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.

Please Sir, can I have some more?

Dear David

I'd like to start by wishing you and your family well in these tough economic times. You and Samantha's combined salaries of £400,000 plus shares and bonuses must be really getting spread thin. I empathise, I really do. Like you, I seem to work all the hours god sends yet that £25,000 seems to just disappears! Still waiting for my mileage expenses to come through though, so that will be an extra £42 in the piggy bank! I love expenses! Anyway, the point of this letter is one of a more serious nature. 

I have waited a long time to write this too you. Let me draw your mind back to your first assault on the Police service. In case you'd forgotten you cut 16,000 officers. Less is more! Quality over quantity! Needs must! Look at the bigger picture! We will all feel the pinch! No one is immune from cuts! All very very true. We must indeed all pay the price for the bankers and politicians sticking our country in the economical dark ages. But, there are consequences to your ill advised cuts. Let me share a story. A story that brings back painful memories. A story that still bears real scars. 

As a paramedic, one who has been through years of training and sacrificed friends and family for such a fulfilling salary, I understand that part of my job, in fact, part of my salary is danger money. Well, not officially, but being abused is part of the job, right? As the Right Honourable Ann Widecombe, recently said, "Public servants worry more about their own safety than that of the public, Britain has sunk to a new low". I'm guessing by your lack of condemnation of these comments you must agree wholeheartedly. So, as an 'ambulance driver' (yes, we are that low in the food chain), a bit of danger comes with the territory. One afternoon, I was called to a residential address to a man who had 'passed out'. 

When I arrived that man was lying on the grass. I approached him, on my own, and he appeared drunk. I went about my business, checking him over, when the ambulance crew arrived. We began to get the bed off the ambulance all the while making sure the member of the public was OK. We are public servants after all and serve we shall. Without warning the patient stood up and swayed a little, then staggered into a fence. Poor guy eh?!

He then beat me with a fence post. He also beat the other members of the ambulance service. Three of us in all. Do you know what it feels like to be helpless against a man beating you with a lump of wood? Despite all of our broken bones we managed to press our emergency button. Let me share a conversation with you.

Me: "Red base red base, urgent police, we are being attac......." I stop because the lump of wood has been broken over the back of my head and then broke my hand.

Crew 1: "Red base, my crew mate has been hit over the head, urgent police" he says with 3 broken ribs.

Red Base: "Getting the police for you now, are you all OK, can you get to safety."

Crew 2: "I'm now locked in the car, I think my wrist is broken, he's still attacking us."

Crew 1: "We are away from him but he's coming after us. Are the police on way?"

Red Base: "The police have no units to send, try and maintain a safe distance."

Crew 2: "He's trying to get in the car, he's hitting it with the wood"

Crew 1: "I think he's stopped, he's lying in the road but we can't drive off."

Crazy stuff isn't Dave! No units to send?! But aren't the police supposed to be there to protect us? Surely in a real emergency they have someone to send. Surely you didn't cut too many? It's OK, 9 minutes later two undercover officers arrived. Part of their job is getting abused too. I should probably mention now that in their efforts to protect us from the patient they too both got broken bones. They were struggling to restrain him on their own so much, that we all helped. We all restrained him for 10 more minutes until more help arrived. Guess what we did then Dave? We all took the patient to hospital for treatment. With our broken bones and bleeding wounds, we checked his blood pressure, he even got to travel on the bed. He is of course a member of the public and we are all their servants.

Now, do you still think less police is the right answer? What if you or your beloved family were trapped somewhere in real fear for your life? What if you called for help? What thoughts would go through your mind when you heard those terrifying words "No units to send." The officer who came to my aid told me that it used to be a team of 25 to police the borough on this shift. Today it was a team of 7. No doubt they got complaints from the public for not coming to their aid quick enough whilst 2 of the 7 were sat in A & E with me and my colleagues. Tut tut. We really must all work harder.

The good news from all of this, was our patient was treated professionally by us and the hospital. He was arrested and charged. He was sent to prison. However, because of your cuts to the prison service he has already been released and I could bump into him anytime of any day.  Oh wait....in fact, only last week, I was sent on a job to his house. Can you imagine the fear Dave, can you? Luckily he wasn't there. 

I am proud to say that in this country we have by far the best police service in the world. The things they do and the dangers they face without a gun on their belt. The professionalism they show at all times is nothing short of amazing. That is in the face of your assault on their salary, their pensions and their working conditions. Now you are making a career in the police as unappealing as possible by slashing the starting salary and rushing through the 'Eton Old Boys' to top ranking jobs without ever having to be spat at, kicked, punched, stabbed, shot, sworn at, had missiles through at them and put their lives on the line. It is plain and simple Dave. There are not enough of them any more. Not enough by a long shot. So, in the words of Oliver Twist, 'Please Sir, can I have some more?'

Just a thought, you know that publicly owned bank, RBS? You know, the one we all bailed out with our taxes. Well they are paying their staff £950,000,000 in bonuses this year. As they are PUBLICLY owned, why not use the money to fund the salaries for 38,000 new police officers on £25,000 a year. I think my maths is right. There are other banks to you know. Other ones we all helped fix. How about they now help fix us? I know, I know, I'm probably not looking at the bigger picture, but in that big picture I just see the words 'No Units To Send'. Silly me.

