The two women sit in the pub drinking heavily. One of them puts down the phone having called for her husband to come and walk her home.

She turns to the other woman and says, "I've going to have a laugh on the way home".

"How's that", the other replies.

"Well, I'm going to get halfway home and then 'discover' that I can't walk. So I'm going to throw myself on the floor and roll around like a two-year old having a temper tantrum".

"Won't that get you dirty?", the other woman says.

"Well, yeah, but that doesn't matter. I'm then going to wail at the top of my lungs - I won't be talking, just grunting groaning and making a noise."

"Sounds like fun", says her friend.

"That's not the best bit, because then someone is going to call for an ambulance, but not until after I've dug my fingernails into some good Samaritans who got too close".

"Oh, you are so funny".

"Then when the ambulance people turn up I'm going to keep doing this, then when they pick me up I'll try to pinch them and then yank the hand of one of them so hard that, even in a few days time, he'll have a painful wrist. Actually, he'll even find it painful to type all the way into Tuesday."

Taking a gulp of her Bacardi and Coke the other woman asks, "But why will he be picking you up?".

'Well, he'll be thinking that drunks don't normally act like this, so he'll be thinking that I might have had a fit (although no one will have witnessed it), or that I'm having a brain haemorrhage. I'll make sure that I'll get an ambulance man who tells any students he meets that 'alcohol doesn't protect you against other serious conditions'".

"Very wise", the other woman says, "Getting a sucker like that".

"It gets better - when I get into the ambulance I'll start kicking the trolley in an attempt to break it, and sometimes I'll take a kick at the ambulance man".

The other woman smiles, "Sounds like good times".

"That's what I thought - what'll make it more fun is that I'll be sure to time the doctor realising that I've just been drinking and kicking me out so that the ambulance man sees it all".

"Won't he be angry?"

"Yep - that's what makes it so much fun - because he can't say anything or I'll complain and he'l lose his job. And even better - he can't go off work sick to rest his wrist, because then he'll get disciplined for being sick".

"Sounds hilarious - time for another before you leave?".

-----

Yes. It did happen, although I doubt this was the conversation, it might have been the husband who commented on his wife's drunkenness and so she decided to prove that she wasn't 'drunk' she was 'ill'. That happens quite a bit as well.

All I know is that, as I was nursing my wrist with a makeshift icepack, there are some people who could probably benefit form having a good slapping.

But, of course, that would be wrong as she is a poor innocent flower, a victim of some terrible trauma. And I'm just the sucker that goes to look after them.

Still doesn't stop my wrist from hurting, while the only consequence she has to face is a hangover - and she call call an ambulance for that...

Sometimes the eyes are blue, sometimes brown, sometimes green. But almost always the eyes are reddened and damp with tears.

Sometimes they are male, sometimes female, sometimes old and sometimes a child. But they've always been hurt.

Sometimes it's bruises, sometimes it's cuts, sometimes a broken bone, sometimes something much worse.

Sometimes I talk to them, my crewmate hovering outside the door, police in the house talking on the radio.

Sometimes I'm the one standing in the doorway, teeth clenched and hands balled into fists as I listen to the tale being told.

The police collect statements, photograph injuries, protect evidence. They provide support and safety, they listen to the litany. I hear them on their radios, this is the third time they have been here, the fourth, the fifth.

Sometimes someone is led away in cuffs, sometimes the police have to hunt for them - but it's always someone my patient knows well.

'He didn't mean it', 'she was just angry', 'it was my fault'. The same excuses. The same 'I don't want him to get into any trouble', or a promise to make a complaint that is later withdrawn.

I don't see domestic violence that often, but when I do it sticks with me. I'm glad I don't see much of it.

The home should be a place of safety, not a place of fear.

I'm often sent to a patient who has 'collapsed', sometimes this is due to a genuine medical condition - something like a heart attack, a stroke or diabetic problems. Often this is due to alcohol - the location and calltaker details often gives it away - the patient is in the street and the person who phoned for the ambulance cannot give us any details because they 'don't want to go near the patient', that or they are phoning for us from a bus or car.

