Suffering in Silence

"30 year old male, suicidal, depressed"

These types of jobs are quite tough to deal with. They don't require any treatment that we can give. All we can really do is take to A & E with is as much use as a chocolate teapot or refer onto a GP. What we can do is talk to them, but often they are in that position because they are not good at opening up. Least of all a complete stranger. We arrived at the flat and our patient, James, cut a sorry looking figure. He looked scruffy, unshaven, bags under his eyes and his clothes appeared dirty. He invited us in and sat on the sofa. It was a friends flat. He was just staying as he'd just come out of a long term relationship and had no where else to go. I sat there while he told me about the past year of his life and to be fair, it sounded pretty shit. His marriage had broken down, he was struggling with only seeing his children weekly, his new relationship had also ended badly and a number of relatives had died. He'd lost everything as far as he was concerned. 

He went onto tell me that three nights previous, while drunk and feeling particularly low he had tried to kill himself by means of an overdose. Obviously, it was a cry for help and he was feeling ashamed of doing it but it happened all the same. Tonight he was having the same feelings and was scared of what he might do. I'm not ashamed to admit that i've suffered anxiety and depression and you do feel very alone. Being consumed by unfamiliar feelings can be suffocating to say the least. It is no wonder the people who are most fragile are left with thinking being gone would be the simplest fix. Suicide is often spoken about as being a cowards way out. It's considered selfish for the family and friends that are left behind and something I have rarely spoken in depth about, with a patient. I asked him straight up.

"What about your kids, your family, you friends?"

He agreed. He said he had a loving family and good circle of friends. He also had a good job, but what he did say, was that when you are depressed none of that seems to matter. He admitted he was wallowing in self pity but at the same time he could not face the prospect of having to start a life all over again, and from personel experience, that prospect is a daunting one. It all got too much for him. Maybe he felt ashamed, embarrassed, I don't know, the fact was the feelings he was having were real. He had taken an overdose of Amitripyline after seeing his GP for sleeping problems. It's an anti-depressant often used to help mild sleeping disorders and is often prescribed without looking at the core problem. James was depressed, he needed to talk to someone, not be drugged into a fake sleep. When he wakes, the problems will still be there and they were. He wasn't keen on being prescribed the drug either but with the targets and time constraints GPs face a quick prescription is more practical than a heart to heart. His objection to the drug stemmed from the fact he didn't want to admit he was depressed and because he knew drugs were not going to fix anything. He was a very level headed guy and I admired his honesty. He was being completely frank about his feelings especially as we had never met before. I think that is what he needed.

I explained our problem in terms of options too him and he agreed A & E wasn't the place for him. I offered a GP referral but he didn't want that either. He was all to aware of the social stigma around mental health disorders and didn't want it on his medical records. He feared it would effect his future employment and to be fair, I spoke about similar fears in 'Mental Health in an Ambulance'. The funny thing was that James knew exactly what he had to do. It was a lifestyle change that was needed and all he had to do was buck the trend he was in. Calling an ambulance was his way of admitting what had happened and I was more than happy to be that person he needed to talk to. It did get me thinking though, about how intricately balanced peoples lives are. We are creatures of habit and if that is disrupted it can easily seem that the world is ending. The old adage of 'what doesn't kill you makes you stronger' was very true in this case. We left James at home with a plan on how to move forward. I was confident he would turn things around and perfectly happy that he wouldn't do something stupid. 

This job raised a lot of questions around mental health. People who have never suffered with mental health problems or don't know they have, have no idea where to go for help or even what to say when they do. All they have is the social stereotyping, perpetuated by the media and employers alike which make the idea of asking for help an unattractive one. Stress, depression and anxiety are becoming so common place, yet in many areas of employment, admitting to one, can halt your career in an instant. Feelings are pushed under the carpet and bottled up until drastic actions are taken as the only conceivable way out. Things are getting better, but for some it's not quick enough. Help needs to be readily available, confidential and easy to access and this can only be done with the full support of the government and NHS. Yes, it will cost money but like everything, in the long term it will save. It's just a shame there is such short sightedness when it comes to Mental Health.

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!

Britain's Got Talent

"3 year old male, cut above eye, lots of bleeding, called by child"

This country, in fact, the entire world appears to revolve around talent contests. Be it Pop Idol, X Factor, Got to Dance or Britain's Got Talent our population seems to become engrossed in watching people with or without talent succeed or fail. If that wasn't enough there is also the string of celebrity talent contests like Strictly Come Dancing, Dancing on Ice and various other seasonal competitions. As much as these programmes do occasionally show some talent they also lord over the countries failings and its bizarre obsession with celebrity culture. What is talent though? The ability to sing a song well, play an instrument, dance, juggle, an aptitude for sport? All hobbies and a bit of fun, a past time, but talent? I did a job a few months back that made me look at talent with a new perspective. It gave me a new set of criteria by which I judge talent. I bet though if the little girl I'm going to tell you about, walked onto the stage on Britain's Got Talent she wouldn't make the cut because it wouldn't make good TV. 

