One of the jobs that we do from our station is inter-hospital transfers, this isn't unusual - most ambulance stations have to do their fair share of them. What is unusual for us (and our sister station) is that we have one of the shortest transfers possible.

The map you can see is our local hospital, at one end of the red line I have expertly drawn is the entrance to the A&E department, at the other end is the 'Gateway surgical centre' (GSC) [PDF]. The GSC is where the planned surgical day and short stay cases are handled.

It is apparently a very green building.

That red line, the length of our transport is 400 metres. I measured it.

When a patient suffers a set-back from their planned surgery - for example they get an infection or they start to suffer angina pain they need to go to the 'big' hospital.

And that is when we get called.

The GSC calls 999 and asks for an ambulance to take their patient to the 'proper' hospital.

All of which is dependant on there actually being an ambulance available - which there isn't always. If we are busy then they have to wait, but if they tell us the patient has difficulty in breathing or chest pain then they get a 'cat A' response.

If there is a shortage of ambulances then little old Doris having a heart attack will not have an ambulance because we are moving a patient 400 metres down the road.

You would have thought that, while they were planning the WiFi, the rain water collection and the heat recovery, they may have given a though as to how to move a patient 400 metres without the need for a frontline emergency ambulance.

I mention this because of a recent job I had transferring someone from the GSC to the A&E department, and the attitude that met me when we arrived.

We'd been called to a member of staff who had been taken unwell, so we dutifully blue lighted the 400 metres to go and pick them up. We pulled our stretcher up to the ward where the patient was, rung the bell to be allowed access onto the ward and waited for the door to be answered.

When it was finally answered* by a nurse I wasn't met with a 'hello', or a 'welcome'.

No, what the nurse said to me was, "Oh, it's you - you took your time".

I looked at my crewmate - did I really hear that correctly? Was a supposed professional being dismissive towards me?

'Did I hear that right?', I asked my crewmate. She nodded yes while picking her jaw up off the floor.

Well, I had to challenge that statement - we'd only got the job three minutes earlier, so Control must have been holding the call for people who were ill, but not within an actual hospital.

The nurse wasn't interested in talking to me. So I did what I do when I get annoyed at nursing homes. I become Extremely Competent And Professional.

So I tried to get a history, none of the staff there seemed to know what had happened. I asked what the patient's observations were - all I got was 'they are all right'. When the staff suggested that I couldn't be trusted to handover to A&E that the patient had been given a painkiller I mentioned that, unlike them, I'm allowed to give drugs without a doctor's say so.

I just kept asking them reasonable questions that they couldn't answer to let them know that I knew what I was doing, even if they didn't.

(At least they had done a blood sugar measurement - they told me that three times. It was one of the few things they did tell me about).

In part I suspect that it is because they haven't the faintest idea what we do, in part it's because they don't often deal with ambulance crews, in part it's because they don't deal with 'emergency' situations and in part I think there is an element of looking down their nose at us.

After all, we are just there to transport a patient for them, it's not like we know how to look after people.

The thing is, "Oh, it's you - you took your time", is something that I would be surprised to hear coming from a member of the public, but to hear that from a nurse - who we are here to help just pushes my buttons.

It was quite amusing to see the expression on the A&E nurse's face when I handed the patient over to them and told them what had been going on.

-----

*In the past I've resorted to going through the hospital switchboard in order to phone the ward and let them know we have arrived in many of the hospitals I frequent

-----

I'm not dead, nor giving up blogging - I've just had a fair bit going on in my life at the moment, hopefully things will have settled down for a bit.

Thanks for all the comments on my last post - all very helpful. Although it seems a bit off that I have to rely on a personal blog to get feedback on a clinical issue, but that's a tale for another day...

Due to me avoiding a et of nightshifts by burning some of my annual leave, I have around two weeks off work. As this is so close to my other holiday I'm running a little short on 'tales from the ambulance', and so I'm afraid that for the next couple of days I'm going to write about whatever interests me.

I apologise in advance - but I'm not just an 'ambulance driver' you know...