'Drive-by calls' are normally for drunks in the street. Often homeless drunks who speak very little English.

The final sort of 'collapse' that we are often sent on is the pseudo-collapse.

This is a person who has not actually collapsed per se, but instead is pretending to be unconscious. Sometimes they will also pretend to have a seizure. As AD calls them 'status dramaticus'.

Now, were I an educated man rather than a mere stretcher monkey, I'd look things up in my big book of mental illness and see if there is actually some proper illness that causes people to pretend to be unconscious. While I suspect that there are situations where a mental illness might show up like this, in most circumstances it's a case of 'bad, not mad'.

So, how can I tell if someone is pretending to be unconscious? The simplest is the eyes - if you are unconscious and someone goes to open your eyelids, they open. In the faker the eyelids stay shut. It requires a conscious effort to keep your eyes shut.

The other way is the 'hand drop'. Raise the patient's hand over their face and let it drop. With an unconscious person the hand will hit the face, for the faker they won't want to punch themselves in the face and so the hand drops to one side.

These two tests, and some vital signs are pretty conclusive as to telling the faker from the really unconscious.

-----

The trick then is what to do about it.

In my old age, my patience for such games has decreased, mostly because I don't want to be carrying someone downstairs who I don't need to - I'd reckon that my back has only a finite number of carry-downs, and wasting them on someone who does not require such service is just accelerating my early retirement through ill-health.

The relatives, for there are always relatives, will also need some serious explaining done to them in order to let them know that their beloved is playing a game. A not very convincing game at that.

And I can spend an hour explaining that their relative isn't actually sick, but as soon as they hit the hospital they will still demand that they be seen immediately as the poor little soul is obviously on death's door.

So, what I mainly do is talk to the patient, tell them that I'm much too wise to be fooled by them and that if they would kindly open their eyes and talk to me I can then fulfil their wishes by either taking them to hospital, or by leaving them at home.

Sometimes the patient will 'wake up', and either go to, or refuse, hospital. Often though the patient will steadfastly screw their eyes shut and continue their deception.

-----

When the person wants to continue playing this game they seem to forget that I have dealt with this situation before.

One of the ways in which we assess unconsciousness is via the 'Glasgow Coma Scale'. To properly complete this assessment the apparently unconscious patient has to have painful stimuli applied to them.

Painful stimuli by someone with knowledge of anatomy.

Just allow that thought to roll around in your head for a bit.

There are several approved manners to cause pain without causing damage - the pen on the nail bed, the pressure to the orbital bone, the jaw thrust. All of which are rather painful.

The one that is frowned upon these days is the 'sternal rub', probably because it is so effective at waking the dead. Just rubbing your knuckles on someone's sternal bone is enough to snap their eyes open and have them talking to you.

Of course, this is devalued, and I would never do such a thing. That is until, like much in medicine, it returns in vogue.

Note, this is never done to punish the patient, this is done so that we can truly assess the level of patient's consciousness.

-----

It annoys me that, when getting the patient out to the ambulance the 'persistently collapsed' will be picked up or dragged by their relatives - there is no need for it, and I keep telling the relatives that they shouldn't do it because (a) there is nothing wrong with the person, and (b) they are only putting themselves at risk of being hurt.

The reason I'm not carrying them is for much the same two reasons.

But still the relatives, while nodding and smiling and agreeing with me, will manhandle the patient down the stairs, out the door and into the ambulance when all the patient has to do is open their eyes and walk.

-----

So, what causes these people to fake a collapse?

Overwhelmingly it is due to either some bad news, or due to an argument within the family.

I'm somewhat more sympathetic to those people who have had bad news, it's the classic 'shock' - not in the medical sense, but in the sense that someone gets a bit shaken up by some news and wants to demonstrate how shocking the news is.

These folks will often 'wake up' with a bit of gentle prompting.

Those who pretend to collapse into unconsciousness due to an argument find themselves perhaps not receiving my full sympathy (for my sympathy is like water in a bucket, it is finite and when that bucket runs dry then I really could care less about your 'troubles').

