We Need to Talk About The Ambulance Service

"An emergency service in crisis?"

Yesterday, I read a brilliantly written blog by @NathanConstable entitled We Need to Talk About The Ambulance Service. If you haven't read it yet, please do so now, otherwise this post won't make much sense! He speaks about a lot of issues that surround the ambulance services in general and what knock on effects that has on the police. Rather than leave a long rambling comment providing my thoughts on things, I thought it would be better explained in a post of my own.

I didn't take anything that @NathanConstable wrote as a dig. It is a discussion that needs to happen, but realistically, it needs to be happening between senior figures in the police, the ambulance service, the NHS and the government. I just wish they'd listen to what we are all saying, where we are not ruled by the politics of a situation! Like Nathan says, for all the inter-service teasing and banter that goes on (and before you ask, my call sign is Whiskey Delta 4-0. Oh, and fireman, hold these fluids, good dog!) there is a mutual respect and a fantastic front line working relationship between all emergency services. We do many jobs with the fire service, some are the most traumatic of jobs we will every see. I do have a huge amount of respect for the job they do. The relationship between ambulance and police is a stronger bond, born from the huge amounts of jobs that we do together. As detailed in 'A Special Relationship' I, along with the rest of the profession, hold the police in the highest regard.

My first thoughts when I read 'The Ambulance Service is broken' was agreement. I nodded my head as I thought about what was wrong with the ambulance service. However, the more I read on, I came to a very different conclusion. Despite its failings with the relatively small things we moan about on a day to day basis (missing kit, hours, breaks, working conditions, pay bands etc), on the whole, I think the Ambulance Service is far from broken and I'll do my best to explain why.

I can't argue with the fact that police are having to wait longer and longer for us. They do. Nathan gave 4 examples of waits he's encountered, but I'm sure he could list another 20 or so without any trouble. And that is probably only the last month or so! I also wouldn't struggle to list the police jobs that I have been cancelled on! THAT frustrates me. I know if I ask for the police, if there is a unit available, they will come. Far too often, we are cancelled for a 'higher priority' knowing full well that police will have to start the wait again. The problem however, I don't believe is caused by the ambulance service alone. It's caused by triage, call rate and hospitals. I'm not saying the ambulance service is totally blameless but it does feel from a front line perspective, that we are being pulled from all sorts of different places, meaning we can no longer function as an emergency ambulance service. Whilst police wait and wait and wait for us, on thing is for sure. Someone else is waiting to!

So, hospitals. Nathan documented seeing 5 ambulances sat at the hospital due to lack of capacity. Well from experience, I'd say he caught them on a good night! Only last week I was stuck at a hospital with 13 waiting ambulances due to a lack of capacity inside. There were patients who could walk and who eventually went to the waiting room but the nurse in charge wouldn't take the hand over, so therefor we couldn't leave. This BBC article - http://www.bbc.co.uk/news/uk-england-norfolk-21999859 documents the problem well. No ambulance service could cope with all 17 of their emergency vehicles being stuck at 1 hospital. Due to huge fines for going on divert, hospitals don't. They just make us wait in corridors. Until the patient is off our bed, they don't become the hospitals patient so departments are in no rush to take the handovers, off a huge queue of ambulances. What's the result? The police are still waiting for an ambulance. It isn't just the police though. Whilst they are waiting, so are dozens of other people who have phoned 999. Is the ambulance service to blame for these delays?

Call rate is another big problem. Year on year the call rate is increasing at an alarming rate. My service alone received over 1.7 million calls last year. Calls are coming not only from the public, but also from GPs, hospitals transfers, the police, the fire service and now the new 111 service, which has seen a huge spike in the need for resources. With government cuts to the budget, there simply isn't the money to replace the 25+ staff who are leaving each month. The crews on the ground are working harder and harder. We are being forced (with financial penalty) to turn jobs around quicker and quicker to try and match demand for the service. Our control room has just started a pilot, of refusing to send ambulances to some calls, in an attempt to ease the pressure. We simply don't have the budget or the resources that the police and fire service have and us such, the service is struggling to cope. 

Despite the calls volume and despite the delays at hospital, there will always be the eternal problem of triage. How does one call get priority over another? Why are the police told an ambulance is on route and then one never materialises? Triage! Calls are categorised, then re-catagorised. Crews are sent, then cancelled for a higher priority, then cancelled for another higher priority, as 200+ calls an hour continue to roll in! The issue is priority symptoms and the police are victims of their own common sense.

