Endings

It's been two months since I last blogged, and I think that this is nature's way of telling me that this blog is finished.

When I started writing this I never thought that it would take off in the way that it did - two books, a radio play, opportunities to speak to lots of people at once and of course the upcoming TV series.

But all good things come to an end and, since leaving the London Ambulance Service, my life has settled down somewhat.

Which means that I have far less to write about the ambulance service, which is what this blog very quickly became about.

So I've decided to put this blog into a 'Deep Freeze'. So the links, posts and everything else will remain here, but I won't be updating it any more. In a fortnight I'll close down the commenting system so that I don't have to spend the rest of my natural life removing spam comments.

The reasoning behind this is that this blog was supposed to be about anything - but due to it taking off as an 'ambulance blog', I felt that I was 'cheating' if I wrote something that wasn't about working on the ambulances. Now I no longer work full time on an ambulance the number of ambulance posts will decrease to almost nothing.

I'm thinking that it's for the best if this blog stays true to being about my time on the ambulances, and I start afresh somewhere else.

I shall be moving my presence on the internet over to Brian Kellett (dot) net, where I plan to write blog posts about whatever interests me. This means that if you are only interested in ambulance related blogposts as opposed to me writing about whatever tickles my fancy, this is where we part company.

For day to day things I shall be continuing to use twitter @Reynolds

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If you want to read about ambulance stuff, there are a few blogs out there that I read and you might be interested in.

From Scotland you have Trauma Queen, who does indeed seem to be a trauma magnet, he also writes beautifully. Much better than me to be honest.

Insomniac Medic blogs while working for the London Ambulance Service - rather him than me.

Then there is 999Medic, Mark Glencorse, who is much more energetic than me. He's also on a mission to change ambulance services for the better.

From across the pond is Ambulance Driver Files, whose politics I almost completely disagree with. He is a top bloke and has a wry sense of humour.

And finally but not least there is Rogue Medic, another American, who posts incredibly well thought out articles about making EMS better, mostly by the use of science.

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So, that's that. Time to move on to Brian Kellett (dot) net, where I shall be writing about things that interest me - not just ambulance related stuff.

And if this is farewell, then may I wish you safe travels, and I hope that while you've known me I've entertained you, and maybe made you think a little.

Lurgy

The interesting thing about my changed work practices is that I'm now much closer to my patients.

I don't mean I feel like holding their hands or buying the Christmas presents, I mean I'm physically closer to them.

Which seems strange, after all the back of an ambulance is certainly more cramped than the examination room that I use to diagnose, treat and educate my patients.

The problem is that I find myself having to get much closer to my patients to examine them.

As an example - if I were to pick up a healthy looking person with a sore throat and a cough, I wouldn't get too close to them. I'd plug them into the machinery of blood pressure, oxygen levels and temperature, then take a seat across the way from them while they coughed and spluttered and made out to be much sicker than they really were.

Now, however, I find myself getting very much up close and personal with my patients - if someone comes to me with a sore throat and cough I need to know what their tonsils look like, whether they are pus-ridden, what their breath smells like. I need to look in their ears, I need to feel their lymph nodes. And so on and so forth.

I was always convinced that when I left shift work I would stop getting ill - and several of my old colleagues have commented on how healthy I look when compared to my time on the ambulances. And this is true - I do feel a lot better.

That was until an outbreak of a viral upper respiratory tract infection became a rather popular reason to attend the UCC.

(And as an aside, are viral URTIs rare in SE asia? I only ask because a lot of the people I see are from there and, while the demographics of Newham are in their favour, I wonder if the reason they pitch up to hospital is because they have had no experience of such things in their homeland. In a similar vein, I would guess that chickenpox is also rare there).

So, I've been seeing a lot of these viral URTI patients. And getting close to them.

And now I have the bloody thing. During my four days off which, I swear, were going to be spent doing interesting and productive things, but which have now been spent drinking lemon tea, lying on the sofa and wondering if this really is just an URTI and not the first stages of The Himalayan Coughing Yak Death-plague. Of Doom.

Thankfully I'm feeling a little bit better now, just in time to return to work tomorrow.

(I suspect that in six months time I shall be immune to everything).

Off Late

One of the advantages of working in an Urgent care centre, rather than on the road (only one, there are many other advantages), is that you should be able to get off on time. Unlike the ambulance service, you choose when to see patients (although you do try to see them as quickly as possible), so if you have only three minutes to go until the end of your shift you just don't call in a patient - instead you tidy the room, fill out a bit of paperwork, or make sure that your hands are spotlessly clean for going home.

Of course, while this is true, sometimes the real world has something to say on this and things go a bit wrong.