Husband and wife, mother and daughter, father and son, cousins and boyfriends and girlfriends (and scarily sometimes a combination of these), it doesn't matter, one feels so aggrieved that they want to 'scare' the other person - and so collapses.

And then we are called.

Only recently I was called twice to the same house, and the same person, for this very reason. The patient ended up telling us to 'fuck off'. Which was unpleasant. Thankfully the family agreed that if the patient did it again they'd drag them off to hospital themselves.

-----

I don't know if there is a cultural element to this - I suspect that there is, but then most of my patient's are from the Indian subcontinent, so it is only reasonable that I would see more of these fake collapses in people originating from there.

So ambulance people in areas with different ethnic backgrounds have the same experiences, in the same numbers, that I do? Something for the researchers I think - although what to do if the actual answers are less than politically correct?

-----

All I know is that these sorts of jobs are a colossal waste of time - I'm sent on blue lights to these jobs (a driving risk to myself and other road users). Meanwhile people who genuinely need an ambulance go waiting.

There is sadly no answer - these calls can't be triaged out effectively over the telephone, so we have to continue going to them, and I doubt that 'patient education' will be much help either.

---

I've not been dead, I've just been without muse. To paraphrase Warren Ellis I went from being a writer to someone who watches television. (The linked video contains some naughty words, so probably NSFW). Although in my case replace 'television' with 'World of Warcraft'.

Hopefully, I'll be writing a fair bit more - as well as getting my teeth into my Secret Project™. Well, one of two secret projects really - but one of them at least won't be secret for much longer.

I shall also be removing the hitchhiking tool from the post-digested food outlet and will be trying to make some changes in my life for the better.

I've just spent longer than I'd like to think in deleting spam from this blog. While I do like the simplicity of the Blogware system, it isn't the world's best at filtering out spam. I wish there were a way of turning off the comments to an article automatically after a month or so.

As it is I've turned on moderation for comments that the Blogware system thinks is spam and decided to not allow HTML in comments any more. Sorry if this annoys you but I have better things to be doing with my time than clicking through and deleting spam.

-----

I've been utterly fed up for the past week or so - I shouldn't have, because I've been busy for much of my five days off work. I took my mum to see 'Priscilla - the musical' for her birthday, and it was superb. The day day we dragged her around London Zoo, which again was nice but spoiled by both her, and my, inability to walk around slowly for hours without getting crippling back pain.

Then I went to the Fymfyg bar to watch some comics and drink entirely too much as part of a friends 'stag do', then the day after that we went paintballing at the London paintball centre. All good fun and I do indeed have the bruises to show for it.

-----

So why so fed up? In part it was the Digital Economy Bill going through parliament, it wasn't just that it went through, it's the manner in which it went through. 6% of MPs sat and debated it, then, when the time for the votes came a load of unknowing members came shuffling in at their Whip's behest. I watched the debate and the complete lies that were bandied about had me grinding my teeth and having to resist the rather strong urge to but something heavy through my TV screen.

But I'll write more on this later...

-----

Essentially all I want to do of late is close my front door and ignore the world - which isn't that healthy I admit, but especially during a run up to the election I think it's a perfectly reasoned insane response.

-----

On to the questions that I got from you folks -

First up, the most common question.

How do I get a job working for the ambulance service, what is the best way to pass the interview and do you recommend it?

When it comes to recommending the job, it depends on what sort of person you are - if you like the idea of helping people, if you like the idea of working either on your own or as part of a two-person crew and if you aren't bothered by icky stuff and time-wasters then I might recommend it. Saying that, all ambulance services are going through a lot of changes, but then they always are, so be prepared to have the ways in which you work change under your feet.

As for how to join - well I wrote about it a bit here (and talked about the sorts of tests that I had to go through, including the interview) - however it keeps changing.