-----

I was having a little to and fro with @Charlesarthur yesterday on twitter; I was bemoaning the difficulty in buying ebooks (after struggling with the rather poor showing of such sites in the UK and then cursing the inability to 'import' ebooks from the US), he on the other hand was suggesting that the format isn't proven yet - much like betamax, minitape and eight tracks.

The discussion started when I started whinging that there isn't a simple 'iTunes' like store for ebooks that might help wipe out regionalisation, encourage reading and drive down the prices of ebooks while also making impulse purchasing more likely. Most of this was prompted by the headache of usability and stability that is the Waterstones ebook site.

[The price of ebooks are often the same as the same title in hardback. This strikes me as incredibly dumb as the cost to 'make' each unit of book is practically zero (that's price per unit, not overall price as you need to take into account copyediting, advances, promotion and the like). Additionally the purchaser cannot do as much with an ebook as they can with a physical product - due to DRM the customer can't lend it, nor sell it on. So why so expensive?]

The price issue is one reason why the Friday project cut the price of many of their ebooks to less than a pint of beer. Well worth a test purchase to see if you like the idea of ebooks. For example you might like 'In Stitches' or the really rather good 'The Equivoque Principle'. [disclaimer - The Friday Project are my publishers].

But this discussion was a really good one, I learnt a few things and then, by talking with someone smarter than me, it led me to a flash of insight...

-----

Digital media has come after pretty much all the recent innovations in other media formats. Before MP3 there were CDs, still the standard for music distribution. Before .avi/DIVX/.M4v DVDs were the standard for movie distribution (I'm ignoring bluray as it's not taken off massively at the moment). Books have pretty much always been text on paper from before computers were a glint in Mr Babbage's eye.

Now, the important thing about the video and music formats is that when you move to digital you can bring your 'old' media with you. You can rip your CDs into a digital format that your computer and iPod can play. It took a bit of time but all my CDs are boxed away in my loft and now reside on one of my network hard drives. DVDs are much the same, it is easy to convert them from a physical disk into a digital file that you can play on your computer, laptop or mobile phone.

If I had the inclination I could convert all them into a digital format.

Both of these shifts in format from physical to digital are trivial to perform (even if it is illegal under British copyright law). You put a disc into your computer, click an import button on a computer programme and -pop- your media is now digital, portable and able to be backed up.

Books however are different.

To convert a book to a digital format there are two ways to go about it - You can sit at a keyboard and type it all in, or you can destroy the book by feeding it sheet by sheet through a scanner, then run OCR software that will do it's best to convert it into a text file, then you copyedit it for the errors put in by the OCR software. Both of these approaches need you to physically be at a machine working on converting the book into digital. You can't press a few buttons and leave it running overnight.

So, the problem with ebooks as a format is that you can't bring along your old media. I have shelves of books, my loft is full of books - I have more physical books in my possession than at any other time in my life. I'd love to be able to convert them to a digital format, but it's just not realistically possible.

Instead, my only realistic and legal, option would be to purchase them again - which, for a few books, I'd be willing to do. But not all of those books are available in the UK in an ebook format, and those that are cost the same as a hardback.

Part of what let the iPod and other digital music players take off was the ability to play your old media, unlike the move from vinyl to CD there was no need to re-purchase your media. Do you think that iPods would be as popular if in order to use them you had to buy all your music yet again? And most of it wasn't available?

If there is anything that is going to hamper the ebook market from growing it is this lack of portability from your old format to a new one.

-----

The solution to promote ebooks and prevent people from visiting torrent sites is quite simple.

When you buy a physical book from Waterstones (who are the big player in the UK ebook market) they give you a coupon or code which allows you to download that book for free, or at a greatly reduced cost, onto your reader. While it is true that some people will then give away the book, I would suggest that not many books are only ever read by one person in their lifetime anyway. And wouldn't you rather have customers coming to your e-store and then coming back for return business rather than visit the torrent sites for illegal copies of your book?

The alternative is to treat ebooks like a poor relation of physical product and then get stuffed when Amazon release the Kindle in the UK and Amazon starts offering a lot more stock for less money.

