Gangs, Knifes and Amnesia

"19 year old male, stabbed in back"

Working in a city, we see our fair share of knife crime. It happens much more regularly than the media report. In reality you only hear about it on the news if its a teenager who has been stabbed or rich white man was stabbed by a black man. In practice, stabbings occur every single day and 99% of it is young males in gangs. The dispiriting truth about the cities gang culture is that it is not only large, with at least 100 gangs, but it attracts ever younger children. There must be worthwhile alternatives for young people to gang membership, not just limited to sports centers. Education is the most powerful force for change: government-driven improvements in schools in deprived areas will, it is hoped, offer teenagers more fundamental alternatives to the gangs, by providing them with the skills and discipline to aspire to employment and further education rather than an existence as drug-pushers.

The London riots showcased to the world the gang culture that exists and the roots of these appalling events are many and complex but none more so than the way Britain's educational establishment has cringed helplessly in the face of ever increasing gang culture; a culture that rejects every tenet of liberal society. It's violent, it's sexist, it's homophobic and it's racist. Unfortunately,  it is broadly tolerated by many people in the poorer communities, which has lost control of its teenage youths. Those youths scare the wits out of teachers and social workers, the public and police officers. Knife crime is rife and not enough is being done to stop it. There is no parity in sentencing for offenders, not enough police resources available to tackle the issue head on and not enough incentives for these young people to buck the trend. In London alone (I choose London because they are the easiest statistics to find!), there were 7,231 knife crimes in 2010/2011, a 29% increase on 2008. There sits evidence enough that the issue is not being tackled and whilst there are Conservative promises of more cuts to front line police the numbers will simply increase.

We were called to an address in rough part of town. Music was blaring, there were scores of people loitering with intent outside the address, buzz words such as 'retribution' and 'revenge' were being branded about. This was clearly gang related but for us, the problem with gang related stabbing is the clear and concise history! Our guy was stood in the living room, tempers were high, testosterone at critical levels and don't even get me started on their dress sense! He however was topless, bleeding from a rather large stab would in his back. I was concerned about the levels of air entry in his left lung and was keen to treat as I found, however, he didn't want treatment, he wanted to go out, I assume, tooled up looking to hit back at the rival gang. Nether the less, the police assured him he would be going to hospital. Now the history.

"So what exactly happened?"

"I don't know"

"What were you stabbed with?"

"I don't know"

"Who stabbed you? Was there a gang of them?"

"Can't remember"

"Did you get in a confrontation?"

"No"

"Where did this happen?"

"Cant remember"

"So you were just walking alone, realised you had been stabbed, but didn't see anyone, hear anything or feel anything?"

"Nah, I got back to yard yeah and my home boy told me I was bleeding, innit"

Wow! Amnesia is so frustrating. To loose the memory of such a memorable event must be a nightmare. How on earth will the police catch the bad guy? In a word, they won't. They will continue to chase their under-resources tails until they come across another teen. Dead. Stabbed by the guy with amnesia. And why? I can't remember!

This guy didn't die but also didn't appreciate the significance of what had happened. It was just another day. Gang life. It comes with the territory. For too long, the less affluent areas of society have been left to breed this hatred and it is now endemic. The softly softly approach clearly doesn't work, job and financial incentives are futile because more money can be eared in pushing drugs. What is needed is 0 tolerance, long prison sentences, removal of benefits, confiscation of property. What the government needs to do is give the police the powers to stop this mindless violence and criminality in its tracks but instead, they have a different solution. 16000 less officers! Genius! That'll fix the problem!


#AntiWinsorNetwork

Above my pay grade

"71 year old male, shortness of breath"

I don't profess to be a GP, nor do I wish to be or act like one. Like nurses GP's range in quality from helpful and polite, to rude, obnoxious and verging on negligent. Many wasted ambulance hours are spent picking up the slack for GP's not willing to do their bit and simply taking the easy option and clogging up a hospital. This is party due to a lack of GP's available during out-of-office hours and partly, in my opinion due to laziness. One consequence of the opt-out policy, which was part of the new GP contracts which came into effect in April 2004, is that the overwhelming majority of England's 298 primary care trusts were left with a huge gap in their budgets as they take on the burden of the out-of-hour service. A burden that has not been dealt with correctly and one which is causing unnecessary strain on hospitals and the ambulance service. Ask any member of the ambulance service, or any nurses if they wanted to 'opt out' of working crap hours and you'd get a resounding yes. There are 24 hours in a day and unsurprisingly, people are in fact ill, between 5pm and 9am. Shocker! 

