Random Acts Of Reality

Trapped

Reynolds — Wed, 10 Feb 2010 08:19:15 +0000

"I know you like doing that sort of thing", my crewmate said, "but I can do it this time seeing as you are getting old and fat".

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It was 3am in the morning (as it always seems to be) and we were being sent out of our area, although quite close to where I live, to go and see an elderly woman who had called for an ambulance and seemed a bit confused.

Knocking on the front door I could see a hunched shape moving around in the hallway. It came to the door, fiddled around a bit and then wandered away.

It's more normal that when people call for an ambulance they open the front door for us.*

I tried knocking again - this time the living room window opened and I was suddenly face to face with a little old lady.

"I can't let you in, the door is locked and I can't find a key", she waved her arm at me - even in the dark I could see that it looked like she was sporting a broken wrist. "I know what", she said, "I'll try the back door".

My crewmate and I walked around to the back door where the same event played out. This time she opened the kitchen window.

"Oh dear, this one is locked as well", she said, "Maybe the front door is unlocked".

I explained that she had already tried the front door.

I eyed the kitchen window. It opened pretty wide, I was certain I could climb through it.

"Can you climb in through the window?", asked our patient. Behind me I could hear my crewmate groan. She knows I love climbing over, through and into things.

"I know you like doing that sort of thing", my crewmate said, "but I can do it this time seeing as you are getting old and fat".

Well, that was a red flag to a bull. I had to climb through the window now.

My plan was simple - the patient was obviously mildly confused, I'd nip through the window, find the keys and open the front door to let my crewmate in.

Climbing through the window was fairly easy, and if my crewmate leaves a comment saying that I barely squeezed through and was panting and red faced by the end of it then I would trust you all to ignore her.

Once I was in the kitchen I could give our patient a look over - my suspicions were right in that it looked like she had broken her wrist while climbing out of bed, although my patient couldn't remember falling, her obvious dementia meant that she couldn't remember much.

But she was a nice old stick and we had a nice chat while I searched the house for the front door keys.

I looked everywhere, from where you would expect to find keys to the more inventive places that someone with dementia can hide something (ovens, fridges, teapots) - but no keys were found.

My crewmate had gone to sit in the cab, there was nothing she could do standing around in the cold.

I'd noticed, because I'm funny like that, that there was a 'keysafe' on the outside of the house - this is a little combination lock box that holds a spare set of keys, it's normally used when a person has carers but isn't always able to open the door for them.

"Do you know the code to the keysafe", I asked hopefully, "the little box outside that holds the keys for your carers?"

"I have a keysafe?", she answered, "Sorry love, I've no idea".

I looked in the care notes for an out of hours phone number - surely they would know.

But, of course, the sun had gone down and the 'out of hours' phone number just went through to the normal office phone.

"Our hours are between nine am and five pm.... please leave a message". Considering my shift ended at 7am I didn't fancy waiting that long to get an answer.

So I called up Control on my radio and asked them to try and get in contact with the care suppliers - maybe they could find a different number and ask what the code to the keysafe was.

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A little while later Control got back to me - the care provider didn't have the slightest clue about the lady.

So I set about a bit of detective work and found the phone number for our patient's daughter. I didn't really want to ring them (it was about 3:45 by now), but she was my last hope if I didn't want to be stuck in the house all night. While the company was lovely, her wrist really needed looking at by a doctor.

The first ring went to an answerphone, but I know how difficult it is to find your phone when you've been woken from your sleep, so I hung up and dialled again.

This time success!

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Now, one thing I learnt when I was a nurse and was ringing relatives all the time, is that you need to keep them calm and relaxed, otherwise they can think the worst.

"Hello there, this is the London Ambulance Service, I'm with your mother and she's absolutely fine, just a bit of a fall...."

All absolutely true - and it's best to get the 'absolutely fine' bit out of the way before their imagination jumps in with "...and she's dead as a dodo".

I apologised for ringing at that time of the morning and I told her my situation. I was very thankful that she didn't laugh down the phone at me.

Happily the daughter knew the combination to the keysafe, and wasn't bothered by me waking her up at the crack of sparrowfart.

So my crewmate was able to open the box, retrieve the key and then fail horribly at trying to open the front door.

One of the keys fit, but it just didn't turn in the lock...