My suggestion is to talk to the ambulance trust that you want to join - they all have websites and their contact details are there. See if you can have a chat with someone already in the job where you work, for example - when London has new recruits they go onto what is called the 'B Relief rota', which is lots of nights and weekends - that might put you off.

Each service is different so you are better off talking to someone who has just been through it.

My personal views on the current ways of training people is that it is all either up in the air, or a bit poo. But I only get second hand reports - however the people that we do get tend to be fine people despite all that.

As for the different routes - if you can manage a degree level course then go for that, otherwise your chances of getting anywhere in this job will be pretty slim.

-----

I'm wondering whether to do St John training for voluntary ambulance work.

While I am contractually obliged to pour scorn on St John ambulance service by my fellow LAS staff, it's actually not a bad idea. Firstly they teach a fair few useful skills, you can get into gigs for free as long as you are working them...

As other commenters have mentioned it also helps you with your 'patient contact' skills, in other words how to calm someone who is scared or in pain - which is probably 90% of 'proper' ambulance work.

And if worse comes to worse you'll know CPR - and bystander CPR is a large part of what saves people. I know that one of my 'saves' was only because a St John fellow was doing excellent CPR.

So yes, while it may cause me some mockery - the Johnnies are alright.

-----

So, what brought you to the LAS and what is keeping you there?

What brought me to the LAS was that I was a nurse in an A&E department, and the fact that I was basically locked in a windowless building for twelve hours a day dealing with an endless rush of drunks while people dying of cancer were packed two to a bay without pillows to put their heads on because there were no beds in the hospital was driving me a little... actually, a lot, crazy. I realised that I needed fresh air and a bit of sunshine - so as I enjoy medicine it seemed like an obvious choice.

What is keeping me here? I have rent to pay and a lack of transferrable skills. Nursing and EMS is pretty much all I have, on paper at least, my computing skills have atrophied since we stopped needing people to program 6800 processors in assembly.

-----

Roughly how many 'managers' are there within the LAS between e.g. the Chief Executive and someone who works on the front line such as yourself?

I wish I knew - I suspect that this is a problem that would tax the finest minds. Certainly I've never seen an organisational chart - I don't think one exists. There are at least three levels between me and the CEO - Station Level, Complex Level, Sector Level and then Overall management. And that doesn't include the non-executive people.

While I joke that there is a 'Director in charge of blankets, an assistant director in charge of blankets, two staff officers an assistant staff officer and a handful of civilian staff' (and we still run out of blankets) I suspect I'm not far from the truth....

I know that we have a director of handwashing - he used to be my AOM.

-----

What do you plan on doing with yourself once you are too old to lift drunks off the pavement?

Kick them until they get up on their own?

More seriously there are people doing this job well into their sixties - I don't think I'll last that long to be honest. I have a feeling I'll be 'passed unfit' long before I hit sixty.

So, suicide or a return to nursing. Probably a return to nursing as I feel the need to start stretching my brain cells again - they tend to atrophy when a large part of what you are doing each day is ferrying healthy people to hospital.

Or maybe I'll get myself promoted to a nice desk job - 'Officer in charge of toilet paper' seems like a decent job.

-----

With flat cash funding in place for the coming 5 years, where do you see the service heading?

With an ever increasing call rate and a limit to the number of patients that we can refuse to send ambulances to I suspect that we will have a lot more solo responders going along to see if you really are in the 10% of our calls that really need an ambulance. I'm guessing that there won't be that much money spent on training staff on this new role, so expect to see a few 'Paramedic left my baby at home to die' type stories, a few sackings of road staff and a hiring of cheap recruits.

It's a plan I really need to expand upon. Remind me some day...

It's not looking good to be honest.

-----

Is Newham really as bad as you make out or are some bits a lot rougher than others.

The majority of Newham is fine - full of decent people trying to make their way in the world, unfortunately I tend to see the nastier sides of things, the assaults, the stabbings and the abuse.

Let me put it like this - I would happily walk around the streets of Newham at night without fear (In fact I do - night shifts tonight). I'd say that Romford was much nastier...

To be honest I don't think that I paint Newham in that bad of a light. Do I?