When the police call and ask for ambulance back up they say exactly what they see and exactly what is happening and therfore a '20 something year old male with a head injury' which has had a dressing put on it by a police first aider will get trumped every time by a 35 year old female with a cough. Why? Because the general public know what buzz words to use. A cough is cough, but when they call, they say they have difficulty in breathing and when asked if they have chest pain, they say yes, because there is pain in their chest from coughing. Now, you have a situation where an ambulance and a car are sent to a '35 year old female, DIB and Chest pain' because those are the priority symptoms she flagged up. The same problem happens with 111. A simple headache becomes meningitis, prickly heat become anaphylaxis and so on. It is a world wide problem. People lie to get what they want and no ambulance service will ever risk NOT sending an emergency response to a DIB or Chest pain. That is, if all their ambulances are not sat at a hospital or busy doing critical transfers and the plethora of other things we are being called to. And who has to wait? Whoever told the truth!

Again, I don't think this is the failing of a particular service, triage is there to get resources to the highest priority of calls the quickest. You rarely hear of there being absolutely no resource to send to a cardiac arrest. All it means is someone else is left waiting. The AMPDS triage system that is used, is modified world wide and if used correctly works well. Unfortunately, until a cure is found for liars, time wasters and hypochondriacs triage will remain an issue. 

One thing that Nathan spoke at length about was the amount of calls they attend to back us up. It's true. They do, and this is a failing of the service and of individuals. I have worked with a number of people who see the words 'mental health' and call the police. If the word 'assault' appears, the police are called and there is a case to answer for us never going to scene until police are there. Records of flagged addresses are woefully out of date, hence why I've been sent to an 80 year old with chest pain accompanied with armed police and ballistic vest! This needs to change but requesting back up at the first sign of trouble is often too late! As I detailed in 'Please Sir, Can I Have Some More' we are not even remotely equipped to deal with violence against us. The half day conflict management course really doesn't cut it. That job also highlighted how the police are stretched so thin that they also 'have no units to send'. Is the police service broken? I'd say no, but I would say, like us, they also struggle to deal with the demand placed on them by all and sundry! The public, the fire service, the ambulance service, mental health services and hospitals all call on the police and there will always be someone, somewhere, who is left waiting. And who is that? Probably the low priority who told the truth, the whole truth and nothing but the truth!

Finally, there is the issue of the merger! Now, this was like a red flag to a bull and the only part of the blog I 100% disagreed with. I've made no secret of my distain for this idea in 'Fire Brigade: Hands off our service' and 'Unhappy Trumpton.....Bless!' . It is something that the fire service is keen on, but they are keen on taking on us rather than the other way round. If the fire brigade became part of our HART team then perhaps that would work but that would never happen. They are far too powerful an organisation to lose their identity for starters. You only have to look at the obscene budget they manage to repeatedly procure to see this! £50,000 on a coffee machine at HQ says it all! They have been after part of the ambulance service for some time, namely, to justify their resources. Their cuts under this government regime have been minimal in comparison to ours and the police. I can see no benefit in merging the police and fire and just as little in merging ambulance and fire. I does work across the pond but a) that's how it has always been so the infrastructure is there and b) with the ability to charge for all emergency calls, you can pay for the resources to cover call volume! The more calls, the more money. Over here, with the ambulance service deeply embedded within the NHS and with the lack of emergency service status, I can't see it ever happening. 

This has been a great opportunity to discuss the failings and trials this countries emergency services are facing and I'd like to thank Nathan Constable for writing such a great post. I don't see them as failings. They merely highlight the detrimental effect this government regime is having. I don't think the ambulance service or the police service in this country are broken. Not by a long shot. I  think they both perform admirably and perform over and above what their resources, diminishing budgets and demoralised work forces probably should. And THAT is a testament to individuals who turn up when someone phones 999. It's an honour to be part of the team.

Private Parts

"79 year old female, abdo pain"

For a change from the norm, I wasn't working on an ambulance. Tonight I was on the FRU (Fast Response Unit) car on my lonesome. A typical 12 hour car shift generally consists of sitting on standby waiting for the higher priority of calls to come through. You generally stay in your area so that you can be on scene quickly for the patients (and to stop the clock before the 7 minute 59 second deadline). Unlike the ambulance you are not sent to anything and everything which is a pleasant change but you do often have to wait some time, often with a sick patient, for an ambulance to arrive. When the ambulance arrives you hand over and leave your patient in their more than capable hands. If there is no paramedic on the ambulance and you either have concerns about the patient or need to administer drugs etc  then you may travel with the crew but more often than not it's a simple handover and off you go.

I arrived within about 3 minutes of the call coming in, grabbed all my kit (so much heavier on your own) and trundled up to the front door. Once inside I was taken to the patient who was sat on the toilet. She was obviously in pain so offered her some Entonox which worked well. The basic aim for the FRU is to a) stabilise the patient and get us much information, history and observations as possible before the crew arrives. I checked her over and most of her observations were OK. Her heart rate was raised a little and her temperature was a little high but other than that it was just a pain problem. I suspected from the way she was describing it, it was an inflamed stomach ulcer or something similar and she had a history and medication list to match that. I couldn't give morphine as she had a known sensitivity to it so it was a case of waiting for a crew to take her in. Simples!