Thankfully one of the keys fit the back door and we could soon get our patient off to hospital where she was well looked after.

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I'm glad that we managed to get the door open, because otherwise it would have needed the police to arrive and rescue me by kicking down the door. Something I could do without...

Sadly, although not unusually, I was let down by the lack of coordination and information from the care team. It really does seem that once the sun goes down and the firefighters all go to bed** it really is just us and the police out there to keep people safe.

But of course, all that will soon change - what with Labour's plans. Why, I fully expect every carer to be bright, determined and committed. Not underpaid, undereducated and uncaring - that would never happen, and certainly never be the norm. I'll tell you what Gordon, Andy, and whoever the Conservatives will have as health secretary - let me come and explain why ambulances count as social care, it was something that your predecessor was surprised to hear from me.

Never mind, I'm sure that the numbers will show that there is more social care - but I bet they won't show the increased ambulance usage because the social care is so slipshod.

What is really sad is that I sometimes see superb social and residential care - it's just that it is increasingly rare.

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*However, I could not count the number of times someone has called for an ambulance, we've turned up four minutes later and on knocking at the door the occupants have asked who it is...

**I do of course jest - they don't go to sleep. They watch porn instead***.

***I love 'em really - mostly because a lot of them look like they box for a hobby and could take me in a fair fight.****

****Especially the women.

That Word.

Reynolds — Mon, 08 Feb 2010 02:00:30 +0000

A lack of energy from these winter hours, night shifts and a feeling that no matter how hard I shout about things nothing is going to change has meant that I've been lacking the will to write. I keep thinking 'no-one listens', or at least nobody who has any power to change anything.*

What I should be writing about is the private ambulance companies that are being contracted to do our A&E emergency work, which is an incredibly bad idea. I should be writing about the utter tosh calls I've been going on of late. I could even be moaning about how our training day was 'postponed' because there is no-one to train us, and even if there was they have no idea how to train us, or what to train us in.

I'm sure it's just the season and that, come spring and a bit more energy, I will once more be waving my fist at the sky and shouting 'all Gods are bastards', albeit with the same effect that doing that always has**.

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When I get angry I find myself doing two things. First I wave my arms around like an epileptic chicken. There is a simple reason why I do this, it's because I keep raising my hands to hit someone, but then realise that, while enjoyable, it probably wouldn't do much good. I also have worked far too long in emergency medicine to be doing anything stupid like punching a wall.

The second thing that I do is I vibrate. I get filled up with energy and start shaking - first on the inside and then as I get angry the shaking spreads to my limbs.

I also shout a lot. Well... not so much shout as 'talk loudly and firmly'.

I have a long fuse, but a huge explosion.

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Why do I mention this? Well the other night I ended my shift an incredibly angry person.

We had picked up a young woman who was alternating between rolling around the floor and pretending to be unconscious. Her problem was apparently 'abdominal pain', but it turned out to be period pain.

Who am I to judge? Besides, it was nearing the end of the shift so if she wanted to go to hospital we were more than happy to take her.

We should have walked her out, but when dealing with someone suffering from Status Dramaticus it can sometimes be easier to just pop them on the carry chair and wheel them out - especially if they are light. So we did this and as we were about to load her into the ambulance she decided that she didn't want to go to hospital - so this poor flower, who moments earlier was 'unresponsive', undid the seat belt and started walking back towards the house.

I was just about to wave her goodbye when the FRU stepped in and convinced her to go to hospital. I can see the FRU's point, if our patient were to go back home and overdose on painkillers it'd be our fault.

So the patient agreed to come to hospital and I jumped into the driver seat while my crewmate did the things that we do in the back of ambulances.

We were halfway to hospital when the patient took off her seatbelt, threw herself on the floor and pretended to be unconscious again.

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We got to the hospital and, expecting the patient to continue the dramatics, I went and got a wheelchair so that she wouldn't have to walk. She stepped down from the ambulance, looked at the wheelchair and, once more, threw herself on the floor. I say 'threw', what I actually mean to say is 'died like an extra in the original Star Trek or Dr. Who series'. You know, 'collapsing' without hurting yourself.

"Why did you do that?", I asked.

"Fuck off", she told me, then stood up and threw herself into the paediatric waiting room where she, once again, threw herself on the floor and acted like she were struggling with death itself.

