Tom Reynolds

I’ve not been writing because I’ve been incredibly busy of late, working my normal LAS shifts (my last shift is on Friday, three more to go and, yes, I’m counting the hours), plus the paperwork for my new job (currently filling out the second Criminal Records Check form because I was sent an out of date one earlier), as well as all the normal stuff that keeps us busy, like laundry and shopping and making sure my Sky+ box doesn’t get filled up with too many programmes.

Hopefully this will all soon change, giving me more time to put finger to keyboard.

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I’ve been talking to a lot of people about my upcoming change in jobs to the local hospital – both ambulance and nursing staff, and the thing I’ve noticed is that sometimes people just don’t get on.

For example – I explain to one of my ambulance friends that I was talking to Nurse Smith about my upcoming job change and that she was very happy for me. ‘Ergh’, says my ambulance colleague, ‘Nurse Smith? I can’t stand her…’

And I find that on both sides, nurses and ambulance staff that I consider good clinicians and good people looked on with some disdain.

I think I’ve worked it out.

It’s because we don’t know what each other does.

Many of the nurses that aren’t liked by ambulance crews are those nurses that expect more. They forget that, for a great number of us, our training is 16 weeks in a classroom. We’ve never been taught ‘reflective practice’, or how to read a research paper, or learnt the meaning of the word ‘holistic’.

These nurses get annoyed when an ambulance worker doesn’t know about a certain obscure disease, or something happens that highlights something that was lacking in our initial training.

And if nurse gets annoyed, then you can be sure that the ambulance worker concerned will get annoyed as well.

On the flip-side, there are the nurses who think that we are little more than removal drivers – we pick people up, wrap them in a blanket, and take them to hospital. They can’t see the reason why we bring to hospital some of the dross that we do (personal favourite call from last night – ‘33 year old male with cold’). These are the nurses who have asked me in the past ‘can you do a blood pressure’.

To be fair, that is from a ward nurse, A&E nurses have a better idea of what we do, but can still have some strange ideas of what our work is really like. Some don’t realise that we refer vulnerable children and adults to social services. They may not realise exactly how many patients we leave at home (endless panic attacks, diabetic hypoglycaemia and epileptics). They also may not know that if someone wants to go to hospital then we can’t refuse them.

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It’s not particularly anyone’s fault – certainly it works both ways, ambulance staff don’t really understand the pressures that A&E nurses are under. I know that I have a privileged knowledge, coming from both worlds.

What is annoying is that the solution is very simple – nurses spending some observation shifts with ambulance staff, and ambulance staff spending some time in A&E, but it’l never happen because of those self-same pressures. Ours to hit eight minute arrival targets, and A&E to cope with understaffing and having too many patients to deal with.

And our free time is precious – spent sleeping rather than volunteering to go rattling around London in an ambulance, or being asked to do ECGs on endless patients in A&E.

Besides, it’s not that important to deal with little episodes of misunderstanding brought about by not knowing each other’s jobs.

Is it?

The NHS White Paper is out and I’ve read pages and pages of analysis, although I’m yet to read the White Paper myself. It’s sitting in my reading queue waiting to be read.

The big change is the PCTs who currently ‘purchase’ healthcare will go the way of the dodo to be replaced by ‘consortia’ of GPs. The thought being that GPs know better the needs of their community.

While I am sure that there are plenty of conscientious, well trained, thoughtful and management minded GPs out there, certainly in my part of London they seem a bit few and far between.

As an example, my crewmate and I were sent to a patient who had seen the GP who had thought that she might need hospital treatment. The patient was described as ‘ambulant’.

She was ‘ambulant’, in that she had walked to the GP surgery – at least one mile away, and the GP had sent her home to await the ambulance.

As soon as I walked into the room I knew that we would be wheeling the patient out on our chair. She was so short of breath she was breathing forty times a minute, her oxygen levels were way below what they should have been (86% – even with someone with chronic lung disease, this would be a worry), her pulse was racing at over 120 beats per minute.

She was a very sick lady – and yet the GP had sent her to walk home.

Similarly I’ve been to patients in the later stages of shock who have been sat out in the waiting room for the ambulance and I’ve had patients who the doctor has, correctly, diagnosed a heart attack sitting on the wall outside the surgery.