"The Kindle edition of Dan Brown’s The Lost Symbol, his follow-up to 2003’s smash hit The Da Vinci Code, has become the top-selling item on Amazon.com. The e-reader edition is outselling the hardback copy of the novel, which had previously become the sixth best selling book of 2009 on pre-publication orders alone.

Commentators are wondering whether the book is heralding a new era in publishing. While Amazon is offering almost 50 per cent off the hardback copies, $16.17 instead of $29.99, the Kindle edition is available at just $9.99 – and there is no wait for delivery."

This is, in part, me telling a story and in part me asking for feedback.

We were away from our usual area when the job came down, by some luck we were on the corner of the road that the call was from, "GP surgery - three month old baby - dehydration". We were so close to the job we reached the surgery before they had finished making the call.

Into the surgery we walked and one of the receptionists led us through to the room where the patient and her parents were.

As I walked into the consulting room my heart skipped a beat and my stomach turned over - this child was incredibly ill.

She was so ill I had to carefully check that she was still breathing.

My crewmate got the child out to the ambulance (where most of our equipment is) while I listened to the GP as he gave me a history of the child. Small for her age she had been vomiting for a few days, now she was severely dehydrated. This is why she looked like one of the babies they show on the news when there is a drought or famine in another part of the world.

I actually jogged back to the ambulance - this was a child that needed to be in hospital as quickly as possible.

A 'capillary refill time' is a good measure of how poorly a child is, you press on the nailbed of the child's finger and see how long it takes the blood to flow back. In a healthy child this is less than two seconds. In this child it took five seconds for the colour to run back to her finger. Her fontanelles were sunken and she was not responding as a child her age should.

We thought about starting treatment on the child immediately, but as the hospital was six minutes away we instead decided to make a run for it.

It's not often I blue light someone into hospital with sweaty palms, but this was one of those occasions. I had a very real fear that this child was going to die in the back of the ambulance.

Straight into resus went the child, to be surrounded by doctors and nurses who could start treating her.

-----

About twenty minutes later we'd finished up our paperwork and my crewmate went back into the resus room. We thought that they would have started treatment, but it would seem that they hadn't even managed to start rehydrating her.

I checked with one of the top paediatric nurses at our regular hospital - she agrees that the child was incredibly sick and needed access for re-hydration immediately.

-----

There is a problem working for the LAS, something that I'm going to elaborate on in a short while, and that is that there is little further training and no clinical feedback on the jobs that we do*. As this was a 'strange' hospital, I don't have an easy way to find out the outcome of this job, or if what we did as an ambulance crew was the right course of treatment.

There are two ways that we could deal with this child - we pick her up and the only medicine we use is diesel. Which means that I drive her quickly to where the experts are - the doctors, nurses and other clinicans at the hospital. In this case this is what we did.

The second option is that we spend a little long out on the street. We could have tried to get some fluids into the child immediately. Why we didn't do this was due, in part to our lack of experience.

There are two ways we could have got fluids into her - the first was to place an IV line into a vein - this is incredibly tricky with a small child at the best of times, let alone one that was so dehydrated as her veins would have been collapsing.

The other way would be via an IO needle. This is a large metal needle that you punch through the skin and into the bone marrow of the shin. The needle is then left sticking perpendicular to the surface of the skin and secured in place. (You can take a look here for some images )

The problem with this is two-fold. Firstly you are stabbing a tiny baby in the bone. I make no qualms about this, but it's something that fills me with no small amount of fear.

But what causes this fear? Quite simply this is the second problem - In over ten years of emergency medicine I have seen this procedure carried out twice. Once when I was an A&E nurse and once as an ambulance worker. In this country at least it is a very rare procedure. My crewmate (who would have to actually do this as she is the paramedic) has never seen one done before outside of the classroom that she sat in about six years ago. Due to this lack of experience and training we don't have the confidence to perform this sort of intervention.

So we had to balance it out as to what to do - are we going to do something that we are barely trained for and have no experience of, or do we 'scoop and run' thinking that the hospital would do it straight away?