There then followed a long ten minutes where myself and two nurses persuaded herself to sit her arse in the chair so we could take her around and put her on a trolley. This was accompanied by both swearing and drooling***.

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I washed my hands while my crewmate booked the patient in onto the hospital system, and then went to leave.

One of the nurses then turned to me and asked me my name - I know the nurse's face but haven't really spoken to her.

"Why is that?", I asked.

"Because she told me that you called her a nigger", the nurse said - and the way she said it made me think that she believed the patient.

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Oh yeah, the patient was black. Didn't really give it much thought until then. After all I can go days at work without seeing a patient that is to be recorded in the great UK ethnic coding database as 'White British', so different skin colours don't hugely register on me.

There are three points I would like to make at this moment in time.

1) I've marched against the BNP. Several times.

2) I don't hate people due to their race or colour or however you want to slice it. I hate everyone. Equally.

3) I may call you a moron, an idiot, a fuckwit, a wanker or an utter... well, you know. I would never use colour or nationality to insult someone - much as I hate hearing kids using 'gay' as an insult. You are what you are and you don't make that choice, so why would I insult you based on that? If I insult you, I'll insult you because of what you do.

What really riled me us was that the nurse seemed to believe the patient.

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I think I said something in reply along the lines of, "Excellent - tell her to write a complaint, maybe I'll get suspended with pay, I could do with a holiday". But inside I seethed with anger.

I phoned the on duty Station Officer for advice. He told me that I should go to the police, that I should have a cup of tea, and that there was nothing he could do about it.

What. The. Hell.

No, "Let me come down and see you and chat about it". No, "Let me go and talk to the patient and see if we can sort things out". No, "Don't worry, I'll take a statement from you while it is fresh in the memory".

Nope - cup of tea and call the police if I feel that bothered about it. Oh, and the implied suggestion that I get back on the road within the next 15 minutes.

Thanks for that.

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So there I was, stalking up and down the messroom before having to fill out the 'incident report' paperwork with my crewmate.

Knowing, full well, that this is the sort of thing that ends careers, after all remember, I was investigated for a complaint after I told a patient that he slaps like a bitch after he assaulted me.

Racism is, quite rightly, not tolerated in the ambulance service - but is the proof on me to prove my innocence in a 'my word against hers' complaint'? I just don't know.

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As I write this I don't know if a complaint has gone in. Has this malicious liar decided to put pen to paper and complain? Or pick up a phone and ring our 'patient experience' line? I just don't know.

What I do know is that I found it very hard to sleep for the next two nights - not so much because of a fear of losing my job, but because I've put a lot into this job and the people who live where I work. My health is shot to shit because of the rota I work and the patient lifting I have to do. My social life is pretty much non-existant because of those shifts.

And yet - one of the people who I serve, and yes, it is serve, called me one of the things that I hate the most - a racist.

And she did it without thinking, as an easy way to try and get me into trouble.

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My thanks are due to my station mates who were there that morning, firstly for giving me advice about what to do next, and secondly for making fun of me by suggesting that it was obvious that I'd soon be wearing a white hood while erecting burning crosses across East London...

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I almost forgot - the lovely Kal writes a very insightful piece on 'Race Relations' in medicine. Go and read it, then go and read Kal's blog.

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*Brought about, in part by the testimony that Tony Blair gave at the Chilcott inquiry and how he seems to avoid arrest for war crimes. That and if I performed as poorly in my job as many of the people I come into contact with there would be a lot more dead people in London.

**i.e. none whatsoever.

*** Not attractive, and a reason to be wearing gloves.

Amazon Blinked

Reynolds — Mon, 01 Feb 2010 00:42:25 +0000

So it would look like Amazon has blinked first.

On Amazon's discussion board,

“Dear Customers:

Macmillan, one of the “big six” publishers, has clearly communicated to us that, regardless of our viewpoint, they are committed to switching to an agency model and charging $12.99 to $14.99 for e-book versions of bestsellers and most hardcover releases.