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Now, I understand that not every GP is like this and that I only tend to go to the patients that are seen by these worryingly poor GPs, but how many of them will be holding onto the public’s purse strings in the future.

In some places they can’t even arrange decent out-of-hours coverage with GPs who are able to speak English.

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The other worry is what happens if a GP consortia decide that they don’t want the LAS handling emergency calls in a certain postcode? Will we be refusing calls because privateambulanceservicecompany will hold that contract? Will we no longer be London-wide, but tasked to only cover certain areas.

Given yesterday’s announcement about ‘Big Society’, will the ambulance service be broken up to be replaced by volunteer services? I heard rumours that the Olympic planning people wanted LAS staff to volunteer to cover the Olympics as they didn’t want to pay them, was that just the start of this?

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Still, lets wait and see what happens in the consultations before we start panicking. After all it’s not like consultations in the past have ignored all the good points in opposition to what the government want to do…

So… What is it that makes an ambulance?

What sort of equipment do you think needs to be on a vehicle for it to be classed as an ‘ambulance’.

You’d probably think that it would need a stretcher, a carry chair and some sort of medical equipment. Perhaps something to take blood sugars, blood pressures and tracings of your heart.

Maybe it would need something to deal with broken limbs, a board to strap you to if the crew thought that you had a broken neck and maybe even some drugs to treat conditions such as asthma, heart problems and allergic reactions.

You might also expect bandages.

You would, of course, be wrong.

We have had the official memo from one of our Assistant Director of Operations.

To be a working ambulance you need…

1) A vehicle which passes the legal requirement of basic roadworthiness – decent tyres, has a windscreen, has working lights and is taxed.

2) A Bag-valve-mask and a defibrillator.

3) That is all.

That is all you need to have a working ambulance – or rather an ambulance that will stop that all ‘important’ (and utterly bloody pointless) ORCON target.

This level of equipment means that you can perform pretty basic life-support – no drugs, no clever airway management.

If you have asthma, you will be wheezing like a wheezy thing with not a thing I can give you.

If you are having a heart attack I won’t be giving you the aspirin that vastly increases your survival rate.

If you have a broken leg, I’ll have no way to splint it. And I may not even have a stretcher to put you on anyway.

But I will have ’stopped the ORCON clock’, and so the job will be a ’success’.

And this is happening – a friend of mine was sent out on an ambulance with this level of equipment. He was concerned by this and wrote a letter to our medical director who replied that this is a good policy.

Over 50% of the time I’m sent out on a vehicle without a blood sugar kit, and without other equipment like Scissors or a Paediatric Advanced Life Support Kit.

The London Ambulance Service calls itself a ‘world class service’ – but I think it’s a bit rich to refer to yourself as this when ambulances are being sent out with this level of kit.

But who am I to complain that I don’t have the right amount of kit? After all, the people who make these decisions are paid a heck of a lot more than me, so they must be smarter.

It is, as regular readers will no doubt have guessed, all because of the frankly dangerous ORCON target – dangerous because our ceaseless chasing of this clinically worthless target means that patient care is suffering.

The government has decreed that a number of targets will be dropped – the four hour A&E wait, the Police Pledge, Literacy (well… they haven’t specifically said that literacy must be cut, but if you are cutting the education budget by 25% then that is the sort of thing you are going to get).

Sadly, no, tragically, it would seem that the ORCON target will remain. And so resources that could be spent on, oh I don’t know, fully equipped ambulances, are instead being spent on beating that damn clock.

However I think that there are those in management who probably like this – after all they can understand how to chase this target as opposed to being capable of setting a standard of excellent patient care.

It’s never a good sign when your patient has her knickers around her knees.

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‘Woman in Labour – outside newsagent shop’.

So far, so boring – another maternataxi job, walk on walk off, baby arrives a few hours after the end of our shift. No sweat.

My crewmate is driving, blue lights to do a job of a taxi, when a minicab swerves across the road and pulls in front of us.

“Oi! Can’t you see the lights!?”, shouts my crewmate – we are used to the crazy drivers of Newham (especially the minicab drivers) but this one really takes the biscuit.