In recent years ambulance services have begun to move away from just taking everyone to hospital. In fact, if a patient can be referred and left at home that is preferred. One of the alternate care pathways (ACP) is a GP referral. We assess the patient, if they don't need to go, or refuse to go, we arrange a GP to call or visit. This applies to the out-of-hours GP service too. And in general it works quite well, a GP will ring, talk to the patient and either make an appointment or come and visit. On occasions where we have concerns for the patient we will speak to the GP and politely request / insist they do visit. Like with everything, you get good and bad GP's. Some will come out at any hour, will do the right thing, go the extra mile and be polite and courteous whereas others, won't come out for love nor money, will be dismissive rude and lazy. I mean, it's not as if we should expect them to see ill people at night on a meagre £100,000+ salary. Absurd!

This particular job, was very common. An elderly guy, having trouble breathing, but despite all the advise in the world refuses hospital. I'd imagine it's partly from pride and wanting to not be a burden and partly fear, not wanting to die in hospital. Either way, he wasn't going. We did all of our checks, the full work up, sitting and standing blood pressures, ECG and a advanced respiratory assessment. We arranged a GP referral and said to our control it was imperative that a GP visited this guy. We completed the necessary paperwork and went back to the truck! Not 3 minutes later, and our patient appeared at the door, beckoning us to return. He told us the GP had just phoned, didn't ask any questions about how he was etc and told the patient to make his own way to the local hospital and see a Doctor there. Needless to say, our patient told us he wouldn't be going to hospital.

Steam pouring out of my ears I phoned control and asked that the GP phone me directly on my mobile. I was livid. What is the point? What chance do we have of unclogging emergency departments when the ACP's in place can be abused by the unwilling and lazy. After 15 minutes my phone rang. It was the GP.

"Hello there, I was informed you wanted to talk to me"

"We requested a GP visit for this patient as he has poor mobility and would benefit from seeing someone with the ability to prescribe medication, the patient isn't well but is too scared of hospitals to go. He says he was told to make his own way to hospital"

"That's correct, I assessed him over the phone"

"You didn't ask him any questions about his health, his mobility or reasons for refusing hospital, he uses a frame, has no family and is scared"

"Well if you're that concerned you should have taken him in"

"We can't kidnap him, he has capacity and has refused admission. That's why we referred to you"

"In all honesty love, you are talking above your pay grade, I've made my decision, and you aren't qualified to question me"

Wow! He picked the wrong girl to mess with tonight. Needless to say, an argument in sued. It wasn't an argument I was ever going to win but one that made me feel better. I was able to rant about all the above. I told him exactly what I thought of him and I didn't hold back either! I went to town on him. We exchanged names for counter complaints, I even offered my call sign and personnel number. Pay grade, really? He went there? The arrogance and self proclaimed greatness was enough to make me seethe for hours and I did. It was like a red flag to a bull. My crew mate looked on in fear as I screamed and shouted (off the phone by now) at him about bloody GP's. When will they realise that we are no longer stretcher monkeys. Many have degrees in paramedic science, some have masters, there are Emergency Care Practitioners and in general, we are good at determining if someone is ill. When will we get the respect we deserve? We all work for the same team and the sooner the other medical professionals stop treating us like the kid that was never picked for anything, the better state the NHS will be in. By 'better state the NHS will be in' I mean the happier I will be! Lets be honest, being nice won't make a blind bit of difference to the NHS as a whole other than remove animosity and ill feeling between two bodies of people who are essentially working for the same team!

Clean up on aisle 3

"72 year old female, generally unwell, at GP surgery, chair required"

A pretty standard job for a Monday morning. Mondays are a funny day. GP's tend not to work weekends,  so on a Monday morning everyone who is everyone flocks to the GP surgery like migrating buffalo and sits there waiting for their various ailments to be examined. As a result GP's phone a lot of ambulance to alleviate their strain. This particular patient was sitting in the waiting room with a wicked grin on her face. She was basically doing a stand up routine to all the ill and needy that Al Murray would have been proud of! Every one around her was smiling!

"Last time I was here I went up to the receptionist and said there's something wrong with my vagina"

"You shouldn't come into a crowded waiting room and say things like that." 


"Why not? You asked me what was wrong and I told you," 


"Now you've caused some embarrassment in this room full of people. You should have said there is something wrong with your ear or something"


"I walked out the door and came straight back in and said I've got something wrong with my ear. The receptionist nodded approvingly"

"And what is wrong with your ear, madam?" 


"I can't piss out of it,"  


The waiting room erupted in laughter. What a character! I'd heard the joke before but she delivered it so well. We explained we had a chair for her. As we assisted her to standing she let rip! And I mean with gusto!

"Sorry about that, had egg and beans for breakfast"

Whilst trying to maintain some form of professionalism my crew mate managed to do the British thing of 'Keep Calm and Carry On'! Me? Not a chance, I couldn't stop laughing. She just farted! It's funny! Fact! We wheeled her to the ambulance, transferred her to bed but in doing so, she let rip again but this time we were in a metal tin.

