. I'll likely never know if my decision to move the patient before the roof was off was the right one, or if I did more harm to them. I'll not get a thank you letter and I don't expect one. The only way I think I'll know about my patient is if they die and it goes to the Coroner's court.

In which case I'm happy to remain ignorant.

So I'll probably never know what happened to my patient and that is the usual course of events. Just clean the ambulance and move to the next person.

I'm woken up by the phone ringing, we'd returned to station at four in the morning and had been put on a break, we had wasted no time in get our head down for some well needed sleep. So far it had been a busy nightshift.

"Morning!", came the cheery voice of Control down the phone, "We have a car vs. car RTA for you".

Barely functioning, let alone awake, we headed to the ambulance and started the engine - thankfully the call wasn't far away. Often with RTAs you can guess what type of call they will be depending on what road they occur. Small roads tend to be more bumps than crashes while there are a few roads on our patch which are notorious for having horrendous smashes (markedly lessened by the introduction of speed cameras it has to be said).

The road we were going to was a sliproad off of a dual carriageway - there was a high probability that this was a high speed collision.

Reaching the scene we saw that the accident had been caused by a low roof van driving into the back of a car, pushing it halfway across the junction. Two FRU's were on scene.

While my crewmate parked up in a way to protect the area we were working on, I jumped out to find out from the FRUs what was going on.

"This one's all right, just a bit shaken up", shouted one FRU, the other looked a bit more worried so I went around to him.

Even half asleep I could see that this was going to be a serious call.

Dear reader, I would like you to consider exactly how tough windscreen glass is - it's actually a fairly strong thing and it's for this reason there are special tools used for breaking them. This is why sensible people wear seatbelts. Even when people wear these we come across people who have cracked the windscreen, 'bullseyed' it in our own particular jargon.

This person hadn't been wearing a seatbelt, she'd been going at a fair speed, then she'd come to a sudden stop. Well... her vehicle had come to a sudden stop, she'd kept going, smashing herself first into the steering wheel then into the windscreen.

There wasn't a crack in the windscreen, instead it had shattered, held together it had a huge bulge in it perfectly matching the shape of our patient's head.

So immediately I'm thinking neck injury and brain injury, let alone what it's done to her face.

"She's admitted not wearing a seatbelt", the FRU told me as he finished putting a neck collar on her.

So if the patient is talking her airway is alright. That's one thing in her favour.

I jogged round to the back of the van and opened the door, thankfully the van was empty and I crawled in and took the patient's head in my hands. The FRU told me more about his initial assessment, but he'd only been here a little longer than us.

As I was holding the head I was free to do some thinking and start directing the people around me. I checked that the other emergency services had been called, the police to close off the road and the fire service to cut the top off the van so we could get the patient out safely. I got the FRU to do some more in depth assessment and set up monitoring - he'd do it anyway, but I'm a bossy swine sometimes. My crewmate was calling for the doctors on HEMS as I thought that we could do with a hand from them.

The patient was still alert and orientated, but I was worried that this would change.

The fire service arrived and started the preparations to cutting the roof of the van, meanwhile the FRU kept telling me his findings while I was thinking of the next step.

I don't know what it was because I couldn't see my patient, all I could do was feel her neck - but something told me that she was starting to lose consciousness...

To be continued.

Often when there is a bit of news about an ambulance service in the news I'll try to expand on the reporting by suggesting ways in which a, perhaps short-sighted, bit of journalism is obscuring the probable truth.

I don't do this just to provide 'balance', in some idealistic 'everyone who has an opinion is equally important' fashion, but instead to give as much of a voice to a member of staff or Trust that can't necessarily be as blunt as I can.

This goes doubly so for some of the more lurid tabloid reporting.

However, in this particular case, I can't think of any reason why the person involved in this shouldn't be fired.

A 999 patient died after an ambulance driver diverted to the depot instead of going to hospital-because he had over-run his shift.

The driver complained to a colleague that he was 15 minutes past the end of his duty and wanted to clock off. He got out of the ambulance without even telling his replacement there was a cricically <sic> sick case being tended by another medic in the back.

The new driver sped on to hospital as quickly as he could - but the detour had added half a mile and four crucial minutes to the journey. The patient, who had suffered a stroke, deteriorated during the drive and died of a suspected heart attack soon after arriving at A&E.

While I doubt that the four extra minutes travel time contributed to the death of the patient (although that isn't a certainty) there is no way that this is acceptable behaviour. If this story is true (and while the News of the World isn't exactly a top quality paper, I doubt they'd make this story up) then the driver has no excuse for their actions.

It's part of our job to sometimes be off late, we try not to be but in some cases it's unavoidable. I've been late off work more times than I can count, in fact it's the norm that I'm at least five or ten minutes off late.

To impact patient care in such a fashion in order to get off on time is frankly criminal and the person involved should have the book thrown at them.

Seeing as I'm working nights this weekend and blogging will be light I thought I'd leave you with something to read while I'm either chasing drunks down the street or snoring in my bed.

In the first of, hopefully many, formats to download, The Friday Project have put my book up on Issuu - and it really does look lovely, and is best in fullscreen mode. The license that 'More Blood, More Sweat And Another Cup Of Tea' is published under lets you embed the book in your own blog, read it from any site, or download it to read on your own machine. Feel free to forward it to anyone who might be interested.

