Vulnerable

The last shift of my tour seemed to be nothing more than one alcoholic after another. Individuals with drinking problems that go beyond binging. Emotional and psychological dependence on the stuff is what I'm talking about. This is not the same for me as picking up a gutter-vomiting teenager who needs to be taught when to stop drinking. This tugs on you and reminds you of how vulnerable humans are and where they can end up when things go wrong and they just can't cope with it all.

Before all that, I'd gone through nights and days where aggression and trauma mixed into the scheme of my world so fluently that they became one and the same.

A taxi driver crashed into a lamp-post, flattening it and continued on until he was stopped by a traffic light post, which was bent halfway by the force of the sudden deceleration. We were the second ambulance on scene and it was immediately apparent that it was not safe. The London Fire Brigade (LFB) was called because the engine was still 'live' and there was a spillage of diesel under the cab.

Inside the taxi were a driver (obviously) and a passenger. Both had been thrown forward violently by the crash but only the driver had been wearing a seat belt. However, he seemed in a worse state than his passenger, who was conscious, alert and somewhat annoyed by the situation. His neck was being held stable by a FRU pilot and one of the crew from the first ambulance on scene.

The driver had apparently been unconscious prior to crashing, according to witnesses. An off-duty doctor and paramedic both helped and they informed us that the driver had still been unconscious when they went to his aid immediately after the incident had occurred  This was a worrying bit of information, so I asked for an ECG to be done and a full set of vitals before we moved him.

The LFB had arrived after a few minutes and they were very keen to cut the doors off the cab (this was going to be the extrication method) but I'd asked them to hold fire until I'd seen what was going on with the man's heart.

A few years ago I was called to a crash where the driver had lost consciousness at the wheel and careered into a barrier. His ECG revealed a massive heart attack. I was determined to check this before we did anything else.

The driver's ECG was fairly normal but his blood pressure was consistently high. He had a history of hypertension and a stroke in the past. This seemed to be the only rational medical explanation, so we carefully removed him from the cab first, followed rapidly by his passenger. Both went to the same hospital and both landed in Resus, but the passenger walked out after a short time because he was 'fed up', apparently. The driver was found to have had a stroke and was taken to a specialist unit for treatment.


We were asked to take a 30 year-old male from police custody to hospital because he'd admitted to having swallowed drugs (allegedly). However, when we turned up, he denied it and became extremely verbally aggressive towards us and the officers. In fact, all the way to hospital, even with a police officer in the back with him, he shouted abuse and hatred at me. He made several statements about how we (paramedics) were all 'worthless' and a 'waste of time'. It felt very personal, even though I knew it wasn't but it's extremely hard for someone like me to keep a 'yes sir, no sir' attitude with an individual like this. There are things I want to say but they'd get me sacked. So, I endured and allowed him to berate me, my colleagues and my Service, until he was exhausted by his own venom.


Then a drunken Italian man continued the abuse and added physical aggression to the equation.

We'd picked him off the street after a concerned MOP had called us. Initially he was just annoyingly vociferous but it did't take too long before the drunken stares began... these are usually followed by insults and challenges. I wasn't attending this patient but I got as much of the offensive stuff as my crew mate. The man obviously wasn't fussed.

We tried to put him somewhere quiet to sleep it off because he didn't need to go to hospital. If we'd taken him (even if we'd managed to get that far without him kicking off in the back), he'd have upset every proper patient there and probably caused grief for the staff. I don't like giving hospital staff the same stuff we have to put up with. So, we tried to sit him outside the hostel we thought he stayed at.

He fell over and looked like he was going to keep falling over until someone else called 999 and another crew had to experience his violence. So, we got him back into the ambulance, after a few swipes and punches, and took him to the police station. We asked an officer if he could be arrested for drunk and disorderly behaviour but the cop wasn't having it... they were full up and had many other drunks to deal with.

Suddenly, as if by magic, the man uttered the name of the hostel he was actually staying at. We decided to take him home and leave him with staff who knew him better. The journey wasn't too far but he shouted at and insulted us all the way there.