For example - if I have twenty minutes to go, I can call in that abdominal pain patient knowing that I should be able to finish assessing, treating and writing up the notes. Where it goes wrong is when the patient gets fifteen minutes into the consultation before springing a horrible surprise on me - such as the real reason why they are in my room is because they took an overdose of tablet 'x', they just haven't told anyone else. Anyone like the triage nurse who would have then sent them to the much more appropriate ED...

In that case you have to do a lot more assessing, a lot more writing up and then refer to the medical doctors - the medics, in my experience, are much quicker at answering their bleep than the orthopaedic doctors - of course the ortho's may well have someone's legs up behind their ears while they replace a hip, so they may be a bit busy.

Either way, you then have to fanny around printing out notes and front sheets and so on and so forth because, while the UCC is paper-free, the rest of the hospital isn't.

And that is why I'm typing this after leaving work over half an hour late.

So, y'know, ignore the spelling and grammar eh? This is a first draft typed before I collapse into bed.

I think I need to practice my time management skills.

(My patient didn't overdose, but they had something even more tricky wrong with them and they still needed referring to the medics. I've changed the actual circumstance to respect confidentiality).

What It Is I Do Now

I don't think that I've properly explained exactly what my new role is. In part because, much like my old job, what initially seems quite simple (For ambulance work - go to a sick person, pick them up and take them to hospital, try not to let them die) is actually fairly complicated.

I currently work in a hospital building, tucked just behind the A&E department (sorry 'E.D'.) while the entirety of the hospital is funded by one structure, the Urgent Care Centre (or UCC) where I work is funded by another completely different group (it gets even more complicated as this group is about to merge with another group...)

The short version of what I do as a NP (nurse practitioner) is I see patients with minor injuries and illnesses, and then I make them better.

This is massively simplified.

There are two main roles in my new post - 'triage' and 'working in the back'. When I triage (which lasts for around four hours of my shift), along with an ED nurse, I see patients as they enter the hospital and book in at the ED reception. Sometimes they want to see the UCC, sometimes they want the ED. It's my job to decide where the patients go. For example, someone with a verruca may well come to the hospital expecting to be seen in the ED (because, of course, a verruca is an emergency) - I will instead direct the patient to the UCC where someone who is 'working in the back' will tell them to get some verruca cream from the local chemist.

Sometimes someone will come in expecting to go to the UCC, but will end up in the ED. A recent example would be the chap who turned up with a 'cough', who actually had a rip-roaring case of pneumonia and would need admitting to hospital for some rather powerful drugs.

Once more I simplify - partly for sanity sake, partly because this is a quick overview, and partly because at the moment there are huge political ructions going on at pay grades far above mine as to the best way to see and sort all the patients that pitch up at the hospital.

'Working in the back' is where you actually see, assess and treat the patients you may well have triaged only half an hour ago. Little two-year-old Timmy with a cut to his head will be called into an examination room where I'll assess him to make sure that he isn't going to drop dead from an undiagnosed fractured skull. I'll then clean the wound, glue it shut and then educate the parent (or Timmy if the parent is a bit dim) about how to look after the now neatly glued wound. I'll also tell them that if Timmy decides to have a seizure or collapse unconscious they should think about bringing him back as the head injury is obviously a bit more serious than I originally thought.

I then type up the notes on the computer system (because we are a paperless system. Mostly), discharge the patient and then call in the next one.

Repeat that for the rest of my twelve and a half hour shift.

This is a picture of one of the examination rooms.

As far as scope of practice goes - we are a mix between the old A&E minor injury department (broken bones, twisted ankles, bumps to the head) and a restricted GP service (sore throats, urine infections, sick children and emergency contraception). In fact a lot of people treat us as a GP service - and that is one service that, for several reasons, we often can't provide - but I'll write more on that later.

Excuses, Excuses. With Promises Made.

I haven't blogged in over a month? Really?

It's strange really back in the day I could write three or four posts a day, saving them for later, and yet during this month I've only occasionally thought of blogging.

There are, to be honest, a couple of reasons why I've not been blogging.

  • My new job. I'm enjoying myself. Well... 'enjoy' is perhaps too strong a word, after all I am still working in the NHS. However it seems that a fair chunk of the reasons for my writing (in the past year or so at least) was anger. Anger at the system, anger at inconsiderate patients, anger at watching the ambulance service circling the drain. With my new job I'm a lot less angry. For one, I'm not swearing as much - which is good because I don't think that the ambulance messroom language would go down too well with some of my new colleagues. But with that lack of rage I've been less likely to have a burning need to write something. I've noticed that I've been avoiding watching any TV news because it would get me angry and I would not have constructive output from it - I'm not a politically intelligent blogger, and I certainly didn't want to turn this site into a constant outflowing of 'Dave Cameron is a oily ****rag who if he wanted to make the world a better place would shoot himself. Slowly' or 'Nick Clegg is a lying **** who has killed the Lib Dem party and should be forced to live out his life in student digs, begging for charity'. It'd get boring incredibly quickly, and my computer would break from all the anger flecked spittle I'd be spraying at it. So, I've been a lot less angry - and that means a fair bit of my muse has packed her bags and buggered off to sunnier climes. Damn that 'happiness' and 'job satisfaction' - it's ruined me.