By the way Dave, this wasn't a work of fiction for effect. This actually happened. To me. Have a read. http://www.barnettoday.co.uk/news.cfmid=3449&headline=Man%20in%20court%20for%20paramedic%20assault

Good luck with the economy Dave, there are tough times ahead.

Your Sincerely

Ella Shaw (Public Servant)

Please Please Please

"Signature Needed NOW"

The purpose of this post is simple! I want you and everyone you know, to sign this e-petition as soon as possible. I want the link to it emailed and re-tweeted as much as possible. The e-petition was set up by the Oliver King foundation and was set up after his death at the age of 12. He died from Sudden Arrhythmic Death Syndrome (SADS).

Their aim is to try and raise awareness about the medical condition SADS which commonly affects people aged between 12 and 35 years of age.

By doing this through their fundraising events and major PR drives, their aim is to boost the awareness about SADS enabling them to take the first steps towards preventative steps being made freely available.

They are currently based in Liverpool, UK and are striving to ensure that schools primarily get the equipment they need to help any young people who are affected by this condition. This is namely defibrillators. They need your help to get the government to listen, as until now the only response they have had has been to refuse to help and pass the buck to the ambulance service. 

"From February 2007, responsibility for continuing the legacy of the National Defibrillator Programme was devolved to ambulance trusts. Most of the ambulance trusts across the UK have community resuscitation departments or similar, which work to place defibrillators in the community, and in areas of need."

What they mean is they won't pay for it! What they also don't tell you, is that the ambulance service places defibrillators in places only where the owners pay for them. We do provide HeartStart training in basic life support and defibrillation free of charge to anyone that wants it but this training is provided by willing staff, unpaid, and in their own time. I myself am a trainer. It is something I believe passionately about and it was of such a surprise to me that defibrillators were not in schools by legal requirement. 

The cardiac arrest survival rate in London is around 32%. That figure is much higher than the rest of the country but it also much lower than other cities in the world. Seattle has the highest survival rate in the world at 55%. The reasons for the huge gulf is simple. Basic Life Support is taught as part of the national curriculum from the age of 6. Everyone knows how to use a defibrillator and there is one on every street, in every school and in every public building. That is the survival rate that is possible but that is what the government are unwilling to do. £650 for a defibrillator is more than a 12 year olds life is worth apparently. They even refused to meet The Oliver King Foundation, yet weeks later 16 defibrillators were installing in Westminster and government buildings! If it's good enough for them, it's good enough for you and your children!

Please please please have your say. We have the chance to make a real difference so lets put our weight behind it. 

SIGN THE PETITION NOW!

For more information on the Oliver King foundation please visit  http://www.theoliverkingfoundation.co.uk/ or see them on twitter at @TheOKFoundation.

Dial 999... & wait?

"A country in apparent shock at having to wait for an ambulance"

On Monday 3rd September the BBC aired a programme called 'Dial 999...& wait?' detailing the failings of the emergency services in this country. It's shocking isn't it; having to wait for something? Just terrible. Like with most documentaries, articles and reports about the emergency services, we all come under attack. I say all, as per usual the PR department for the Fire service has been working overtime so they came away unscathed. There was no such escape for the Police and Ambulance services. The culture of targets and response times was what the programme was about and, rather than talk about the real causes, it just highlighted the failings of the services using some well-placed stories about people suffering due to waiting times. 

First in the firing line was the police; the shocking statistic that out of 1 in 5 calls made, the police take more than 15 minutes to arrive. Outrageous. We surely expect more from our police?! I wonder what the government had to say about it... oh yeah, they declined an interview. Obviously the cuts are to blame, there is no denying that; a 20% budget cut is huge, but instead of doing a programme blaming the government they blame the police for basically being greedy. The short interview with Andrew Haldenby from the "think-tank" Reform showed only the attitudes of those not directly involved in working with or in the police. The police have 'never had more money than they have now' and 'for far to long, forces have rested on their laurels'. If cuts are being made, services will be affected. The reason the police have more money now than ever before is because year-on-year the call volume goes up. Don't for one minute believe isolated statistics of a decrease in crime; it is simply that the type of crime is changing. The police still require resources to deal with the 100's of 1000's of daily calls. This call volume will not change, yet somehow, on skeleton staff, they are expected to arrive anywhere within minutes of a call.

The example they used of peoples' suffering was a shop owner who had been burgled. She was 'shocked' at the police not arriving for 20 minutes. How many shop alarms are triggered each night? How many violent assaults are there? How many domestics? How many hoaxes? How many RTCs? How many requests from the ambulance service? How many raids are being done? How many criminals are being hunted? That is just a fraction of the work our police force is doing. In the London borough where I live there are about 330,000 residents. The borough covers 87 square kilometers and is the second largest in London. While chatting to an officer a few weeks ago on a Sunday morning, he told me there were only 13 front line officers responding to calls. He also told me he remembers when there were 30+. It's no surprise that with such huge cuts low priority calls like a shop alarm are getting a delayed response. To be perfectly honest I'm 'shocked' that the police got there so quickly.