"Sorry, how un-ladylike, that's not going to be pleasant"

I was beyond help, I was supposed to be treating her but I couldn't control the laughter. I was shaking! Verging on a seizure. With a raised eyebrow the keys were past to me and my pen confiscated. It was a sign I was to remove myself from the situation. As I stepped over my crew mates legs to get out, in the most ungainly of fashions, she did it again. This time though her tone changed, she had 'that look' on her face and the sudden smell told us all we needed to know, but she put it so well.

"Oh dear, clean up on aisle 3"

This is the kind of humour you'd expect from a drunk 20 year old but a sober 72 year old who is apparently ill? Amazing! It made our day to meet such a lovely, funny, albeit smelly woman. This is why our job is the best job in the world! You'd pay good money for that calibre of entertainment yet we get paid to watch it first hand! I didn't stop laughing for a very long time. Even writing this blog I can't help but giggle! Everyone hates monday mornings, that will never change but a little laughter goes a long way to improving ones mood!

To Blue or Not to Blue?

"30 year old male, unconscious"

Can I just say, before I rant, I like nurses. Most, who I come into contact with are very nice indeed. Some are a bit moody, some are a bit snappish, some epitomise the 'matron' we all fear but generally I won't have a bad word to say about them. Generally.

We arrived on scene and soon realised it was the same guy we picked up yesterday. An alcoholic. He was a young guy, about 30, well dressed, but clearly fallen on bad times. He was lying at the bus stop, on the floor, empty bottle of vodka next to him. A picture paints 1000 words. Attending so many alcohol related calls can and does become frustrating and it's easy to become complacent and lazy. I try not too. You never know when complacency will bite you in the arse. Due to my over caution and paranoia this 'drunk' got assessed and treated the same as everyone else.

A quick primary survey told me his airway was slightly compromised, his respiratory rate was low, around 8 breaths a minute, and he a weak radial pulse, probably due to low blood pressure. We loaded him on to the bed, I inserted an oropharangeal (OP) airway and my cremate 'bagged' him while I put some fluids up. We also raised his legs to try and raise the profound hypotension. At the end of the day, this guy may be drunk, but left to his own devices, was in real risk of dying through positional asphyxia or aspiration, not to mention the long term effects of alcohol abuse. Alcohol damages almost every organ in the body, including the brain. The cumulative toxic effects of chronic alcohol abuse can cause both medical and psychiatric problems.

I only ever pre-alert the hospital if I genuinely believe the patient is severely ill, at risk of rapid deterioration or there is airway compromise. The fact this guy was tolerating an airway, was unresponsive to fluids or any pain stimulus I deemed that he warranted a blue call. The fact his condition is self inflicted has no bearing on the clinical decision making process.

We arrived at our local hospital. Every crew likes their local. They know the staff, the staff know them and it generally makes for a more pleasant experience. We went straight into resus, transferred patient to bed and began a handover to the waiting Dr. During my handover, the nurse in charge came marching over.

"I knew it would be him, he certainly doesn't warrant a blue call, you should know better"

"He's GCS 3, tolerating an airway and not responding to treatment, that's airway compromise. Blue call"

"No, it's a waste of my bloody time. I'm just gonna stick in 2 grey cannula's, give him a litre of fluids until he wakes up then let him stagger out"

"And there lies the problem"

"What would you know, I spend all day every day in this department and you clogging up my resus with pissheads doesn't help"

On that note, I walked out rather than get embroiled in an argument I wasn't going to win. She had a chip on her shoulder the size of Peru and views ambulance staff as untrained stretcher monkeys who bring her work. She was rude, dismissive and in many ways, adding to the problem. Professional courtesy is a big thing for us. We are treated like the pond life of the NHS food chain by GP's, some nurses and our own management and without good cause. They may not have faith in our abilities and that's fine, but there is no need to be rude and condescending. Like nurses, we work long hours, are treated like crap by peers and patients alike but at the end of the day we are doing a job. We are working for the same team. If someone phones an ambulance, they get one. If that person wants to go to hospital, we have to take them, and if that person is unconscious we will take them. That's how it works. What does she want us to do? Leave him in the street? Dump him in the waiting room? Has she not heard of the duty of care or is it only something that applies if she deems the patient to be deserving enough of her oh so valuable time. I for one will continue to do what I do, treat how I treat and 'Blue in' who the hell I want to regardless of her issues and PMT. The funny thing is, if we hadn't blued him in and gone to triage with a patient with an OP airway being bagged not only would we have been sent to resus but would have more than likely got a complaint!