  • The return of my depression. Which is perhaps an illogical thing to say after admitting that I am happier and less anger filled. But it's a weird thing depression, in my case more about a lack of energy, a desire to withdraw from the world and a slight, but nagging, suspicion that I would be better off dead* rather than sitting around crying**. Everything in my world can be going wonderfully (and at the moment, both personally and professionally, it is), but when those brain chemicals decide to slosh around my skull in one way rather than the other it can really bugger you up. Thankfully my depression is, I suspect, what most people would call 'pitifully minor'. So I can often just muddle through the day with just general feelings of shittiness.

    Interestingly, when I'm at work, although I'm watching the clock tick down to the end of my shift, while I'm there I'm often in a fairly good and energy filled mood. Perhaps it's the uniform.

  • I've been rather busy - trying to get my brain up to firing on all three and a half cylinders and pointed back into the general direction of being a nurse. It's quite a thing to blow the dust out of the crevices of my mind and see what sorts of knowledge and skills are still tucked away up there in a cardboard box marked 'Misc. odds & sods'. Skills like steristripping wounds are still there as if I had been using it every day, which is strange as I was expressly forbidden from doing such things in my time in the ambulance service. The risk of course is that while my mind and memory muscle may still recall these skills - medical practice may have moved on. I don't want to be seen as the sort of practitioner who thinks that bleeding patients is still acceptable practice. So I've been reading up and reading around, and asking questions and generally trying to cram as much into my brain as possible. Having come from a job where on the job training was often being given a sheet of A4 to read, this has been taking up a reasonable amount of my daily energy quota.

  • Along with the mental settling into my new job, I've not felt confident enough to write about it (although my new boss has asked me if I'm writing nice things). Mostly because it takes a certain amount of time before you can get your feet under the table and understand most of the driving forces that mean something is done one way rather than the other. I'm still of the mind that when you are new in a job you should 'keep your eyes and ears open and your mouth shut'. So what great insights am I going to bring to this little corner of the NHS when I'm still learning what boundaries are already in place, what I can push, and whether I have the completely wrong end of the stick about a situation?

  • Confidentiality has always been incredibly important, personally as well as professionally. But now I'm sitting in one place it is a lot harder to obscure some of the identifying attributes of my patients and the stories that they tell me. And it is the stories that I am told which are often the most interesting thing about my job, but as these stories are, by definition, very individual you can perhaps see my problem in trying to relate them. Over the last month I've been collecting stories in enough numbers that I can now start to mix and match and mash together some stories to remove all identifying marks.

  • I'm not sure that people are that interested in Urgent Care. For the large part I'm seeing patients for a very short period of time, and for illnesses that are normally self-limiting and are almost certainly not life-threatening. Writing about it this while keeping it at least vaguely interesting is fairly tricky - that's why 'Doctors' has to throw in the occasional kidnapping or explosion to keep the viewers engrossed in the lives of the GPs. There are no explosions at my workplace - although we did have a leaking water pipe last week.

So those are the excuses.

I do, however, have a plan - and it's one that involves me writing a lot more. I'm going to do the best I can to write every day that I'm not at work (so that's three or four times a week as a minimum) - partly to keep my brain active, partly because it's a therapy to be able to let off steam, and partly because I enjoy it.

The plan also involves me writing every day for at least this week - and then... well... there will be a bit of a change...


*No, I'm not actually suicidal - too far too sensible for that.

**Although that does sometimes happen - it's why I'm steering clear of alcohol for the foreseeable future.

Naked Apes

Channel 4 has commissioned two new drama series for 2011, as part of the broadcaster’s commitment to double its output of original drama from next year.

Camilla Campbell, Channel 4 head of drama, said the series had been commissioned using money freed up from the cancellation of Big Brother, which has seen the drama department benefit from a £20 million boost to its budget.

The new series announced today are Naked Apes, which will air on Channel 4, and Beaver Falls, for E4.

Naked Apes is penned by Brian Fillis, who wrote Fear of Fanny and The Curse of Steptoe for BBC Four, and is inspired by Tom Reynolds’ book, Blood, Sweat and Tea.