When we tried to walk him to his hostel, he became very aggressive and his arms swung at us. So, I went to the hostel and got the manager to come and collect him. This worked (eventually) and we finally got rid of our cargo.

Ironically, I was told by the manager that the man didn't usually drink and that he was normally very quiet and gentle as a lamb. Alcohol has a way of stripping away the human side.


I got chatting to a lovely 74 year-old lady who works in the theatre (she still teaches young Thespians) after we'd been asked to take her to hospital following a fall in the street. I suspected she had a broken nose, so an x-ray was needed at the very least. She was quite embarrassed about an ambulance coming for her and said "I thought they'd send a bicycle".

We talked about Groucho Marx and 'The Broons' from our lives in Scotland (she was from Edinburgh). It was refreshing to meet a patient like this after the night we'd had so far.


Our only true emergency of the shift was an 88 year-old female who'd had a recent chest infection and who could barely breathe. We had to take her into Resus on blue lights. Her condition was serious but when I saw her later on she was a completely different person; normal colour and breathing well again.


The first alcoholic we dealt with was a 53 year-old female who was shouting the odds when we arrived. Her carer looked terrified - she'd called 111 and was directed to 999 (this happens a LOT), so we had to attend.

The woman was drunk. She had no immediate medical issues but she had a long history of physical and emotional problems. She'd lost a few important people in her life and everything had spiralled out of control.

She didn't need or want to go to hospital and we could see that she had en extensive history of having ambulances come to her and then leave without taking her in. Dozens of calls like this had resulted in absolutely nothing being done about the problem.

It was very clear that she had mental health problems but that they are not being addressed, simply because she gets drunk and then refuses all help. This cycle has to be broken before she will get any better. Until then, thousands of pounds of tax payers money will be spent allowing her to continue on until she kills herself, dies accidentally or kills others by misadventure. She smokes a lot and it doesn't take a genius to see that if she is drunk enough and drops her cigarette on the floor, among the debris of cooking fat, paper and alcohol, she will burn... and so will her flat, and the flats above hers. It's happened before. It's a fairly reasonable prediction.

In the end we had to leave her, after an hour of chatting and trying to persuade her to go somewhere safe with us. Her sister arrived and sat with her and this woman made me think harder about it all. She was very defensive with me, very agitated and laughed almost manically when she spoke of her sister's condition. It was clear that the poor woman was reaching (if not at) the end of her rope. From what she said to me, nobody had shown any real interest in her sister's problems. I could see the depth of her hopelessness and I wondered how easy it was to get there.

Nobody seems to care. Her GP and the other services are trying everything they can but there seems to be no solution. That just can't be right. At the very least, a Section for her safety should be considered.


Our second alcoholic is someone I know. I've attended to her several times. On each occasion, she leaves hospital without treatment, begs for money on the street and then goes to the nearest shop to buy booze to keep herself drunk. It's not unusual to attend more than two or three times in a single day because  if she doesn't call us, a MOP will. It goes on and on.

She is very well spoken 61 year-old woman and she always says that she knows what a burden she's become and that she wants to end her own life. This is pretty much what they all say but the reality is they want help. REAL help. They don't need us taking them on pointless runs to A&E and they don't want pity or anger or hatred.

Economically, it would be far cheaper to give them the help they need. Take them away from their environment and all alcohol for as long as it takes. Give them new purpose. Instead, we just keep chucking money at the problem without reaching a valid resolution.

I'm not being Utopian, believe me, but up close and personal... these are vulnerable people with nowhere to turn except us. We are NOT Social Services, neither are we the AA or any other agency responsible for this kind of support. It's time we looked at this again.

Be safe.

The happy Space Hopper

Aww, bless her. She went through a lot of pain and yet allowed me to write this story up. This is Laura and she had an accident.

If you look closely at her right elbow you'll see it's not quite the right shape or size. In fact, she's fractured and dislocated her Humerus so badly that the Radius and Ulna (the lower arm bones) have detached completely and slid upwards and behind the upper arm. This photo was taken by her boyfriend 'Brummy' while she was being treated.