We were called to a block of flats, middle of the afternoon, middle of the week. We headed round there fully expecting to find a toddler with a cut on his forehead, not complicated and probably not even bleeding. We pulled up outside, clambered up the stairs and knocked on the door. We waited.....and waited. We could hear the crying from somewhere in the flat so we knocked again. We waited.....and waited. Eventually the door opened, at the door was a little girl with a beautiful smile on her face. She beckoned us in and skipped off down the corridor towards the crying. I entered the room to see our patient, the 3 year old, sitting on his mums lap. 

"Hello there,  what's happened today?"

The mother looked blankly at me and nodded towards the little girl.  

"My mummy doesn't understand English, and she can't talk because she is deaf"

"That's OK, what language does she understand?"

"Ukrainian"

I looked at the mum and introduced myself in sign language thinking I was being clever! That didn't help either! There is a general misunderstanding, one I was guilty of, that sign language is universal, the same in every country. In reality, sign languages vary from country to country just as spoken languages do. Each natural sign language that is being used by the Deaf community is part of the country’s cultural, social, historical and religious heritage. Sophia, the little girl, told me what happened. It was as we had expected, he'd walked into the coffee table causing a minor cut which we just put a plaster on. 

"I can translate to my mummy if you like"

"How old are you?!" I said in amazement.

"I'm 5 years old and one month"

My boy is 4 and I was impressed when he was given year 3 words to learn. This 5 year old was bilingual in English and Ukrainian to the level where she could hear my English and translate it into Ukrainian then convert to sign language, then translate back for us. She had called the ambulance, given her address, said what was wrong and spelt out her brothers name for the call taker. I was amazed. The mum was a single parent in a foreign country with such a reliance on a little 5 year old. A 5 year old who had taken up the mantra of responsibility so well. This was talent. This is what should be celebrated by our country. It is kids like this who should be in the headlines. 

Britain is full of talent. Sophia isn't alone. There are kids who care for their parents and take on phenomenal responsibilities at such a young age, ones I can't even comprehend, and they do it with out complaining. They clean and tidy, cook for their siblings, get siblings ready for school and help their parents any way they can. This country needs to celebrate its talent and I don't mean by putting a tubby, cross eyed hippy from Grimsby on a stage to impersonate Lady Gaga dressed in a piece of sirloin steak and offal. Let us just highlight the remarkable talent and strength of character that our young carers have.

A School Report

This is in essence an ambulance blog. Yes I know, I often drift off into policing, politics, random thoughts and health care in general but so what! It's my blog and I'll do what I want when I want. I don't have the time to manage two blogs so therefore I don't have a personal one. Because of that, when an opportunity presents itself I will share where I can my proud parent moments and where possible tie it in to the blog!

"4 year male, been a very good boy at school"

My son came home from school yesterday with a 'mini report' to let me know how he was doing in this current school term. Obviously, being only 4 years old it isn't in depth and is simply an exercise of highlighting the correct statement in a list to show how he performed in a particular area. It doesn't discuss aptitude to learning or progress etc. but concentrates on the things that matter for a kid in reception. The things that make him a good little boy. He tries hard, his attendance is good, he's always on time, he does his homework, reads at home and is always well behaved. That is what any parent loves to see! It did get me thinking though about how were are judged as ambulance staff though. 

Frustratingly, we arn't judged on things that I think matter. We get generic print outs based solely on statistics and percentages of targets met and paperwork compliance. We periodically get given our Clinical Performance Indicators (CPI) which tells you how good you paperwork is. Every Patient Report Form (PRF) we do is scanned and audited. Once checked your PRF is then given a percentage of compliance based on various boxes you have or haven't ticket. You loose marks for petty things like not putting a patients ethnicity down, for not writing the postcode from where you were activated and for not writing in one of the ridiculous amount of times down. Origin of call time, dispatch time, time of mobilisation, arrive at RVP, arrive at scene, arrive with patient, time of first set of OBs, time of second set of OBs, time you left scene, time you put in a blue call, arrival at hospital, clinical handover, patient handover, green mobile time, left hospital time and finally time of the next call! That is 16 times you have to write down and all so that the  targets can be monitored. That list doesn't even include the times for drugs given, time of cannulation, intubation, shocks given, ROLE and ROSC etc. Miss one off and you get marked down. If you write a drug you gave down but don't also write the acronym for that drug, you are marked down. The list is endless. 

Once you have your paperwork compliance score you are given a staff report of your times in each category, each with their own target. You average time for each target is highlighted in a different colour to show where you stand in terms of what is expected. Green means 'keep it up', amber means 'work to be done' and red means that 'you are a disgrace and should much more target focused!' The targets by which we are judged are as follows:

1. A8 - % of Cat A calls reached within 8 minutes of call origin time.
2. Mobilisation - Time in seconds from which you are dispatched to when the ambulance wheels are moving.
3. Running - Your average time in minutes to get to a job.
4. At scene - The average amount of time you spend on scene with a patient. (I'm always in the amber or red!)
5. At hospital - The amount of time you spend at hospital after a job. 
6. Handover TG- The amount of time elapsed from patient handover to greening up for the next job. (Strict target of less than 15 minutes)
7. Job cycle - The total time that a job takes from call start to greening up again.
8. VOR - Amount of time in % your vehicle is off the road.