It follows a group of paramedics and is being made by Daybreak Pictures, which produced Britz for Channel 4.

Yep.

I had lunch with one of the producers earlier this week where he told me that the chances of this actually making this to screen are pretty good. Although, as in all things TV, there is also a chance that it will all fall through.

At some point in the near future I'll be having a meeting with the writer and producers.

I haven't seen the script yet, although it is a *drama* based on my book rather than a literal filming of the episodes. TV, and drama as a whole, works in it's own way so there have got to be a lot of changes in order to turn the book into interesting television. Also it has to be something that will be interesting to the Channel 4 demographic.

So I'm not going to be precious about it.

This is now Daybreak Pictures baby and I'm interested in what they are going to do with the source material. It should be fun.

First Week

Wow.

My brain overfloweth.

The new workplace is lovely, the staff are nice, I have a lovely boss and there is a real opportunity to deal with patients and make them happier and healthier.

It's pretty much perfect.

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Well, I say it's perfect - but there is but one pubic hair on the bar of soap of pure awesomeness.

All the patient notes that I make are typed straight into a computer, it is a paperless office (apart from the information leaflets that we give to the patients). I have no problem with that as, surprisingly enough, I'm quite happy around computers.

The problem is... It's all Windows systems.

Urgh.

So there will be some retraining while I try to get used to typing on 'cherry' keyboards and remembering that the key commands are different from everything that I use at home.

Also, due to being unable to install any software I don't think I can sync Outlook 2003's calendar with Mobile Me/Google.

Oh, and the browser is IE6.

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More seriously though - I'm really looking forward to getting my teeth into working here, the boss is already trying to get me onto a week-long course for minor illnesses and I'm keeping my fingers crossed as it is apparently a really good one and gets me 35 points towards a degree (for my nursing is a lowly Dip(HE)).

I've another three weeks of being 'supernumerary' which means following people around and generally learning things. For example today I learnt more about knee assessment than I have ever dreamt possible from a brilliant physiotherapist who is seconded to the Urgent Care Centre.

My day ended with another man's testicles in my hands so I could examine them - which is a first for me as normally the only reason to have someone else's testicles in my grasp is for the purposes of 'self defence'.

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While I'm only working eight hour shifts at the moment I'm finding that I'm more tired than twelve hours of ambulance work - I suspect it's because my brain is, for the first time in ages, consuming huge amounts of energy while I take in both the formal learning and the more 'soft' informal learning that is necessary when trying to integrate yourself into a new group of people.

So basically it's all brilliant (apart from having to use Windows) and I am incredibly happy to have made the switch.

My Last Shift

I would like to start with an apology.

A little while ago, I asked the question 'What is it that makes an ambulance'. I then went on to inform you that the only equipment that an ambulance requires is a defibrillator and a bag-valve-mask. I may have made the suggestion that this shows the priority that the LAS has on patient care.

But I must apologise, for I made a mistake.

You don't need the defibrillator.

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Yes, on my final shift I found myself on an ambulance without a defibrillator, going to calls of elderly patients with chest pain. Then our tail lift stopped working, so there was no way to use the stretcher.

We we refused our request to go 'unavailable' in order to return to station in order to get replacement kit.

So the last shift continued my tradition of trying to give good healthcare despite management policies.

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The patients were also a fair mix of the normal sorts of patients I've spent the last eight years going to - a fall, a drunken and abusive alcoholic, a homeless chap with chest pain, a runny nose, and two hospital transfers.

My last call was for one of those transfers, an elderly chap that the doctors at a local hospital suspected was having a heart attack that we blue-lighted to the heart-attack centre.

They didn't think that he was having a heart attack, but given his long, complicated and somewhat obscured medical history I still think that the local hospital did the right thing.

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So, no bangs, no whimpers, just a continuation of what my shift has been like since I joined the service.

I'm going to hold off on writing about my new job for a while until I get settled in a bit, I think that it's important that I get the lay of the land, and besides, it's better to reflect than immediately report.

I've still got a few things to write about the ambulance service sitting in my notepad, so that will keep me going for a bit.

(Plus I need to work on a new banner for the blog, maybe a new layout and who knows what else...)

Nobody Likes Us

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?

CCTV And Drunkeness

'Male, collapsed in street - cannot see if he is breathing'.

Once more I found myself speeding towards a drunk in the street. It's *always* a drunk in the street, except of course on the one occasion when we don't whizz to scene - then they will be dead.

The Sod's Law of collapsed or deceased patients.

Like many of the drunk calls, we also had the information that 'caller will not approach patient', of course not, because the 'possibly dead' person is drunk, smelly, and possibly violent. That, after all, is why we are called to wake them up and move them on.