Avoiding the fire, ironically, was the Fire Service; no shock there. No talk of missed targets, only that they arrived at a fire within 6 minutes. To be fair, it is easy to arrive anywhere in 6 minutes if you are sitting and waiting for that call to come in and get to spend all day perfecting the art of getting into your vehicle quickly. Last year the London Fire Brigade had a budget of around £437 million compared to £288 million the Ambulance Service got. They received 230,000 calls compared to the 1.6 million the London Ambulance Service received. They attended only 138,385 calls compared to 1.2 million that LAS did. They did so with their 5800 operational staff (almost double that of the ambulance service) from their 112 fire stations (compared to the ambulance service's 70), and of their calls attended, only 29,215 were fires. That is about 80 a day across London. Considerably less than 1 per fire station. Is it any wonder that they are able to respond quickly?! What was highlighted by the programme though was the crippling cuts that they are now facing. A whopping 3% in their budget! Wow! How will they cope?! Maybe they will have to send less than 25 fire-fighters to rescue a seagull from a 3ft pond. Oh wait... they refused to go in; they just sat around and watched a member of the public go in. Yes, THIS happened. Click here. It's weird how all of these facts and figures were omitted from the programme, hmm?

Saving the best until last, the Ambulance Service came under attack for people having to wait. They opened with a tale of an elderly lady waiting on the floor for hours, with the addition of an interview from her daughter about how terrible this was. I agree. In an ideal world no one would have to wait for an ambulance, least of all our elderly population. Unfortunately, the medical world uses a triage system based on what the caller tells the call-taker. As horrible and uncomfortable as it is, an elderly lady with a knee injury is not a high priority and when there are only a handful of ambulances covering a large area priorities have to be made. In this instance it wasn't life or death. Who knows what other calls were in progress. Long have I banged on about the fact that time wasters and nonsense calls just need to be told 'NO'. Sadly, Panorama decided to interview Tony Hughes for the GMB union who decided to highlight the few calls that slip through the net and are wrongly triaged. SO WHAT?! Out of the millions of calls the services receive that is bound to happen every now and again. There are not enough ambulances and staff to send one to every single 999 call that comes in.  Fact.

What annoyed me most about the programme was the failure to highlight the cause of these delays and lack of ambulances. Yes, we have faced cuts like everyone else but as of yet it hasn't had a huge impact in the amount of ambulances working on the front-line. The problem is that the call volume is going up year on year. This wasn't mentioned once. Nor was the massively high proportion of calls that we go to that are a complete waste of time and resources. No mention of the alcohol related calls we go to, the hoaxes, the split nails, the stubbed toes, the headaches, the colds, the can't sleeps, the noise in ear, the finger injuries, the needing a lifts to hospitals; basically 80% of the work we do. No mention at all that the delays people are facing are caused by the public's misuse of its ambulance service. Despite all of that though, for the first time all of the services met the category A target of reaching 75% of life threatening calls within 8 minutes. Instead of leaving it there and heaping praise on the service they interview people to highlight the apparent cheating that is going on. Calls being downgraded to meet the target? Calls being upgraded to meet the target? Is there any proof that this goes on? All ambulance staff, myself included, moan about the conspiracies, the stitch ups and mis-categorising of calls, but personally I don't think this is done to meet targets. The categories of calls change as new information comes in and I think it's highly irresponsible of Panorama to throw out accusations without a scrap of evidence. Then again, who ever said investigative journalists were supposed to research...?!

In the presenter's introduction he said 'What happens when the ambulance service decides you're not sick enough to get an ambulance?' Well as far as I'm concerned the answer is pretty simple; you don't get an ambulance because you are not sick enough. If the public and the media want an ambulance immediately then give us a budget proportional to the calls we attend. Based on the London Fire Brigade's budget per calls they receive, the London Ambulance Service's budget should be around £3 billion a year. Now mirror that across the across the country and you'll see the shortfall we face. Just imagine how quickly we would arrive with that budget at our disposal! We could probably all sit around waiting for calls, practicing getting into our ambulance really quickly, sending 5 ambulances to an elderly faller and do countless public demonstrations of our equipment... ring any bells? People expect miracles and in this economic climate miracles are not going to happen. 

So, you dial 999....& wait?! Yes. That's life. Build a bridge and get over it.

One tape fixes all

"9 year old ambulance, not feeling well"

When we all buy cars we want something that won't break down. We look at the body work, the interior  and the mileage. Low mileage is always a selling point! When we insure the car the insurance company ask your annual mileage and it varies from person to person depending on the commute. Now take an ambulance; many of them are 24 hour vehicles, 07:00 to 19:00, then a crew change to the night turn on 19:00 to 07:00. This is repeated every day, 7 days a week, 52 weeks a year and only gets a rest when it breaks down. The driving that it puts up with isn't your average drive either. It is driven at speed, at high revs, it's swung around corners, there is repeated heavy breaking and it is pushed to its limits every day. We have a team of fitters who try their best to keep them working but invariably they break, and break often. There are so many vehicles breaking down that they are left doing quick fix after quick fix, and it is not just the mechanical side of things that go wrong. There are cupboards, trolley beds, carry chairs, blue lights, reversing cameras, 2 sets of steps, signage, clocks, Sat Navs, MDT screens, radios and tail lifts; all which get used and abused. 