I'd love to see it on as many blogs and sites as possible. The more eyes it gets in front of the better. You can download the .PDF from the Issuu website.

Next week I'll explain exactly why almost everything that I create is licensed under a Creative Commons License, and by then I can probably get back to writing about ambulances rather than pimping my book.

< Once the plain text version is ready we'll see about getting it into as many formats as possible.

Because I'm spending most of today running around like a runny-around thing, I'm going to cheat and show you a rather splendid film on EMS called 'Level Zero'. It's about twenty minutes long and I hope you enjoy it.

LEVEL ZERO - The Movie from Thaddeus Setla on Vimeo.

You can find out more about it here.

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You can also hear me try to make some sort of sense on the EMS Garage podcast. I say 'try and make sense' because it is recorded at around 3am my time, so I'm not at my best you understand. I've just taken part on another one that should be posted fairly soon. Which is why I'm posting this at 4:45 am.

The sun is coming up, that means I need to go to bed...

I thought I would wait until I saw what was in the public domain before commenting on this story, some friends of mine had attended this call and had told me about it.

A police patrol car which hit and killed a teenager in east London while answering a 999 call had not been sounding its siren, police said.

Khaleel Rehman, 16, from East Ham, was knocked off his bicycle on a pedestrian crossing in Ron Leighton Way, East Ham, in the early hours of Saturday.

|t is a terrible, tragic, incident and my sympathies go out to all those involved. Whatever I write here is not designed to deflect or apportion blame to anyone involved, but just to provide some information that the media might not be aware of.

The main concern is that sirens were not being used by the police car. According to earlier BBC reports the accident occurred around half past midnight. At these times of the night we do not routinely use sirens - in most cases the blue lights of a vehicle are easier to see than trying to place where the sound of a siren comes from. We are also aware that people are trying to sleep - and so running around with sirens blaring at all times of the night would result in a large number of complaints to the emergency services.

Imagine also if you live near an ambulance station, or one of the popular junctions.

The choice is simple - do you run the sirens all the time in the unproved theory that it will stop an accident, or do you let the driver use their judgement as to when they are needed?

When I'm driving around at night I often see bicycle riders, and it seems that for many of them the standard dress, as it were, is that of dark clothes and no lights or reflectors on their bike. On more than one occasion I have had the urge to pull up alongside such a cyclist and remind them that what they are doing is likely to have them end up in the back of my ambulance.

Obviously I don't know if Mr Rahman had a light and reflectors, that will be something for the IPCC to investigate.

I'd would also like to point out how surprised the police are when they hear how little blue-light driving training us ambulance people receive, I believe that the police training is both longer and much stricter than ours.

I suspect that the IPCC investigation will take some time although police cars have comprehensive 'black box' recorders, so the facts should be simple to find out. If the driver was driving dangerously, then I would hope that they suffer the same sanctions as any member the public. If they are found not responsible for the accident then I hope that they can put these terrible events behind them.

I suspect that the media would only report on one of those two outcomes.

So, as well as having book two released, book one has been given a fresh cover. The blue cover is my original, first book, and has nothing new in it - if you have the black and yellow cover book then you don't need to buy the blue cover.

The new book is a bit bigger and has the red cover, and of course a different name, but it's similar enough that people might make a mistake and pick up the wrong book.

Here they both are so you can compare them.

So - original book on the left, new book on the right. I just want people to know so that they don't get the wrong one by mistake.

So, my second book is out in the shops. Amazon have also been delivering their copies (and it's now back in stock in their store). Over the weekend I've been getting messages through my twitter account and the odd email.

I've even noticed one of the better MPs ordering a copy. Hopefully, once he's finished with it he'll pass it to Phil Hope, the minister for Social Care as Phil's predecessor Ivan Lewis didn't think that ambulances had anything to do with social care.

I'm actually yet to see a copy myself - there is one sitting at my local post office that I shall pop down and get once I've finished posting this.

What I would like to do is ask a favour.

I have a tiny ego, it sits somewhere just above my spleen and is a fragile and dirty little thing - it seldom gets any chance to be polished.

What I ask is that if you read/buy/see my book I'd be very interested in hearing your thoughts on it (even if you think it's bad). Some of the ways you can let me know about your thoughts on the book are this.

• Twitter - You can either Direct Message or '@Reynolds' me.

• Blogs - If you can stick a review up on your own blog I'd be extremely grateful - I have a Google alert for the book title, but if you'd like to leave a link to your post in one of my comments you can be sure that I don't miss it.

• Flickr - I'd love to see what shops my book gets to. I'd like to see where it ends up, especially people who are saving it to read while on holiday - if you tag your photos 'BST2' I'll be able to find them.

• Email - My normal email that hides behind the spam shield of 'How to contact me' on the sidebar on the right.

• Delicious - Again, if you use the tag 'BST2' I'll be able to find it.

• Amazon - If you would be so kind, I'd love you to leave a review on the Amazon page. I think it'll help me sell more books, which will make my publishers (and me) happy.

UPDATE: A quick warning - the first book has a new, blue, cover - the new one is a bit bigger and has a red cover, I'd hate it if someone bought the wrong one by mistake.

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The free, complete and fully open for remixes downloadable edition will be along soon. The reason for the short delay is that Harper are making sure that it really shines - from what I hear it sounds like it's going to be something lovely. As soon as I know something I'll pop it up here. Remember that the original can be found here at archive.org.

More on that when it appears.