In this case however, it was much more reasonable, the caller was a CCTV operator.

So we rolled up and found our man snoring gently in the middle of the pavement. Hopping over the fence between us and the patient I went up to him and woke him up.

The man was apologetic (or at least I think he was apologetic, but then sheepish smiles and a bowed head are pretty universal despite the patient not speaking English). He then walked off to catch a train.

I looked around to see which CCTV camera had 'caught' him, and spotting the only one I could see I gave the camera a thumbs up, and then mimed drinking from a bottle.

The operator obviously got the message as the camera nodded up and down in acknowledgement.

Last Night

I recently had my last ever night shift, I would have written abut it earlier but the effects of the shift work had basically knocked me on my arse and made me incapable of doing anything except sleeping and dozing on the sofa.

It was, ultimately, a not unusual shift - no jobs that leapt out as being anything out of the ordinary.

My first job was to a woman who was intensely isolated because of her being unable to speak English, the only person she knew was her daughter who has a full time job. We were called because the woman was 'behaving strangely'. We arrived with the police to find her crying on the floor. We did the only thing that we could do, take her to hospital to see a psychiatrist.

It was handy to have the police there, because initially the woman wanted to refuse to come, but as she was distraught and had threatened suicide it was important that she see a professional.

The next job was to someone who'd been minding their own business and then been punched in the face with a knuckleduster. Often you can tell when someone is hiding something (because, let's face it, a lot of assaults in my area have a reason behind them. Not a good reason mind you, but there is normally a reason). In this case he didn't seem the type to be in a gang, he didn't appear to be a drug dealer and I don't think that he was secretly sleeping with someone else's girlfriend.

We took him to hospital in order to rule out a fracture of his facial bones.

The next patient had been indulging in some cocaine, some cannabis and a lot or alcohol. So had his friend. We had been called because he was 'off his legs', or as it was described to us 'he had been on his hands and knees like a dog'. I may have resisted the urge to ask if he had taken to barking.

As he got to the doors of the ambulance he let forth a huge spew of vomit, simultaneously passing flatulence. 'Better out that in' goes the old saying, and truly it is better out than in, as in outside the ambulance and not inside it where I need to mop it up.

During this he had developed a bellyache, so we assessed him and took him to hospital where, a few hours later, he was feeling much better.

(Seriously, is Red Bull and whiskey a sensible drink?)

Our next patient. Oh dear, our next patient...

The short version is that she was faking a panic attack in a pub. Once more I'm left wondering why people think that they can fake medical conditions in front of people who've seen them all before. This patient was very trying as she refused to get onto the ambulance (until she realised that her audience were bored and going home), then she alternated between not telling me anything and telling me about everything.

At the hospital she refused to get out of the ambulance until I had sweet talked her, then she refused to enter the hospital, then she refused to go to the toilet while crying that she needed to pass urine.

She was put into the waiting room (eventually) where she then argued with one of the nicest nurses in the unit...

I'll be the first to admit that it was very hard for me to remain the consummate professional that I am.

The last I saw of her she started by telling her new audience that her four year old child had called the ambulance (rather than the bar manager who'd actually called us), and that everyone was against her. She then went on to try and damage a police car before drunkenly disappearing off to the local bus stop.

I think it's called 'personality disorder'.

A much simpler job followed - a man who was stuck in the bath. The FRU had got there before us and had already solved the problem. We didn't even see the patient, as he'd gone to bed, so we caught up on some gossip with the FRU responder and made ready for our next job.

A nightmare job. Not because of the patient (who was confusingly suffering from a mish-mash of symptoms that had us blue-lighting her into hospital). No, the nightmare was the spider on the wall of the staircase that was the size of my hand. Garden spider or escaped tarantula in disguise, who knows what it was?

One of the elderly relatives saw the look on my face and managed to dispose of the creature in a piece of kitchen roll - as he walked into the kitchen with the ferocious monster I listened out for any screaming as the spider broke free of the paper and tore the old man's throat out...

An interesting job as there was a mix of heart problems, probable sepsis and undiagnosed diabetes - the best thing for the patient was for us to treat her symptoms as best we could and get her into hospital as quickly as possible so that the doctors could sort things out.

And a nice family, adept at dealing with the sorts of giant spiders only seen in horror movies.

Then I had a nap for twenty minutes in the passenger seat of the ambulance as, for a few minutes at 5 a.m, it seemed that people were getting some sleep and not filling their time calling ambulances.

Our final job was a transfer of a patient from our local hospital to the heart specialist unit. A nice patient, a nice family member and an uneventful journey finished the night off lovely.