We have expressed our strong disagreement and the seriousness of our disagreement by temporarily ceasing the sale of all Macmillan titles. We want you to know that ultimately, however, we will have to capitulate and accept Macmillan’s terms because Macmillan has a monopoly over their own titles, and we will want to offer them to you even at prices we believe are needlessly high for e-books. Amazon customers will at that point decide for themselves whether they believe it’s reasonable to pay $14.99 for a bestselling e-book. We don’t believe that all of the major publishers will take the same route as Macmillan. And we know for sure that many independent presses and self-published authors will see this as an opportunity to provide attractively priced e-books as an alternative.

Kindle is a business for Amazon, and it is also a mission. We never expected it to be easy!

Thank you for being a customer.”

At least now Macmillan and it's ebooks will stand or fail on the pricing that Macmilan chooses to set, as opposed to being forced to set a certain price by Amazon. Although it is interesting to see Amazon try to paint themselves as a victim in all this as opposed to trying to force a monopoly and monopsony in the ebook market.

One amusing part of this message is this.

"We want you to know that ultimately, however, we will have to capitulate and accept Macmillan’s terms because Macmillan has a monopoly over their own titles"

Yes - they have a monopoly over the books that they own - that is, after all, what copyright means.

Which is, of course, completely different to having your books only readable on a Kindle...

Amazon, Apple, Macmillan and Me.

Reynolds — Sun, 31 Jan 2010 13:17:18 +0000

For those people who are interested in ebooks and the technology market the past few days have been 'interesting' to say the least.

It started when Amazon pulled all the ebooks published by Macmillan from their Kindle store.

Speculation ran rife - it eventually seems to have boiled down to Macmillan wanting to set the price of their ebooks and adopt an 'agency' model while Amazon wants to keep the status quo.

I shall leave it to the wonderful John Scalzi and Charlie Stross to explain.

Do I think Macmillan (or anyone else) will be able to sell $15 ebooks? They could; after all, they sell $25 hardcovers (and similar amounts for ebooks, depending on the retailer). Now, some people won’t spend that much for a book, so they pick up the book later when it’s an $8 paperback. That’s fine, too.

Likewise, I think it’s fine to attempt to charge $15 (or more) for an ebook for a brand-spankin’ new release to service the folks who just can’t wait, drop it to a lower price point (say, $10) later on in the run, and then drop it again to $8 or so when the paperback hits.

That’s how I would do it, in any event. Would it work? Hell if I know. But that’s not to say it (or some other pricing scheme) is not in a publisher’s interest to try. And to be blunt about it, it’s in my interest as an author as well, because, you know what? My royalty is a percentage of the sale price. I have a mortgage, I have a kid to send to college, I have an addiction to games that allow me to shoot zombies in the head. I’d like money for those, please.

It’s not unreasonable to test the market and see what it will bear.

John Scalzi

This whole mess is basically about duelling supply chain models. Publishing is made out of pipes. Traditionally the supply chain ran: author -> publisher -> wholesaler -> bookstore -> consumer. Then the internet came along, a communications medium the main effect of which is to disintermediate indirect relationships, for example by collapsing supply chains with lots of middle-men.

From the point of view of the public, to whom they sell, Amazon is a bookstore. From the point of view of the publishers, from whom they buy, Amazon is a wholesaler. From the point of view of Jeff Bezos' bank account, Amazon is the entire supply chain and should take that share of the cake that formerly went to both wholesalers and booksellers. They do this by buying wholesale and selling retail, taking up to a 70% discount from the publishers and selling for whatever they can get.

Their stalking horse for this is the Kindle publishing platform; they're trying to in-source the publisher by asserting contractual terms that mean the publisher isn't merely selling them books wholesale, but is sublicencing the works to be republished via the Kindle publishing platform. Publishers sublicensing rights is SOP in the industry, but not normally handled this way -- and it allows Amazon to grab another chunk of the supply chain if they get away with it, turning the traditional publishers into vestigial editing/marketing appendages.

Charlie Stross

I suggest that you read both blog posts (and the comments) to get a full handle of the situation.

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I have two things to add to this, one is where I see Apple in all this, and another about my experience with Amazon.

Firstly, I suspect that this has a lot to do with the Apple iPad, while it's not confirmed I suspect that Apple are going to follow a similar pricing systems with ebooks as it's App Store. This is the 'Agency' model where the owner of the book lets Apple list it on their store and then the money is split 70%/30%, Apple getting the 30% for the running of the store.