This job also highlighted one of the major problems with the NHS. As the nurse said, she was basically going to wake him up and push him out the door. Yet she seems surprised that he is back the next day. And the next and the day after. What he needed was help. I spoke to his family. He is a good guy. He had a good job and wife he adored. She died. And so will he unless he gets help. For too long the NHS has been throwing money at 'cure'. Perhaps if that same money was thrown at 'prevention'  in the long term maybe those cut backs may not need to be so severe. 

Unions, Strikes and Scabs

I ummed and arred over writing this blog but like most things I ponder over, I end up doing them anyway. I pondered because as is often the case my views are not popular but hey ho, they are my views and I don't try and encourage anyone to agree!

The ambulance service is a very unionised institution. Staff are actively encouraged to join one during their training or once they are posted to a station. I am with Unison. I am with them because they are the only union represented at my station and because unions in general are very good if you need representation with any issues at work. They also try to act in the best interest of their members when it comes to government policy and changes to working conditions. They are however biased and i believe anti-democratic. They are very closely aligned to one political party and dictate everything from policy to leaders. That is where a high percentage of our monthly fees go. As their affiliated party is not currently the party chosen by the people, I think its fair to say, that that is their motivation behind persistent strike threats. 

As most of you are aware, the government have been making some very radical and drastic cut backs to reduce the national deficit. One of the main things to effect us and all public sector workers is changes to our pensions. They want us to pay more, work longer and receive less. Obviously, we don't want this. Why would we? We work hard enough and long enough as it is and quite frankly, we feel we are being treated like crap. After much deliberation, Unison decided to ballot its 1.1 million member on strike action. The result was a 78 per cent majority, with 245,358 in favour and 70,253 against, on a turnout of only 29 per cent of the members balloted. Whilst I don’t agree with the length to which the government are going I also don’t believe the unions are being realistic in their demands. This country and Europe in general are financially up shit creek, and without drastic measures, further financial misery is inevitable. Yes, it wasn’t our doing, it was the greedy bankers but everyone has too pay the price. It’s just how it is.

I for one won't be striking for a number of reasons, and its not because I'm happy with what is happening, I'm not. Firstly, I don't agree with striking. I don't believe that what is essentially blackmail, is the correct way to make a case for what you want. Secondly, I joined the job to help people. It wouldn't sit well with me to stand on the picket line knowing that people would die or suffer because of our action, and they would. I assure you of that. There may well be a skeleton staff running but not all the holes will be plugged. People wont phone 999 because we are on strike and that is not what the ambulance service stands for. Finally, from a selfish point of view, I can't afford to lose a days pay! If I have to work on the 30th November, I will. I will make no apologies for it  and if that means I have to relinquish my union membership, get called a scab and take flack in the mess room then so be it. I've never been one to suffer fools gladly and I wont start now. Everyone has the right to do what they believe in, but I feel union culture removes that. The 'us vs them' attitude puts walls up with can't be easily removed. 

As well as my personal reasons for not striking I believe there will be much greater consequences should the strike go ahead. Public opinion and trust in the ambulance service will be damaged and it's not David Cameron or Nick Clegg who will bare the brunt of that, it's us. As per the riots, public frustrations against the government will be aimed directly and the people on the front line. The strikes of 1989 had great public support but today, the public are in the same boat as us. Everyone is being pinched financially and I don't think they will accept us putting lives at risk for money at a time where they are become increasingly sympathetic towards the governments cause. The government itself wont tolerate it either. Striking is becoming more and more frequent and at such unstable economic times, the government will not be held to ransom. As unions repeatedly push with strikes and threats of strikes based on low turnout they are making the case for legislative reform even more compelling and much harder to resist. Having striking made unlawful will mean the end of any positive dialogue and that will not be in the best interest of its members. 

For what has been billed as 'the strike of the century' turn out was poor, very poor indeed! It doesn't convey the showing of strength that was promised nor does it show that members have any confidence in their unions.  If the strike goes ahead, it will do so on the say so of less than 25% of it's members and although it may be enough to legally go on strike I don't think that it conveys the right message. It smacks of desperation, a final roll of the dice that if unsuccessful may end any hope of protecting our pensions and working conditions. It also poses the question of whether we need unions any more. Unions were founded when workers had no rights but times have changed. All workers are protected by law to such a great extent now that the need for union representation could just as easily be filled by any solicitor, most of which can be obtained free of charge. The unions clearly don’t have a majority of support from their members, through either frustration, disillusionment or apathy, and without full backing and confident of it's members the once booming voice of strength is now nothing more than a polite whisper.

I'm all for taking the fight to the government, whether it be pensions, working conditions or wages but it needs to be done in the right way without compromising what the ambulance service stands for and without bias from political agenda. We are there to help the public at their greatest times of need (yes we moan about the drunks etc but still....) and that principle must not be lost in the fight for our working rights.