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And that was it, my last night shift. I drove home with a huge smile on my face - no more would I need to feel sick in the stomach after a long night shift, nor would I need to batter my body clock into submission any more.

No more night shifts means that I will be able to rejoin the human race, no longer will I have the constant feeling of jetlag dragging me back.

As I write this I have another stupidly big grin on my face and an urge to dance a little jig around the room.

Done

To whom it may concern,

I wish to resign from my post as an EMT-3 in the London Ambulance Service. If possible I would like to go onto a bank contract so that I may work the occasional shift.

I would appreciate it if you could tell me my last working day as soon as possible as I am moving elsewhere in the NHS and they would like to know the earliest date that I can start.

Many thanks in advance.

Brian Kellett

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I handed this letter to my immediate boss today.

People who follow me on Twitter will have already heard that I have a new job, one that I'm due to start in approximately one month. In one month's time I shall be going back to nursing where I am taking a post as an Urgent Care Nurse Practitioner at Newham hospital.

I've been led to this by a number of factors, a majority of things that have pulled me towards a career change as well as more than a few things that have pushed me away from the LAS.

My AOM described it best when she gave me my reference, she said that I was bored and that I needed new challenges. We both agree that in most cases the job that we do turns our brain to mush.

So, I'm going back to nursing because I want to develop my clinical skills, I want to learn new things, I want to be more responsible for providing people with the best healthcare that I can.

It's pretty much impossible to do this within the LAS because, for example, our ECP (Emergency Care Practitioner - our top clinically trained people) programme is effectively being shut down. There is nowhere to progress to and... well... you have been reading all about it on this blog for the past few years.

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So, some big changes - one of which being that I'm going to go to writing under my real name, Brian Kellett, rather than the helpful pseudonym of Tom Reynolds. At the moment I'm in the process of changing this on all the social network profiles that I can remember belonging to.

If you take a look at the top of this very blogpost you should see that it no longer says 'By Reynolds'.

As for this blog... well... I'm unsure of what form it's going to take in the future. WIll I be still writing about ambulance stuff? Will I be documenting my journey into urgent care? Will I just natter about whatever interests me at that moment in time? I'm not quite sure. Certainly I'm not going to stop writing and in fact, later today, I'm heading into town to have drinks and a chat with a friend about something we are planning together.

So I'll keep blogging, but I'll no longer be the 'ambulance blogger', I'll be 'that annoyingly nerdy blogger', which I think puts me in good company.

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So there you go, a change in career, a change in direction, a change (of sorts) of name. I'm looking forward to it and will be writing about it in the coming weeks.

It would be a lie to say that I'm not at least a little bit nervous about this, but nervousness is just a form of excitement - and while this is a big step for me it's one I'm looking forward to taking.

An Indulgence

The monster, who was once a man, sat on the bonnet of the burnt out car and looked out across the London night.

He was deciding what to do, after all immortality could get boring after a while. So he sat on the car and tried to decide whether he should let himself die.

The problem, he thought, was that with endless years the space in your mind would fill up - forgotten names, faces without names, memories blurring into one another.

It wasn't that long ago he had London in the palm of his hand, ruler of the night court. Taken through fair means and foul, politics and violence, from the one who came before. And he couldn't remember her name.

He remembered other things though, the massacre at Osbourne house - trading on his survival at that bloodbath gave him his first footstep on the ladder of power. He'd risen through the ranks, slowly at first, then ever faster - his comrades at his side. One he would trust, the others could only be trusted in a well lit room.

Then the one he trusted returned to his homeland, the monster smiled at the thought of him now, probably dancing around burning orthodox churches.

He thought of the reward he had received for waging war against the other half of the city, the reward that ended in his near assassination.

But his survival fed his fame even more.

He remembered the lord of the undercity, he remembered him from when that lord was still a man and not the twisted but honourable monster he became. That lord had met his final death not too long ago from monsters older and nastier than he.

The things he had seen, the monstrosities in Norwich, the art gallery filled with elephant dung somewhere on the south coast, the things that flew invisibly in the air and invaded your thoughts.

The friends he had made, sitting around swapping war stories, insulting those who had not truly lived before they died and became monsters together.

The people he had killed to slake his thirst for blood. The murders he had planned, the murderers he had sent off to do his bidding.

The sky was lightening, too slight for human eyes, but easy to discern with his predators eyes. His decision would have to come soon.

Those of his kind that he called friends were largely no more, he had outlived most of them. The humans he had cultivated were now all moved on, taking roles that were of no consequence to him. Those enemies that still lived, to smart to fall to his blades, he could not count them all.

Back before he was made the monster he was just a man, a soldier, endless battles across Europe, fought for King and country. Different kings but the same country. He didn't care for the cause, but he cared for his brothers in arms. When he was a man he belonged to a family, now he was the monster any family he'd built had scattered to the winds, under their own steam or as ash, it didn't matter.