We were called to a 'possible dislocated elbow' and managed to get to the address without being cancelled or diverted (which could easily have happened as it was a very busy night for drunks and they, as always, take priority over broken bones).

When we got into the flat, Laura was on the floor and her boyfriend and three others were around her. There was a bit of giggling going on because alcohol had been imbibed (responsibly in this case) and they were all good mates who thought this was awkward and rather amusing, which it was at times. Although having broken a bone myself, I sympathise completely with the general feeling in the room - you know, if we don't laugh, we'll cry... that feeling.

My crew mate and I started putting her at ease and I explained that I'd give her a little pain relief. She was quite drunk - not stupidly so, but enough to keep her grounded while all this was going on and her arm looked pathetically useless to her. So, I gave her a little morphine and a LOT of Entonox. She was perfectly capable of self-administering the gas and it helped her a lot. So much, in fact, that she was positively bursting with happiness at times. She was like a giggling crippled starfish on that floor.

This was going to be an awkward removal because the flat was a couple of flights of steps up and walking her out was our only option. My crew mate, who is a student paramedic, had never seen such a  serious fracture/dislocation, so I spelled out the plan so that we could move her safely and without causing any further harm if possible. It was not going to be easy.

After a bit more gas and a bit more reassurance, and with all her friends settled down to the reality of her condition, we began to move her from the floor to the ambulance. We had no vacuum splints, which would have been ideal, so I made do with a box splint and padding when I got her out of the flat. Holding her arm stable whilst walking with her was the only realistic option we had, given the position she was in, the position her arm remained in and the environment we had to negotiate.

It was a long, slow and careful process. I felt the bones of her arm shift only once during the move; there was a bit of a crunch as they ground together (crepitus) but it wasn't allowed to happen again.

As soon as she was safely in the ambulance, we packed her arm into the splint and positioned Brummy so that he could keep it stable during the slow drive to hospital. He was more than happy to help and assisted with humour and smiles for Laura. That's the way it should be really. She was in pain and she had a fairly serious injury, but it wasn't life-threatening and she needed to be kept up-beat so that she could bear it.

She told me she'd had several fractures in her life; she seemed prone to them when she had the most benign falls. I suggested she may want to investigate the possibility that she had EDS, or another condition that was causing this.

We popped in to see them both in the Resuscitation Room, where they'd been taken so that Laura could have the dislocation reduced. They were in good spirits (well, Laura was mostly off her head on drugs by then).

The arm was reduced but it failed and the plaster had to be cut open and another attempt made. For a good few hours the poor girl went through painful and uncomfortable procedures to make her joint behave. It finally settled into its anatomical position on the second reduction and re-plaster.

The X-ray shows the extent of the dislocation. Laura had to return to hospital to have bone fragments cleaned out and may have to have pins put into the joint.

And how did she manage to do all this? Well, you are already thinking she was hopping about drunk and fell off the big rubber ball... but you're wrong. She was hopping about, as were the others, having a laugh and enjoying a dinner party with friends, but she successfully completed her hopping fun and dismounted. She then took a few steps around it and fell to the floor so awkwardly that she did the damage that now renders her temporarily disabled.

Crazy huh?

They had been drinking, yes... but in the privacy of a friend's home. They had been fooling about on a big inflated ball whilst a little drunk, yes... but they were having a dinner party and it was that or Charades. They called an ambulance, yes... but they needed one. This is a genuine accident and there was a real injury. Not one of these people went out to get so drunk they'd end up in a gutter, vomiting their stomach inside out. They were, in fact, pretty sensible, decent and thankful individuals. Brummy had even been preparing to take his injured girlfriend to hospital in the car, rather than 'waste our time'. I can tell you right now that her injury would have been much worse by the time she'd reached hospital if they hadn't called 999.

My sincere thanks to Laura and Brummy for their permission to highlight this call and for their great sense of humour and common sense. I wish Laura the very best of luck with her recovery, and I'll keep you all posted.