Of course, we had hoped that the hospital would have gained that blood system access straight away, so when they didn't it had both me and my crewmate wondering if we had done the right thing. If we'd put that needle in on the side of the road, would the child now be getting the fluids it desperately needed?

So I'd like to ask those of you who have experience of such things - what would you have done? Would you have done as we did, no treatment and a six minute journey to hospital, or would you have 'stayed and played' on scene for maybe twenty minutes doing something that you don't feel trained for?

I don't feel ashamed to say that it has given me a crisis of self reflection, and of confidence.

-----

Sometime in the next two weeks I'm going to highlight the problems with training in the LAS - then offer a solution, so this post isn't really about our training. You will have plenty of chances to comment on that when I do those posts...

Oh, and big kudos to Kal, for the taste of victory.

-----

*Not strictly true - there is always the coroner's court.

Demonstrations are expected as one of the world's largest arms fairs opens in London's Docklands later.

The biennial Defence Systems and Equipment International is due to take place amid tight security.

Activists from a separate group, Disarm DSEI, will hold another protest and warn they will target the banks and firms which invest in the industry. The group also says it will not co-operate with police ahead of its demonstration.

Yep.

My patch.

Loads of people, some of them perhaps reasonably annoyed.

Quite a few police, some bodyguards.

If the police do some kettling there could be a fair few collapses/illnesses/injuries.*

So you would think that we in the LAS would have some sort of plan, something that those of us working in the area would be privy to.

I've not seen a single memo, bulletin, policy or plan concerning this.

However in the latest bulletin I have learnt that the 'Equality and Diversity' department is changing it's name to 'Equality and Inclusion' (something to do with the future).

Oh well, it'll be interesting seeing how the next few days play out.

-----

I'm not saying that there isn't a plan, just that I'm completely unaware of it - and the officer I spoke to yesterday was also unaware of any plan.

*Stationary kettling is, in my opinion, a bloody stupid idea and probably against the law.

We are called to an eighty year old collapse with a cut hand, and arriving find him and his wife in the kitchen.

What we originally thought was going to be a collapse followed by a cut hand turns out to be the other way around.

He cut his hand, saw the blood and fainted.

He doesn't like blood. Or needles.

His wife is diabetic, when she injects herself he has to look away.

The cut is rather small, I teach my crewmate about the thenar eminence while she dresses it.

The patient doesn't want to go to hospital, and the cut is of the type that one of our ECPs can deal with. We will do a full assessment on our patient and leave him at home to await the ECP.

Everything is going fine, we are having a chat about children.

He seems quite calm.

Then he stiffens, vomits and stares straight ahead.

He doesn't answer to my calling his name.

He starts to sweat profusely.

I scrabble to feel a pulse, can't feel one.

No pulse.

Then it's back - thudding slowly away. He looks at us quizzically.

'Did I faint again?'

I take my own pulse.

He's a nice man. His wife is nice. I had visions of CPR on the tiny kitchen floor.

My crewmate says it, 'You are coming to hospital'

-----

I'm sure you'd like to join me in wishing Jess Smith good luck as she heads of to Afghanistan.

-----

More news on the FRU that was shot at which I mentioned in a previous post....

A London ambulance worker today described the moment she was shot twice after treating a patient.

Emergency medical technician Suzanne O'Rourke, 40, pictured left, had been responding to a call. She was saved from serious injury because one shot was stopped by her stab-proof vest and the other grazed her shoulder.

Ambulance bosses voiced their anger at the attack and highlighted the dangers faced by their staff.

Mrs O'Rourke said she was attacked as she walked back to her fast-response car after treating a patient in King's Close, Leyton, at 3.30am on 23 August. “I was on my own when I heard a bang and something hit me on my back. I must have turned around to see where it was coming from when something hit me on the shoulder as well. It hurt a lot.

These shots were fired by someone who might need us one day. I'm actually speechless about this, not from fear, but from anger and disappointment.

'Cardiac Arrest - Mental Health Unit'

My regular crewmate was sunning herself in France and I had someone working with me who'd only been out of training school for her first practical experience for the last two weeks. I'd already done one job with her and she seemed totally sensible.