Perhaps, he thought, the choice to be made wasn't so black and white as to be a choice between life or death.

Once, when he was a man, the choice had been simple - to avenge his fallen comrades, hunting the monster through the alleys of London until cornered the creature that he thought a man turned bared it's fangs, and leapt for his throat. Life or death, it didn't matter, he would die for his family.

Now he couldn't, for he had no family.

So, if not life and if not death, then what should he choose?

Perhaps rest, a slumber for a decade or so, buried beneath the earth where his dreams could wipe away the last fifteen years. What changes would he see when he woke?

The bluing of the sky was more pronounced, his skin starting to itch from the sun's power. His choice would have to be made soon. To stay on the banks of the river and turn to ash, or to hide in the shadows and continue for one more night into the endless stretch of time.

He was bored. He'd won his game and kept his prize. But the boredom was his undoing, he'd would take more and more risks just to spice up each night. Seizing the praxis of the neighbouring counties, returning the power when he was bored.

And one night that boredom led to him losing the power in London. He'd tried to go it alone, but knew that it would not last, so one night he stood up and left - and didn't return.

Since then he travelled, looking for something to keep him interested, but the same old fights were repeated everywhere.

So now he sat on the bank of the river waiting for the first rays of the sun to appear over the horizon. To burn his flesh and blacken his bones.

The moment was approaching - to choose. Life, death or something else.

'I think a nice rest', he said quietly to himself, 'one day I might be wanted again. And besides, I wonder what will happen next.'

He strode out into the river and, picking a spot no different from any other spot, buried himself deep in the silt. Feeling the cold of the water and the slickness of the riverbed he thought that this would be a good place for a sleep of a few decades.

'I wonder how interesting the future will be', was the vampire's last thought before he slipped into the torpor of ages.

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An indulgence, an inside joke and a banishing with laughter. Tomorrow a big step to be taken and a line to be drawn under the past.

My Intial Thoughts On the NHS White Paper.

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...

Ambopost

You would think that it is pretty obvious what us ambulance people do; pick up sick people, treat them and then take them to hospital.

If you've read this blog over the last few years you will have realised that we do much more than that.

It's why I carry a Swiss army knife, because more than once I've been called to fix something.

The other day I had one of the weirder calls, it was sent to us as 'Having heart attack because of two boxes'.

Needless to say this piqued our interest.

We arrived as scene quickly, after all it was a 'Cat A' call and so be there in eight minutes or be a failure - but we were also the quickly as the address was just around the corner to the station.

Once the patient opened the door we recognised her, I'd say all LAS and half of the Police force in the area would have recognised her as well...

She is elderly and lives alone. She is also probably schizophrenic, or at least has some form of dementia. She has daily carers who are good, but they aren't there all day so she gets worried and scared easily.

The last time I was sent there was because she hadn't had her morning cup of tea and was worried that she would faint.

This time we were there because some delivery pillock had picked her address, out of all possible addresses to mis-deliver two large boxes.

These boxes turning up on her doorstep had, as she described it, 'given her a heart attack'. She'd phoned the police, and they had directed her to us.

And here we were.

The two boxes were lurking in the corner of her living room, staring at her with malicious intent.

Well, not really, but she was acting as if they were the most evil things in existence. There was no way that we could leave the boxes here because she would just keep phoning us, or the police, back.

So it was time for our problem solving skills to get a bit of exercise.

I phoned Control to get the phone number of the address on the box. This was not that easy as our radio kept cutting out, I would guess that we were in a b it of a dead spot as there wasn't any rain...

Control then looked up the p-hone number and relayed the number to me - I then phoned the person who was supposed to have the boxes (he only lived around the corner).

He was greatly surprised to hear from the ambulance service about his mislaid parcels, but was more than happy to come and pick up the bosses himself.

I suggested that this wasn't a good idea, and that we would come and drop the boxes up to him - after all if he turned up after we left our patient would probably call out the coastguard as well as us and the police.

So, as I knew the address I threw (ahem, rather I 'placed carefully') the parcels in the back of the ambulance and drove them around to him.

He was both exceptionally happy and very grateful.

Parcels delivered I returned to my cremate (and FRU, did I mention they were sent as well?) and picked her up after she finished assessing the patient.

Problem solved, and no need to drag our woman off to hospital.

Airwave

It would appear that the radio system that the LAS uses has been in the news of late - claims that it doesn't work in the rain, or that vehicles are without radios.

Or vehicles use the 'Airwave' standard, a digital network shared by, amongst others, the police. We have a main set that is fixed to the ambulance and should have two handsets that we carry everywhere with us.