-----

As someone who rides a motorcycle every day through town I often have people tell me how I am going to 'die' and they always 'have a friend' (or rather 'had a friend') who was injured/killed on a bike.. I've been going 7 years without a incident. Do you see a lot of bikers in your work day? What are the factors that separate the 'bad injuries' and the ones that are relatively minor?

Speed and driving like a prat. Riding with sandals on. Alcohol.

I don't see much in the way of road fatalities, those that I do see are mostly cars with young men in them and with bottles of cider rolling around in the shell of the vehicle. I think the last M/C fatal on my patch was some drunks racing their bikes. That or someone who forgets that large, high, vehicles have nasty blind spots.

Certainly I don't think that motorcycling is any more or less dangerous in my area.

I think the worst injury I've seen with respect to motorcycling is a fellow whose bike fell on his ankle. While stationary.

(My crewmate is currently doing her MC course - her test is next week and I've got my fingers crossed for her)

-----

I live in the US, how hard would it be for me to become certified in the UK? I am graduating soon with my medic?

As above, I think the best thing is to talk to the ambulance trust in the area that you are moving to. you may be surprised by some of the differences in the ways we work.

-----

What would be your "death row meal"?

Something with large amounts of heroin in it so I can cheat the system and kill myself? Probably one of my mum's stews, that or a Wetherspoon's mixed grill.

-----

Can you still remember your first call?

Not really - I remember my first drive to a job, because I crashed. I think my first attendance call was a kid who'd been hit by a bus. Nothing seriously wrong with him, but loads of precautions taken.

I can remember the first baby delivered though - it was in the back of a car in an unlit street, no-one spoke English and they weren't booked into any maternity department. Fun...

-----

Hey, do you know Luke Eastwood?

Never heard of him.

(At least I don't think so)

-----

My students would like to know whether patients or collegues of yours have ever recognised themselves and become annoyed about being in your blogs? How much, therefore, is there censorship of what you write?

I have been recognised once - I wrote about it here, and then the people involved left some comments to the post.

I do a lot of censoring - primarily for the reasons of patient confidentiality, I'm often either changing details or writing about something in such a generic fashion that it could apply to any number of calls or ambulance staff.

I still live by these rules.

Those people who would be angry about my writing wouldn't recognise themselves in my writing. I take confidentiality very seriously, and there have been a number of things that I just can't write about because they are just too identifiable.

My colleagues tend to like my writing on the whole (quite a few have bought my books), because I do only speak the truth and they recognise that.

-----

It seems that the ambulance service is pretty badly run, with less equipment that you need, stupid management targets, and lack of support for staff. And your union doesn't seem effective in backing you up either. After British Airways and Rail management have successfully used legal action to prevent strikes it strikes me that with our current health and safefy leglisation that the unions could use legal action to punish the worst management thinking.

Let's just say that there is a reason that I don't belong to a union. The current staff-side representative was kept in his seat by around 5% of the LAS workforce, so you can see what an important mandate he has...

My personal opinion of the union (which is Unison) is that why our local rep is very good, when there is a larger issue the union management seem unwilling to rock the boat. As I say my information about such things is limited.

Personally I think that we should set up an internal LAS only union with minimal fees to represent staff in these larger issues.

-----

Also, I know you yourself say you are quite shy away from the job and I am also quite shy. How did you get through your interview process to get into the service?, what have you found most challenging about being shy and getting into the ambulance service?

I am quite shy, but when I'm wearing a uniform everything changes - and let's face it, an interview suit is just another uniform.

Besides, the 'rules' and social mores of interviewing are pretty solid, so both sides know what to expect. They expect you to be a bit nervous, and you expect the familiar questions to be asked.

-----

What has been the best/worst moment of your career so far?

The best? Going home at the end of a shift.

Seriously - it's whenever you make that bit of a difference, be it saving a life or hearing about a vulnerable adult referral to social services going well.

The worst? - Just the constant lack of kit, support and training. It's sad really, we could be really good, but a lot of decisions are 'quick fixes' and not too well thought our. We are far more reactive than proactive.