The other day I was working on a 9 year old Mercedes Sprinter. It had 248,000 miles on the clock and, to be honest, had seen better days. There was a hole where the radio once was, the sat nav was hanging off, all the air con vents were missing, the air con wasn't working, there were no lids for the bins, a cupboard door was missing, there were holes in the seats covered with gaffa tape and the oxygen mounting was held on with micropore tape.

Micropore! The entire ambulance service, infact the entire NHS, is held together with micropore. It is used for everything. It has become a running joke that if something breaks, it's nothing that micropore tape cannot fix. You would struggle to find an ambulance in service that doesn't have micropore tape holding something together. The same applies to the newest vehicles. As with everything in the NHS our vehicles are provided by the lowest bidder and as such the quality of workmanship and materials used is poor. There are 100s of vehicles less than 3 years old and a quick look through their defect books will reveal just how much has gone wrong with them in such a short space of time! It can be embarrassing when a patient gets on board and you see them looking around at the bodge-job of a truck they are in!

About 3 hours into our shift, we were called to an unconscious male in the street. We pulled up to the bus stop to find him lying face down on the floor. Once we were within 6 feet of him it was clear he was an alcoholic; the smell was awful, his clothes were dirty, his hands filthy, his face was flushed and he had the drinkers nose. A quick shake and he was mumbling and groaning away. Unfortunately for our backs he was in no state to stand and stagger without assistance. We opened the tail-lift to get the bed out but it wouldn't open. Nothing we did would make it budge. Bugger! Back to the pre-tail lift way of doing things. We picked him up off the floor, onto our chair, and then lifted him up the steps and onto the bed. We took him to hospital and did the same at the other end. Job done! We then informed control that our vehicle was broken and were told to wait where we were for an engineer to come to us. An hour later he arrived. He looked at the tail lift, opened it as far as we had been able to and then said:

"You got any micropore?"

Micropore in action! 'Now get back to work'

I laughed and handed him the roll of tape attached to my trousers. Sure enough, he had seen the issue and binding the loose switch with tape would fix the problem. Taping complete the tail lift was working like a dream! Off we went to the next job. 14 miles away through traffic, engine screaming, heavy breaking and taking corners at speed. I could hear the vehicle crying in pain.

I guarantee everyone, in any ambulance service, all over the world has used or seen micropore used for something other than what it was intended! It really is the glue that holds everything together! Without it there would be no ambulances on the road! I know in an ideal world broken parts would be replaced, things would be fixed properly, and vehicles would be replaced after a certain amount of years served. Sadly, our government won't allow that. I shudder to think how many ambulances could have been bought with the fines for missed targets. Services are left with making the best of a bad situation. I just wonder how David Cameron would feel if it was his loved one in cardiac arrest in the back of an ambulance and there is a delay getting them into hospital because the micropore on the tail lift has come off?! Hmmmm... maybe taking the money and resources away from the emergency services wasn't such a good idea after all!

We all make do, we all carry our micropore and, in general, make it work for us.

Pass the Donkey - Part 3

"46 year old female, suicidal"

Continued.....

Writing this blog has been a very interesting and worthwhile project, and one I thought I had finished! However, the power and interaction that social media (namely Twitter) brings is debate and opinions from many areas. On this particular job I only sourced opinions from the people and services directly involved on the night; ambulance, police, hospital and of course the patient. What was highlighted was that this job was a 'symptom of a fragmented system'; a system we are all aware of and often vent frustrations against. It was suggested by a number of people that it would be interesting to hear from an AMHP, community MH services or someone with experience in the treatment of mental health. So I did!

Jakki Cowley (@jakkicowley) used to be a practicing mental health and mental capacity advocate. She now has a national role promoting and developing best practice guidance on both Acts (the Mental Health Act & Mental Capacity Act) for advocates and other professionals. With experience in the two key aspects of this job, mental health and mental capacity, I asked her what her thoughts on the job were and what solutions or lessons could be learnt in the future:

"My experience comes from many years working as an advocate, in mental health, learning disability, forensic and acute settings and eventually as a mental capacity advocate.  I now lead on mental health and mental capacity advocacy in terms of promoting and developing best practice guidance, so although no longer a practicing advocate my perspective remains the same – the person at the heart of this process.

I’m lucky and in a privileged position that I don’t have other factors at play when carrying out my job.   I’m there only to find out from the person what they want, what’s important to them, what help they feel they need and how that can be communicated and articulated to others so that their views and wishes are heard and their rights upheld.

In this instance the patient is already known to services.   She threatens self-harm and/or suicide and is known to action these threats.  She’s known to take up a great deal of services time and energy which impacts on how she’s dealt with by all involved.  She’s viewed as a difficult client and that view of her has been set in motion - from the professionals that are familiar with her, those who receive a handover about her ‘difficult behaviour/presentation’ to those she’s never met before - and immediately puts a barrier between her and the professionals involved.  It may not be a conscious barrier, but it exists, she’s viewed as a ‘difficult job to do’.  This leads to a spiralling effect from the private ambulance through to the A & E department and the police call handle centre that means she’s treated as a problem that needs to be dealt with and not a person in mental distress.