I can only talk personally, but in my experience the radios are often a bit flaky (but remember that this is a system that was forced on us by the government), but not any flakier than any digital phone network.

The problem is that they are digital, if they have a poor signal then they just refuse to work, unlike the old VHF analogue radios that would transmit, although over a load of static. With analogue though the human brain is a great signal filter, and so you could make yourself understood. With a digital system you just have silence.

So it's not perfect, but it's not bad - at least we have handsets now, it's been something we've been wanting for crew safety for quite some time.

As for not having radios on vehicles - I suspect that the spokesperson for the LAS is counting the main set in the vehicle as a radio (quite rightly as that is all we have had for years), but the HSE are also counting the portable handsets.

These do go missing, but there is normally at least one handset on a vehicle. When we were trained in the use of the radios we were told about the system for replacing them if one should go missing - sadly this seems to have gone out of the window.

Oh well, no change there.

The switch to digital has meant some changes. For example you can no longer hear everyone on the radio talk group, so you have no idea where your workmates are or what they are doing - this results in much less awareness at street level of the situation across your sector. I can't tell if a hospital is full or not just by listening to the radio, nor can I hear if any crew needs assistance. This makes you feel a lot more isolated on the road.

The other side effect of not hearing the rest of the talk group is that, when it is busy, you 'buzz in' to talk to Control, but you don't get an answer, all you have is what seems like an empty channel while Control seemingly ignore you. With the old system you would hear them talking to the other crews, and so you would know that they were busy so you knew you weren't being ignored.

Overall, the provision of handsets has made crews safer, although I can't comment on the panic button as I've never had to use it. Some things are better, some things are worse. But at least the LAS has made the effort and the problems are with the design of the system rather than with the LAS.

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Can I also take a moment to mention one thing that I forget to write about in the last 'Transplant' post - that you should also discuss your being on the donor list with your family, so that they are prepared should the worst happen and that they know your wishes and don't overturn them. You might also be able to persuade some of them to sign up as well.

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Finally, big changes coming up, but it's something that I need to sit and write with plenty of time, not fire out in the half hour before I leave for work. And I'm not just talking about the NHS White Paper.

Transplant

A lot of the people I follow on Twitter have been talking about #transplantweek, a way to get everyone aware of the need for organ donors.

In my years as an A&E nurse I only knew of two people passing through my doors that went on to be organ donors, helping people that they never met. Two people in many years is simply not good enough.

In my ambulance work I find myself going to dialysis wards, people who desperately need kidneys. The chairs are always full - people connected to machines that clean their blood and keep them alive.

I've been to people who need liver transplants, waiting for someone to donate their liver to them so that they can live. These patients are swollen, yellow and in pain, and all I can do is take them to hospital where they can be 'managed' for a little while longer.

There was a child on my patch who needed a heart and lung transplant. She was lucky and got one, and I don't see her any more.

Once upon a time, when I would go to people who had suffered trauma, we would rush them into hospital where they would get blood transfusions that would save their lives. As a nurse I can't even guess at the amount of blood products I've given people. I used to be the one sent for the blood because the storage was halfway across the hospital and it never bothered me walking the hospital grounds late at night.

Organ donation saves lives - of that there is no doubt.

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There are myths that doctors will 'let you die' so that they can get their hands on your innards - I can tell you that this is completely untrue.

I've been on the organ donor list for as long as I can remember. I wouldn't be on it if I thought there was anything 'dodgy' about it.

You'd accept a kidney if you needed it to survive, why wouldn't you donate one when you no longer need it?

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Why don't you sign up today - help someone out when you pop your clogs. It's the ultimate in green recycling.

Register as an organ donor.

Self Promotion

Di you know that both my books are still available in shops and on Amazon?

Blood, Sweat and Tea

More Blood, More Sweat and Another Cup of Tea.

But did you also know you can download them for free for pretty much every platform under the sun. (And here for the sequel)

They are also now on the Apple iBook store, also for free, so if you have an iPhone or iPad you can read them on that platform as well. (And it has been downloaded quite a lot from there - a few more and I might make the top twenty free downloads chart). For some reason you can't like directly to an iBook store page. Which is a bit daft - do try and fix that Apple.

And finally - 'Blood, Sweat and Tea' is now available as an audiobook. Huzzah!

iTunes link

Amazon link to CDs.

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Feel free to download the free editions, and then, if you like it, buy a physical copy for your loved ones (from the emails I get, it would appear that mothers really like them). That way both my publishers and I get some lovely, lovely money.

OK, self-pimpage over.

On How Targets Directly Screw Patient Care

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'.

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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.

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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.