Personally - the worst bit was fighting to keep my job after being sick following an assault. But I did have tranquil fury and logic to keep me going.

-----

Is overtime available?

It depends on the balancing of hitting the targets and keeping funding under control. At there moment there isn't that much overtime.

-----

How are shifts arranged, do you work say 3 13hr shifts a week, or 5 13 hr shifts one week and then less next week?

We tend to work in bursts, so I'm working four 12 hour night shifts, then I have sic days off, then I'm working another four with three days off, then two on, two off and so on and so forth. The nice bit about this rota is that you do get a week off which can turn into two weeks by taking 24 hours worth of leave.

In other words, sometimes I'm worked like a dog, other times I can be incredibly lazy.

-----

Do you feel valued by management ?

HAHAHAHAHAhahahahahahaaaaaa..... *chortle*

No, not really - I'm employed to get to somewhere in eight minutes and that is about it. Sadly I don't expect anything different.

-----

What made you choose LAS over says SECAMB ?

Location - I live in London and it's the bit of the world I know - working 12 hour shifts means that the shorter the commute the better.

-----

Are there any private companies you or your staff work for to earn some extra money?

There are one or two - but I'm no expert on that as I like my days off to be as much like days off as I can.

-----

I have often wondered if you've thought about moving countries or trying another area of emergency medical service?

My problem is that I really like London, while I like travelling, I like being able to come back to London. In your larger question you mention Toronto, which I have visited - while it is a really lovely place, it feels a little 'small' compared to London. I guess I'm not feeling at home unless I can chew the air and get crushed to death on Oxford Circus.

I don't know, maybe I'll change my mind one day, but I'm not too sure how my qualifications would translate - and I don't have the money to emigrate anyway.

-----

Also I hear you talk about paperwork, doe this take up a lot of your time and is it hard to fill out?

Nope - the paperwork is an A3 sized bit of paper with a lot of tick boxes. It's annoying to fill it out for a 'nothing job', but it's certainly not hard. I'll show you all the paperwork in an upcoming blogpost. Compared to some jobs it's surprisingly little to be honest.

-----

Well you did ask for our questions! I’m just wondering of your personal opinion of Newham Trust (acute, not PCT). I used to work there but hindsight tells me it ain’t so grand in the scheme of things. How do you view it as a professional? Are they getting better, worse or just plodding along? What could they do that would make you a happy ambo? (apart from not putting the treatment centre and mental health on the same site that requires a big white taxi to take them to emergency?)

Given what they have to work with, a large, sick and undereducated population, a building that needs to have a fair few more beds in it. A lack of status that means that they can't 'headhunt' the better staff unlike, say, the Royal London. I think that they do all right to be honest. When my mum was sick I took her there, rather than our local hospital because I do trust them more.

As to getting better - I think they are trying, but I'm not sure if they will succeed.

What would make me a happier ambo? A much larger and better staffed A&E department and Walk in Centre would be a start. Some patients have to be put out in the waiting room even if it's not really appropriate just because there aren't enough beds in the department (and they can't 'work faster' because some things do just take time).

A mental health unit that would take direct admissions from us, even if the person was a little tipsy. But that will never happen.

Find some way to have nurses come out on the road with us - a lot of them have absolutely no idea what we do, or what we are capable of. We did a transfer once and the nurse asked if we could do blood pressure measurements.

I think that the best thing they could do would be to employ me to stalk the halls and boardrooms with my big stick of learnin' to slap the slackers. Either that or handle their internet strategy.

-----

Right - I think that's all those questions answered.

There has been a bit of a meme going around where people are using Formspring.me to have questions asked of them. I'm somewhat wary of formspring, but I do have a blog. So this week is your chance to ask me any question you'd like. On Friday I will answer as many of them as I'm able.

-----

You can ask your questions in a number of ways.

You can leave a comment on this blogpost.

You can email me at reynolds@randomreality.org

You can direct message me on Twitter @Reynolds