Once you have your paperwork compliance percentage and your times you can be judged! This is what we are scored by and in all honesty I think it is total crap. It doesn't in any way show how you interact with other staff and how well you treat your patients. It doesn't show if you are well presented, courteous and respectful or any of the other things that I think are much more important than times and numbers. What should happen, just like reception kids, is we should get a 'Mini-Report' showing how good we are, just like this:

Do you agree?! As light hearted as this is, what more do you actually want when you call 999? Surely you want a professional looking, caring and considerate person standing at your door with a smile on their face, who will try their best for you or your family and treat them with clinical excellence. If everyone did that then you would have a 'world class ambulance service'. Sadly if that person arrived at your door but took too long to mobilise, took over 8 minutes to arrive, spent too long with you, forgot to tick a few boxes, didn't write down the time they mobilised, forgot to say what ethnicity you were and then spent more than 15 minutes at hospital then they'd probably be 'let go'! Times and Targets, that's the name of the game!

It's not all bad

"16 year old female, self harming, using glass, ? violent"

I'm often very critical of mental health services. That criticism is based on personal experience in dealing with staff at mental health units, crisis teams and AMPHs. In rather heated exchanges I have been told by mental health professionals that it isn't all bad and there are good staff out there. My response has always been that I can only write about what I come into contact with. If it's bad, then I will say just how bad it is but if and when I get a positive experience I will also share that. Well last night I had one. Not only with a mental health unit, but also a crisis team and the staff I met. 

We were called to a private address to a young girl who was self harming. It is always sad to see someone so young suffering as they are and they are often very difficult to interact with, especially with the limited training we have. When we arrived we were pointed in the direction of an upstairs bedroom by an apparently unbothered mother. Perhaps here is one of the reasons she is was self harming in the first place. That aside we went upstairs to meet Amy. She was in her room and having some kind of manic episode. She was very twitchy, on edge and was acting rather frantically. She had the most captivating eyes, and despite her behaviour a really gentle manner about her. She was smiling and talking to herself and sadly, bleeding from her arms. I began talking to her, keeping my distance as I didn't want her to think what we were encroaching on her space. Gradually, as the conversation went on I edged in and sat down. We discussed her recent treatment and then I asked if she had a crisis team. She did. Going by past experience, the prospect of having to go through the uphill, hapless task of getting them out was something I was dreading. 

To my pleasant surprise I had a very fruitful conversation with her case worker. I got a full history, a list or do's and don'ts and a promise that she would be with us shortly. And she was. By the time she arrived we had dressed and cleaned the wounds so I stepped out while they spoke. I few minutes later she emerged and said she was going to call her unit to see if she could be admitted there. I was happy with the cuts so if we were able to bypass A & E that would be better for everyone. I overheard an extremely heated conversation between the case worker and the unit.

"I don't care, I am bringing her in, make space"

No idea what they replied!

"Fine, I'll stay with her but I'm not having her sit in A & E for hours on end. The ambulance have said she if fine to come with me, we'll be there shortly"

Boom! So refreshing to see someone go that extra mile and be in a position to insist on an admission to the correct facility. We took them both and left the unit very pleased with the outcome. Normally, that would be the end of that patient for the day but clearly this was no normal day!

About 9 hours later we got a call to the same mental health unit. We started heading round and the screen updated with more details.

"16 year old female, cut to arms"

It was the same girl and amazingly we had got the job. Shortly after her arrival in the afternoon, she had cut herself again with a broken glass. Staff had cleaned and dressed it but when a doctor visited in the evening, he wanted it closed properly at a hospital. We arrived at the unit to be met by waiting, friendly staff. On the walk to their medical room the nurse gave us a full history, one we already knew but useful all the same. Amy seemed relaxed to see me. She also seemed in a much much better state of mind than before. She skipped to the ambulance and was very chatty. The case worker who had stayed with her came with us. It was so nice to see. The staff were very compassionate towards the patients that we saw. 

Amy had had a troubled upbringing with huge attachment issues. Her manic depression, low self esteem and history of abuse and neglect were horrible to hear and read, but seeing respond so well to people who clearly cared about her mental well being was great to see. I was a prime example of the what benefits there can be when an ambulance looks for other options other than A & E, when a crisis teams comes out on request, when a mental health patient is taken to the most appropriate place and when staff are attentive and willing to go the extra mile for the right outcome. It also showed the results that can come from continuity of care. Far too often, people complain that they never see the same staff and information isn't passed on. It can feel like starting over, every meeting they have. Clearly, if all areas within the NHS work together, have transparency and support each other the patients will only benefit. I live in hope that these types of jobs will become common place and not a rarity.