"We'd better take all the kit in", I told her while buckling my seatbelt, "this could be anything from a cardiac arrest to a blocked nose".

It is somewhat telling that when we get sent to a mental health unit, no matter what they have called us for, we never quite know what to expect. It's one thing to accept that a member of the public can't tell 'chest pain' from 'bellyache', it's quite another to have such mix-ups from a healthcare professional.

We arrived at the unit to discover an ambulance already there - it would seem that we were being sent as a second pair of hands. Sure that the first crew would have all their kit we still took ours in, you can never be too careful.

The door to the unit was locked, so I leant on the buzzer and one of the nurses came towards the door with the normal foot-dragging shuffle that I see a lot in these sorts of unit. She opened the door and stood there with her mouth open.

"Cardiac arrest?", I asked striding past her.

"In", was all she said.

I kept walking, obviously the patient was 'in' the unit, but where?

As we reached the end of the corridor I saw a group of people, all wearing unit ID badges standing around with their arms crossed watching two of my fellow ambulance staff working the resus. I relaxed somewhat when I saw who it was, the crew who were already there are one of the good ones ('I'd trust them to treat my mother' as we say in the service). The medic was passing a breathing tube while the other was doing CPR.

So, my crewmate and I bundled in and gave our assistance, it was a fairly straightforward resuscitation to be honest, CPR, breathing tube, IV access, drugs, more CPR.

What annoyed me was that the 'crash team'* from this unit were standing around watching us work - no offers to help, no-one suggesting that they get IV access, no-one offering to take over the CPR from EMT who started some minutes ago**

No help, no talking - just standing there watching. Doctors and nurses seemingly not knowing what to do at a cardiac arrest, yet still on the 'crash team', watching four stretcher-monkeys getting on with it, making the decisions, performing the interventions. We are lower status, are on lower pay, and yet we were the ones having to take charge.

I wondered what they were doing while they were waiting for the ambulance to arrive.

We took the patient to hospital, where they sadly died.

I mention this, not to celebrate ambulance crews, but more to show my concern that the hospital unit staff seemed so aimless. The scary thing is that this sort of occurrence doesn't seem all that unusual. At least where I work.

-----

*A Crash team is a group of doctors and nurses that come running in the event of a cardiac arrest

**I understand that the latest guidelines, in America at least, is that you swap whoever is doing CPR every two minutes because it's too tiring.

A round up of recent media stories about ambulances and the talk of the ambulance loading bay at the hospital the other night.

Dozens of patients were removed from hospital wards after two ambulances caught fire and exploded.

I'm glad there were only minor injuries.

-----

Bottle thrown at ambulance on emergency call

“We were on blue lights on the way to a call and we heard an explosion. The next thing we were covered in glass – it was everywhere”

Ambulance bicycles stolen in the City

The London Ambulance Service is appealing for the return of two cycle response pushbikes after they were stolen from outside the home of a patient in Finsbury. The custom-built Specialized Rockhopper mountain bikes were taken yesterday evening (Wednesday) from Joseph Trotter Close, EC1, after staff had been called to attend a man who was unwell.

Which sort of sums up how some 'members of the community' treat ambulance services.

-----

Woman Dies In Pub After Paramedic 'Delay'

Then there is this, which is very sad - but I know that there are certain pubs in my area that I hate going into because, well, people get killed in them. Once more it's a case of 'blame the person who wants to survive their shift'. And once more, as usual, the blame is being put on 'health and safety' - at which point I'd like to tell those commenters that if they would like to live without health and safety legislation I'll be seeing them later in the back of my ambulance.

This sort of story is happening more and more - I really should just do one blog-post that I can refer to when another similar story happens.

Incidentally, can someone explain the laws of grammar that have newspapers 'quoting' their own stories? I always read it as indicating sarcasm.

-----

The current gossip outside the A&E department the other night was how there is a local estate where someone seems to have taken a shine to shooting at ambulance crews with an air pistol. Apparently the official advice is that if you get a call there the crew should wear their stab vest and safety helmet.

This is the sort of 'welcome' that we are dealing with.