But what if she wasn’t seen as a problem?  What if she was seen as a person in distress whose coping mechanisms mean she lashes out, threatens harm to herself but who wants to be heard (she rings an ambulance for a reason even if it’s not apparent).  If she were calmer, polite, rationally explaining why she wants to harm herself, how would she be treated then?  I suspect with compassion.  The issue is the same, but instead the emphasis has become about getting a task done, passing the ‘problem on’, fitting her into a piece of legislation or policy. She has become the least important part of the decision making process. 

@Sectioned_ says it best when she explains she’s in a vulnerable place and needs to be recognised, communicated with and listened to.  Simple yet could make a difference to the process as well as the outcome if she wasn’t viewed as the problem but someone in need and distress who is finding any way of reaching out."

An interesting point was that of not having other factors at play when treating a patient. I think it is often something that hospitals and others services don't understand or comprehend. When the police and ambulance service deal with patients they are often in the public domain and this brings with it its own set of challenges. In this case swigging pints, brandy and wine from strangers' glasses in a packed pub was just one of the challenges we faced. The bystander and the crowd have a lot to do with our decision making process. In a hospital, the nurses of whatever speciality have a cubicle or room in which to treat the patient where confidentiality and due process can be maintained. They generally don't have a sweaty 50 year old drunk man grabbing their arse or the remnants of a Jaegerbomb poured down their neck whilst trying to find out exactly why the patient is suicidal and deserting her wheel chair! A chirpy git leaning over your shoulder saying "I want that one" is not helpful in any way. You also have the onlookers who know best, who all have an opinion and are not shy to share! 

Viewing the patient as a problem is in itself, a problem. Yes, I agree tact and differing approaches are needed but again it comes down to luck. There are 1000's of different combinations of ambulance crews and 1000's of police officers. Some will be willing and open to go the extra mile, some won't be. There are times where I have been faced with 'someone in need and distress who is finding any way of reaching out' but if reaching out means I get verbally abused, spat at, punched, kicked or vomited on, then that is where the 'reaching' will stop; I'll be reaching for my radio and requesting police, and so starts the cycle again. As much as we all want to do the right thing, circumstance, guidelines and personal safety all get in the way. That is the flaw with pre-hospital care. We are in unknown, uncontrollable, often volatile environments, with not only the care of our patients to worry about, but the risks they may pose to unaware members of the public.

Jakki continues:

"The Mental Capacity Act in this instance doesn’t apply as she’s assessed to have capacity.  However if she was assessed as lacking capacity and it was deemed in her best interests to take her to hospital, consideration would need to be given to the use of force and/or restraint and whether it was necessary and a proportionate response to protect her from harm.

However section 136 of the MHA was the therefore used and the place of safety in this instance was a hospital. But it doesn’t need to be.  Local policies and procedures should consider a range of options that may be more appropriate and have a less detrimental effect on a patient.  Whatever their presentation, consideration should be given to the impact on the person’s mental health: will the place of safety exacerbate their distress for example; what environment would ensure a mental health assessment runs more smoothly, would a relative's home be a more temporary appropriate option?  

To end, given this is a complex case with a person with a long history of presenting to services, has her mental health AND her capacity been thoroughly assessed and is there a need for a multi-agency safeguarding meeting to progress the case long term so that all agencies are working together?  Also, given the numerous professionals involved, should she be given the option of having an independent advocate?"

The most frustrating observation from doing this project is that all of the services seem to be singing from the same hymn sheet; the ambulance, the police, the hospitals, the mental health services and the patient all want to work together to find the best outcome. It's a shame we are just the people doing the work. It's a shame we are the ones in contact with the patients. It's a shame politics and budgets play such a huge part in patient care. The concept of 'failure demand' is painfully evident in all facets of mental health care. There is a huge failure to do what is needed, and what is done is not being done properly. That is what let this patient down to a point. None of the services she interacted with on this occasion can be free from blame, likewise, neither can she. Her actions, albeit triggered by cause and a lack of appropriate care and management, put us in a no-win situation where the police are our only option, as only they can restrain and section. Not at all ideal for any party involved, but everyone did what they had to do to cover their asses as Laptop Cop eluded to. I have no doubt her behaviour is a symptom of her mental illness but we can only act on what we see in a moment. We knew her on this occasion but another crew may not, and without any prior knowledge of her history, her actions cause a barrier to be put up between her and those who are there to help.

If all services were allowed to work together, like we all clearly want to, then change can and will occur. Maybe if more people could see that through social networking different aspects of the health services are indeed trying to understand each others' roles better and then perhaps that could be transferred into improving patient care. At the end of the day that is what we are all here for; the patient. How can anyone expect a patient to buck a trend, make positive changes and take steps to get better if the very services there to help them won't do the same? Just sayin'!

I'd like to thank Laptop Cop, Mental Health Cop, @jakkicowley and Stewart Thomas for their input on this project and a special thank you to @Sectioned_  for sharing her feelings and experiences from the patient's perspective. EMS and police blogs can be very one sided I feel that, in this post especially, the patient's view was the most crucial. I recommend all their blogs and Twitter accounts for anyone interested in policing, health care and mental health.

Pass the Donkey - Part 2

"46 year old female, suicidal"

Continued........