The important part of this is that the publisher sets the price. If they want to charge £25 for an ebook and the market supports that then that is what they will do - if they want to sell the same book for £2.99 then that may end up making more money for the publisher (and ultimately the author).

It's all about the free market and finding what price the market will bear.

Take, for example, the successful experiment by my publishers The Friday Project. They sold 65 times the number of ebooks at £2.99 rather than at the RRP. And didn't cannibalise physical book sales either.

There are good arguments that ebooks shouldn't cost as much as physical books - but allowing publishers to set their own prices ultimately lets the market, by which I mean 'people who buy ebooks', affect the price.

(I don't intend to get into 'windowing' at the moment - while important it is somewhat tangental to my above discussion)

If Apple don't follow this model for their EPUB book store, then people will continue to make their books into standalone apps that do sell under this model...

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How does this affect me?

Well, as I think that Amazon are seeking to monopolise the ebook market and protect practices that are unfair and anti-competitive, I shall simple stop buying from them. I have a Sony Reader (well, I have two) and while the back catalog of books for that device is smaller, I suspect that this might change. I suspect that publishers will stop looking at the proprietary Amazon format as a good deal and will instead move to the more open EPUB format that can be read on more devices (including the Sony Reader the Cool-ER and the iPad).

What is interesting is that Amazon are opening up the Kindle to it's own 'App store' - I would be very surprised if one of the first applications isn't something that allows you to read EPUB files on the Kindle, something that is impossible at present.

It also wouldn't surprise me to see Amazon ban such an application*.

Because of this anti-competitive, protectionist and downright icky behaviour, I shall no longer be linking to, or affiliating myself with Amazon. Rest assured that they will be quaking in their boots at the thought of the pennies that they will be losing from me.

Well, they won't - but at least I'll feel better.

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As an aside - I note that Amazon are selling my two ebooks on their Kindle store without the permission of me, or my publisher. My publisher has already asked for them to be taken down (when the book was launched), as of Sunday the 31st of January this has not happened.

I know I can be bloody minded - but if I were my publisher I'd be phoning the lawyers on Monday morning...

My books, as always, are available for free download in multiple formats (including Kindle) from Manybooks.net

Blood, Sweat and Tea

More Blood, More Sweat and Another Cup of Tea

Please don't buy them from Amazon for $12 (or whatever the cost)

As I said - interesting times, and it'll be even more interesting to see how this all shakes out. After all, who would have thought that Apple would be the one supporting a free market?

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*The problem is that the DRM that Amazon uses is not allowed to be used on devices that can use other DRM formats - which may lead to new and interesting legal battles.

UPDATE: Slight edit to make it explicit that Amazon shouldn't be selling my ebook, they are fully able to sell the physical edition of my books.

Student

Reynolds — Mon, 25 Jan 2010 23:39:00 +0000

We had a student with us for the past two weeks. It was her first ever time on a real working ambulance so she had a more than a few 'firsts'.

She saw her first dead body.

She drove for the first time with the blue lights and sirens.

She used the radio for the first time, talking to Control.

She spoke to her first patient, calmed her first scared patient.

She met her first alcoholic (who was nice) and her second alcoholic (who wasn't).

She got cut out of her first car, holding the neck of the driver who'd crashed it.

She filled in her first accident report form (neither her fault, nor connected with the previous point).

She took her first 'real' blood pressure, her first blood sugar reading, her first pulse and listened to her first chest.

She carried her first patient down a couple of flights of stairs.

She filled up and paid for her first tank of diesel.

She dealt with her first case of domestic violence, and her first heart attack.

She also ganged up with my crewmate and bullied me like an expert - but I'm used to having that effect on women.

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I sometimes forget, having seen most things, done most things and gotten bored of most things; how interesting this job can be. Sometimes it helps to look through the eyes of a student to see that we do have a job where every day contains a story.

It's very easy to get disillusioned with the job, I know I have - but when you are teaching someone, the tricks and tips that they don't teach in school - the ways to look at patients, the ways to talk to them to ease their fears, the ways to not get burnt out too quickly - well, then you get a chance to take a step back and realise what it is you enjoy about the job.

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Blogging should be more regular now as I've attacked my old computer with a screwdriver and now have a (much slower) working machine. If you've sent me an email in the past month you should be getting a reply soon.