“Erm… That’s our patient”, I say.

In the rear of the minicab that is parked across our nose is our patient, her husband and her two other children, both under the age of six.

I hop out of the ambulance and walk to the back of the cab. Inside our patient is stretched out and screaming, the husband is on the phone to our Control (and seems a bit upset that they don’t understand that he is on some road in some part of town – he isn’t sure where he is and is annoyed that the calltaker isn’t psychic).

Her knickers are down around her knees – this is not a good sign.

I quickly peer between her legs – and can see nothing out of the ordinary.

I’m aware that we are blocking one of the main roads on my patch – behind our ambulance is a bus, and behind that I row of cars.

Our woman stops screaming and I suggest that we change vehicles to our ambulance. She agrees and, exposed to the world and before I can cover her, waddles into our ambulance giving the bus passengers a sight they never expected to see today.

My crewmate gives the husband a hand with the luggage and the children while I put my patient on the trolleybed.

For some reason people seem to want to bring the entire kitchen sink with them to hospital when they are having a baby – this woman has four bags, along with two children she made earlier.

I take another better look between my patient’s legs – again nothing unusual, and I’m certainly not going to stick my hands anywhere they don’t belong to see how far along we are – besides it’s outside our training.

We get the other children buckled in and I tell my crewmate to start heading for the hospital. I let the patient know that I’m glad that she tried getting a cab rather than just calling for an ambulance like many of our ’service users’ – but that maybe she should have called a little bit earlier…

Then my patient lets out an awful cry and I realise that this isn’t the normal wimping out about early labour pains.

I take another look and see a bulge…

“On second thoughts my beloved”, I shout to my crewmate, “We’re are going to be having the baby here – grab us the spare maternity pack from the side cupboard”.

“What?!”

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And so I find myself hemmed in by luggage, with two small children undoing their seatbelts to come and have a look at what is appearing from between mummy’s front bottom, all while trying to deliver a child who seems to be in two minds about coming out or not.

The head delivers, and then stops. My patient is convinced that she can’t push any more and I suddenly turn into a midwife and start being… rather firm… with her.

A bit of pulling, a bit of pushing, and the baby boy pops loose. The cord is not so much ‘cut’ as chewed through by the, apparently rather blunt, scissors in the maternity pack, and dad gets to hold the newborn as mum is too tired.

I look at my audience – two gape mouthed, but excited, children and I tell them that they now know where they came from when they were babies.

Turning my attention to the dad I tell him that it is his job to tell them how they got up there in the first place.

Smiles all round, not least from me, because I’m fully aware that if there were a serious problem with the delivery, my training would be sorely lacking.

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We arrive at the maternity department after pre-warning them that we were coming in with a ‘BBA’ – ‘Born Before Arrival (at hospital)’. The midwives ignore us until finally one slopes off to make a bed up for the patient. They aren’t massively interested in hearing my handover either – but I give it anyway, I’m far too used to dealing with this particular group of midwives to worry too much about their attitude towards a lowly ‘taxi-driver’.

Outside, with the luggage and the other children, the father shakes my hand and thanks me – his face a big grin.

And it’s all fine – and I’m happy, and it keeps me happy through the shift even though my next patient is a drunk who tries to hit me.

Role Models

In the final part of my series of whinging, moaning and general grumpiness I’d like to look at the one thing that road staff truely have no-one to blame except themselves.

Where are our role models?

It took Mary Seacole, Florence Nightingale and others like them to start to drag nursing up from it’s roots as a ‘Doctor’s Handmaiden’ into a profession of it’s own.

Likewise you have Sir Robert Peel and his effect on policing, Elizabeth Fry and her prison reforms and countless scientists from Gallelio up to Prof. Brian Cox and Dr. Ben Goldacre.

So, who is the role model, the innovator, the spiritual leader of the ambulance services?

Josh from Casualty – a fictional character?

What name do we think of when we, as a profession, ask ourselves – who is the paragon of ambulance work, who is the person we should aspire to be like?

I can’t think of anyone who fills those shoes and the people who I think are great EMS are rarely heard from.

I think that it is about time that we started looking for role models, or start aspiring to be one ourselves.