When we arrived at the hospital we were not greeted with open arms; in fact, quite the opposite. For the first time in my career the charge nurse refused to accept the patient. He didn't 'want her nonsense' in his department. As far as he was concerned she had been discharged from A & E and was not his responsibility. Obviously I didn't take this lying down but at the end of the day I have no power at all so we went and waited in the corridor like naughty school children until someone above my pay grade could decide what to do next. Obviously there were implications for our patients current mental state. I can only imagine what it must feel like to be taken somewhere you don't want to go and then be refused entry the place you have been assured will look after you. She did not take kindly to this rejection and despite the corridor being full of other ambulance crews and their patients she continued to scream, shout, swear and abuse. It was frankly embarrassing and something the hospital has a responsibility to avoid at all costs.

I felt it was important to get the hospitals view so invited Stuart Thomas, a charge nurse in a busy city hospital. I asked him how he felt about regular patients, suicidal patients and what he would do in this situation if presented to him and if there are circumstances in which a hospital refuses patients:

"From a nurses point of view, there isn't really a question of whether to accept hand over or not, the patient 'claims to be suicidal' so the patient stays to be assessed for suicide risk and medical clearance with an aim to refer to mental health services. Standard practice for any mental health patient. 

Capacity needs to be assessed and documented, if they have capacity then at least if they leave, your partially covered. 

So the treatment of the patient in question, isn't really an issue, it should happen, it needs to happen and clear discussion about the management of this patient should be carried out with the mental health team. 

What's more concerning in this case is the aspect of staff safety, without knowing why the police were called it's difficult to assess however standard practice can be carried out, nurse in two's, remind staff to look after personal safety, clear exit points for example. Request security to be nearby to maintain staff safety. If the patient kicks off then police get called, senior review and look at other options (section by mental health team or prison or sedation...but not too much or the mental health team won't be able to assess) 

What people often forget with frequent callers is that every episode should be treated separately, with respect and dignity, something I pass onto staff constantly. 

This case when broken down is simple and clear cut. Easy to manage with the right input."

Clearly, for the second time in an hour, the proper procedure was not followed and again we were left in a situation where I was unhappy and the patient was getting more and more aggravated. As we couldn't stay with her indefinitely and as the hospital would not accept her I had no choice but to call the police back. After 5 minutes we got the following message:

"No units to send, we will not be attending unless requested by the hospital. We have already attended this CAD"

So now we were stuck a corridor with nowhere to go and no plan ahead. I then asked the patient to get off our bed and sit on a chair. She refused. I'm guessing it was her chance to fight back and in a way I don't blame her. We had effectively been playing the kids card game 'Donkey' where the object is to make sure you are not left with Donkey at the end of the game. That was no different to this situation, as crude an analogy as it is, to look at the mental health patient as the donkey. As an ambulance service we want either the police to take charge or for the hospital to take her. The police didn't want to get involved as it would tie up officers for hours and the hospital didn't want to know because then they would have the responsibility. We were stuck with the 'donkey' with no one to pass it to. A cruel analogy yes, but despite knowing what should be done, no one seemed willing to do it on this occasion. We sat in that corridor for a further 2 hours, totalling 4 for the job. When she got off of our bed and used the hospitals toilet she became their responsibility so we left. Not ideal for the patient but what could we do? It is therefore only fair to get one more opinion on this. 

I'd like to introduce @Sectioned_ who has been a patient who's experienced the our ailing mental health system and has had dealings with the police, ambulance and hospital from a patients perspective. I asked her what it is like to be a patient in a similar situation. What is the mindset? Where no one wants to know, being forced to do things you don't want to do and having doors closed on you by the services supposedly there to help:

"When you’re suffering extreme emotional distress, let’s face it: you’re not at your best. You may not be great company or easy to deal with. That’s because you’re in pain. Not the bleeding-from-the-head-put-on-the-oxygen-mask kind, but pain nonetheless. And you want that pain to stop. But you don’t know how to make it stop. And you don’t necessarily pick the best options for making that happen because you’re not in an especially “resourceful” state of mind. (At least not in a helpful way: after all, swigging from strangers’ pints is a pretty resourceful way to get drunk and blot out the pain … but it’s never going to end in a good way.)

Whenever I’ve dealt with emergency services personnel, they’ve arrived at a time of crisis. Of course they’re human beings, good and bad; but in a crisis they interact in institutional ways, according to training, codes and protocols. They’re there to do a job, which is to somehow resolve the situation that presents itself to them in the moment.

They’re not there to fix your life. They’re not your mummy. They don’t love you. Similarly they’re not the housing benefit office that’s just written to say your benefit’s being cut; or the doctor’s receptionist who didn’t give you an appointment right away; or the hole in your pocket that meant you lost your purse. But it’s all these sorts of things and a million others that will be pressing on you in that one moment to contribute to your emotional distress.

Sometimes when you don’t know how to deal with these emotions you end up feeling completely worthless. Totally messed up. That you’re a burden. That people would be better off if you were dead. And that you’d be better off dead.

But here are the emergency services standing in front of you, trying to get you to do something you don’t want to, like move here, sit there, when all you want to do is cry out in pain. The priority of the emergency services is not to make your pain go away. Though they might well see you as a pain to be resolved, one way or another. 