Then, the crew arrived. Not a crew from my NHS Ambulance trust but a private ambulance service. The two middle ages guys were rude to the relatives who were trying to tell them what was happening on their way up the stairs. 

"We'll find out what going from the car driver if it's OK."

What a douche bag! Sure, clinically, you'll find out what is happening from the FRU but there is no harm is at least pretending to be interested in what the family have to say. Also, 'car driver'?! Seriously?! Two middle aged guys stood in the door to the bathroom, the one who appeared to be attending had his arms in his pockets and was chewing gum in a hugely grotesque way. I started my handover with full history, observations and differential diagnosis and it was clear he wasn't listening to a word I was saying. In fact, half way through, he turned to his crew mate to say 'reckon she can walk'. I ended my handover with, 'so if one of you could grab a chair that would be great'.

"I reckon she'll be alright on her feet"

"Well I'd like her to go in chair, so could you get a chair please."

He didn't bother hiding his displeasure and rolled his eyes. They BOTH went to go and get the chair, clearly to have a bitch about me. I've been on scene for 25 minutes, if they had listened to my handover they would have heard me describe her pain and would have heard me say that the Entonox is helping but is making her dizzy. They would have also heard me mention her usual mobility is slow and she uses a frame. A lifetime of tax and national insurance and being unwell entitles a 79 year old to god dam chair in my opinion. These numpties would just have to suck it up. 

After helping carry her down the stairs because one of them 'had a bad back' we got her onto the ambulance. The driver got in the front and the attendant sat behind the head of the patient. I find this impersonal and rude but that didn't surprise me from these two. 

"Are you going to monitor her and give her some more Entonox?"

"We don't have any and what are supposed to monitor?"

"Her pulse, oxygen saturation, her blood pressure etc."

"But you've said they were OK"

"But it could change!"

Again he rolled his eyes and reached for a blood pressure cuff. I'd had enough, I didn't want to spend any more time with them but I also didn't want to leave this lovely elderly lady in their 'care'. I decided to travel with them, bring my Entonox and monitor the patient myself much to the annoyance of Tweedle Dum and Tweedle Dee. Eventually, we go to hospital, I handed over to the nurse and managed to grab another FRU to take me back to my car. Before I left I told the private crew what I thought of their lacking professionalism and told them in no uncertain terms I'd be lodging a complaint. They didn't seem to care one iota. 

This job is not an isolated case unfortunately. If you speak to any FRU who has come across one of the ever increasing amount of private ambulance services you will hear similar tales. At busy periods, my service is becoming more and more reliant on them rather than using the money to staff their own ambulances. There is little or no quality control and you also have a situation where vast numbers of staff who have been sacked for a wide number of reasons from drink driving, drug offences, misconduct, patient complaints and having sex in ambulance service vehicles are now working for the service again through the private companies who's only motivation is money. 

This is having an effect on patient care and it is only getting worse. The training these private ambulance services provide to their staff is minimal at best, they are generally staffed with much less qualified members of staff because it is cheaper that way. They also are picking from a much smaller talent pool because generally, and there are exemptions, the people looking for work in the private sector are not qualified or not allowed to work for NHS trusts. i.e.: criminal records and those previously struck off by the HCPC. As the role of Emergency Medical Technician, Emergency Care Assistant etc are not protected or registered titles, anyone can do them. I met one crew who between them had had 6 days of training before stepping foot on the ambulance. It's a liability. They are a bunch of cowboys and chancers. 

In my opinion these companies need to be irradiated. Where money is the primary focus, patient care will suffer. That's a fact. Sure, it may be cheaper for the government to gradually privatise the ambulance services but at what cost. I certainly wouldn't want these imbeciles to go to a member of my family. Would you want them to come to yours? It seems that the budget cuts are being used to undermine the ambulance services for the ulterior motive of future privatisation. If you cut our staff and cut our budgets we cannot work as efficiently with the ever increasing call volume. Then, to blame us and say private ambulances are the way forward because we are not providing the level of cover required is absurd. Put the money to where it is needed. Well trained staff on well equipped ambulances. What do I know, I'm just a bum on a seat, I probably can't see the big picture. 

By the way, that 'Big Picture' the Tories tell you all about is this...... A picture of our elected MPs and our unelected Lords sitting round a big table, raising a glass to the stroke of genius that led them to all own shares in private medical companies and then sell of the NHS to the highest bidder, thus making them all richer than they were. Great picture from down here.