This woman needs help with how she copes with her life. She needs coordinated mental health, physical health and social care services; pre-emptive measures. Each time she calls on the emergency services, it's an example of "failure demand": a demand generated by the failure to do something or to do it right ("Failure demand" is a concept invented by occupational psychologist Professor John Seddon and introduced to me by @MentalHealthCop.). It’s not about who’s going to transport her, or whose bed she sits on. These practical problems, which the emergency services are tasked with solving, are merely symptoms of a fragmented system that’s clearly been passing her around between different services for long enough for her to be seen as a right royal pain in the nether regions."

I decided to do this blog out of frustration. Frustration the patient didn't get the treatment she was entitled too. Yes, she drains resources, yes, she is often abusive and yes, she is an extremely difficult patient for us, the police and the hospital to deal with, but this does not negate anyone's responsibility towards her. Stuart Thomas summed it up perfectly. 'Easy to manage with the right input'. I think the one thing that is apparent after gaining a variety of opinions is that a lot depends on who you get. Like in every job there are good eggs and bad eggs. There are people at the start and end of their shifts. There are people who have passion about certain areas and not about others. There are good people on bad days. Luck has a lot to do with it. What that proves I don't know, but I think it does highlight the need for more communication between services, mental health teams AND patients. The patient's voice often goes unheeded but is one which I feel should carry the most weight. I think this is much more pertinent in mental health as we are not adequately trained to deal with it and therefor don't understand their mind-set and what does and doesn't help. If there was an open dialogue and agreements between services in place this job may not have escalated like it did. Personally, if the PRIVATE ambulance hadn't kicked out a vulnerable adult onto the street I probably wouldn't be writing this blog in the first place! Just saying! *cough NHS Bill


To be continued........


Part 3 - Click here

Just a Personnel Number

"25 year old female, stuck between a rock and a hard place"

Being a relatively new member of staff I'm a 'relief'. This basically means that although I am assigned to an ambulance station, I can be sent to work with anyone, anywhere, without notice. Your shifts change daily and you work a horrible rota. In fact the rota is affectionately known as the 'divorce rota'. That maybe something to do with working 7 out of 10 weekends, mainly lates and nights and having no social life whatsoever. I did two and a half years on the relief rota before I had a change, albeit temporary! I got a 'ghosting' which means I cover a gap on a 'core line' at my ambulance station. I got a permanent crew mate, a permanent rota, less nights, more weekends off and a social life. I knew exactly what I was doing for 6 months in advance. Sadly this has come to an end and I'm back on relief.

As horrible as it is, I think relief work is a good learning tool when you are new. You see different parts of the city and work with so many different people. I don't think it should be pertinent though. It takes a lot out of you physically and emotionally and your rest days end up wasted on sleep. Having to do 9 12 hour shifts in 10 days is a grind. Runs of 5 12 hour night shifts in a row is a killer and working with someone new every day is difficult. You don't get a routine, you end up 'attending' more often than not and end up existing rather than living. The rota itself is not fit for purpose and despite 4 years of promising that it is changing and / or being scrapped nothing has happened. No shock there! Despite it's failings it's seen as part of course. A right of passage if you will. Getting a permanent line is the goal. Having had the same crew mate for 6 months and a constant rota I can testify to it's benefits! It makes such a huge difference knowing who you are working with, knowing you can drive and attend on alternate days, being able to make plans instead of having flexi-weeks where you might or might not be working. Having someone you can rely on, someone who gets how you work and does things without asking. Even having a conversation you can carry on the next day is a big thing. The problem is, like everything, relief work has changed, making it much more of a drag and contrast to those with permanent crew mates. Whereas until a year ago you were on your home station more often than not, occasionally being send off to an adjacent complex, now it's quite the opposite. 

In an attempt to meet targets management (senior, not station) came up with the idea of 'priority complexes'. In areas where call volume is high and concentrated, reliefs are sent to man vehicles there instead of their own area no matter how far away it is. As the percentage of calls meeting targets in that area has a greater impact of the overall target for London, this has continued. It doesn't matter if some areas are neglected because in the big picture of targets they are succeeding. Apparently. As a result though, reliefs in my area are spending weeks on end without ever seeing their home station. Instead they are sent miles and miles away, with no consideration to cost of travel. Mileage can be claimed but you don't get it for at least 2 months and it's a very complex form to fill out. Most don't bother. It has now got to the point where people are being sent 20-30 miles away because that area is the new 'priority'. For me, I've been given my shifts for the next month. I have 2 on my station. That is only 2 that I can cycle to. Instead I have a 75 mile round trip from home to get to work every other shift, most if which will be through rush hour traffic. 

I cannot afford this. I won't go into my financial difficulties but all you need to know is times are hard. I'm barely keeping my head above the water as it is. I've raised this with my union, resources and management. 'Tough' was basically the response I got. It says in my contract that I can be expected to work wherever operational requirements need me to. Obviously this is being abused to its fullest but who am I too argue. I'm just a personnel number. With travel time and a late finish I'm looking at 5 consecutive 16-17 hour days followed by 1 day off then another 4. I'm facing the very real prospect of having to find another job as I simply cannot afford to get to work. It won't be medical work either. Let's not forget, I have no qualifications. As a student paramedic I get no recognised qualifications until I fully qualify as a paramedic. As the final part of my training was cancelled due to 'winter pressures' and then deferred a year due to 'olympic pressures' I have nothing to take with me to another employer. I could be the best part of 4 years down the shitter. It's worth noting that the contract I signed said I would qualify as a Paramedic within the 3 years that the fixed term contract runs. It appears they are allowed to breach their part of the contract but I am not! It's also worth noting that my current, modified, fixed term contract ends just after the Olympics and BEFORE I'm qualified. I'm yet to receive a new one telling me I have a job even if I qualify. The cynic in me tells me to get down the job centre, stat!

In all honesty, I'm gutted. I've given everything to the job. It's a job I love and a job I have made HUGE sacrifices for. My marriage being one of them. It is called the divorce rota for a reason! I came into this seeing it as a career for life. It's a shame that the lack of respect for staff and the way we are treated with utter contempt by resources and management could be putting an end to that. Do resource staff have uncertainty about their rota and financial penalties for being sent from pillar to post? No. Do management have to be abused with 72 hour weeks? No. Do either of them work without proper contracts? No. Just student paramedics then. I don't want to leave, far from it, but if things continue the way they are I'll be one of the 25-30 staff quitting every month. By the way, none of the 400+ staff losses per year are being replaced. None. Why? Ask David Cameron and Nick Clegg. 


To what end will this continue. It is clear, despite the propaganda that patient care is not the priority. Staff wellbeing is an annoyance they have to pretend to do something about when in reality they don't give a crap. How many disillusioned staff have to quit before senior heads roll. If you speak to any EMS they will all tell you the exact same thing.


"It's a great job, I love the job, I work with great people but it's ruined by crap management"

NB: Today, 12th March 2012 I should have started work as a registered Paramedic having completed all my training. Instead I have an 11 month wait, 'operational pressures' pending! There's a morale boost if ever I've seen one. Anyway, got to go, got to give some training to Community First Responders, unpaid and in my own time on a rest day! Seriously! Mug!

It's Happening

"42 year old male, fallen down stairs, ? # leg, obvious deformity"

Clearly a bad day at the office! We headed round to the address. The door was open and Dave was lying sitting at the bottom of the stairs. There was absolutely no doubt his ankle was broken. Badly broken in fact. Seeing bone protruding from the skin is never a good sign. We dosed him up on Entonox and gave him Morphine. On the count of 2 of 3 I pulled the ankle to straighten it. He screamed, I cringed, it wasn't pleasant but totally necessary. We got his leg splinted and transferred him to ambulance. It is at this point where the NHS bill will change things. 

Pre-NHS Bill

• Up to this point it would have cost Dave nothing.
• He will be transported to the nearest hospital.
• He will be put in a cast.
• He will have an x-ray.
• He will have surgery. 
• He will need medication.
• He will need crutches.
• He will need physiotherapy. 
• He will be off work for 2 months.
• He will be charged £7.40 for each prescription he needs.
• He will be grateful for the treatment he receives.

This is how it works. This is how it has worked for decades. This is fair. Everyone gets the same. This isn't going to continue. 

Post NHS Bill 

• Up to this point it would have cost Dave a nominal fee for calling the private ambulance.
• He will be transported to the nearest hospital should he wish to be.
• He will be put in a cast at a cost.
• He will have an x-ray at a cost.
• He will have surgery at substantial cost. 
• He will need medication at a cost.
• He will need crutches at a cost.
• He will need physiotherapy at a cost. 
• He will be off work for 2 months at a cost.
• He will be charged uncontrolled charges for each prescription he needs.
• He will resent the treatment he receives.

He will be left with a bill that could be in excess of £30,000. Why? Because Dave is self employed and cannot afford the expensive monthly premiums for Health Insurance. Dave is a victim of NHS privatisation. Dave will walk with a limp for the rest of his life because he couldn't afford the surgery or the physiotherapy. Dave suffered in pain because he could only afford Paracetomol. Dave picked the things off the price list he could afford. Next time Dave won't call an ambulance. 

Dave won't be alone. How many people can realistically afford over £100 a month or more for medical insurance? The private health insurance company are already starting their campaigns and as predicted, are not targeting the people who need treatment for severe chronic conditions. These people will sadly be priced out of the market as it isn't 'cost effective' to insure them. Instead they are targeting the 'fit & well' who don't need and are unlikely to need any treatment. They will be profiting from fear alone and the vulnerable with be left by the way side.


Let us not be fooled into thinking we will no longer pay national insurance. Of course we will. We just won't get anything for it. How many people like Dave with have to sacrifice their well being because they are not well off? How many of the elderly will refuse to call an ambulance through fear that health care will cost them their home? This is the reality of what the NHS Bill will mean in the long term. It starts with a bit a outsourcing and before you know it, we are the USA, where every politician receives financial benefits from the "Health Care' companies that are crippling its population. These proposals are a complete joke and regardless of the spin that is put on the NHS Bill, this is where it is heading. We will no longer be the world's biggest 'free at point of contact' ambulance service. We'll just be another money grabbing, profiteering ambulance service owned by a faceless millionaire. We will no longer have an NHS where everyone can get treated free of charge regardless of social status. We'll be all be treated in relation to our wage packet. The only people who stand to benefit from this are the Eton Old Boys who run this country for their own personal gain. It's happening.