* With respect to recent emails. Can I just clarify once again that Laura gave me express permission to use her name, so she has no objection whatsoever to having her name seen on this x-ray! The photo was taken by Brummy specifically for use here! Thank you.

Be safe.

Major trauma

My friend got a delivery of heavy shelving recently. This is where the delivery guy decided to leave it when she didn't answer the door. She was in at the time of the delivery but she just didn't hear him. Her door opens outwards....


Two patients at once after a fight broke out in Covent Garden. Both men had been beaten up quite severely and one had been left unconscious. Both had head injuries but I was more concerned about the man who'd been KO'd than the other one, because, although he had a fractured nose and cheek bone, he was alert, orientated and responding appropriately. The other man began a slow decline from the same state to somewhere relevant to the severity of his injuries.

His skull appeared depressed where he'd been kicked or punched - probably whilst on the ground - and that gave me all I needed to divert him (and his mate) to a Major Trauma Centre (MTC), rather than Accident and Emergency.

We can take serious trauma patients to specific hospitals, where specialist treatment is immediately available. It has to be done with caution, however, using good clinical judgement or, as in the case of this man, instinct. I don't mind getting it wrong if the alternative is that I could take someone to an inappropriate treatment centre and there's a delay in their care. I think that applies to most of my colleagues too.

En route, the man with the broken nose bled all over the ambulance floor; it was difficult to stop the flow until I wrapped a dressing around his head. The other man began vomiting. I'm sure we made the right call.


I'm known for my opinion on binge drinking, especially with young people and I still believe our NHS ambulance services should not be tasked to recovering people who deliberately go out and poison themselves with alcohol. However, there isn't much option and no resolution of the problem is in sight. So, we take them off the streets and to places of safety (usually hospitals) and that's that. But everyone has a duty of care for young drunks when they are in their professional arena. So it was disturbing to hear that a bus driver allegedly told a semi-conscious 17 year-old and his friends to leave the vehicle when he became sick.

Taxi drivers have little tolerance for this either, and I completely understand - they will spend a good few hours cleaning up the mess and will earn nothing while they do it. Bus drivers will have to get their vehicles cleaned too and they will be off the road.

The problem is that throwing a young person off public transport and leaving them in the street might just put them at risk. Years ago, I posted an incident where a taxi driver had taken a teenage female off his vehicle because she'd started vomiting. He left her in a doorway, in the small hours of the morning, in the freezing cold, with very little in the way of clothing to keep her warm. She was left exposed and dangerously vulnerable until someone called 999 and we picked her up. It happens almost every weekend.

In this case, the young man had friends with him but he was still left in the street, surrounded by people waiting for buses. He was almost unconscious when we arrived to take him to hospital. He was very cold and had been sick all over himself.

It may not be appropriate or convenient when a drunken person starts vomiting and messing up your clean vehicle, but it is a simple matter of judgement for anyone to assume that, if they are in such a state, then maybe they should be going to hospital - but not via the street.


Our last job of the night was another head injury but this time it was much more serious. The man had been hit by a taxi and had almost gone through the windscreen and into the cab, such was the force of the impact.

We arrived after the FRU and there was a paramedic and student paramedic dealing with him as he lay motionless on the ground. A small crowd had gathered and were watching and filming, so I asked them to leave the area. I've never understood why people would want to film someone's personal horror. It's not illegal because it's in the public domain but it tasteless and pointless.

There was a lot of blood around and it made the scene hazardous for everyone working there. The four of us managed his airway, started getting IV access and assessed his injuries, which were multiple and major. He was still breathing and still had a pulse, so there was still hope.

HEMS arrived and soon we had blood being transfused and more advanced intervention going on to save the man's life. It took almost 30 minutes to stabilise him and get a decent pulse so that he could be moved. He'd been RSI'd and immobilised fully for the journey to MTC and when we got there he was still breathing and had a better BP than we'd measured whilst treating him in the road.

Heading home after a shift like this invokes two things; a feeling that something worthwhile had been done and a life might be recovered from tragedy, and reflection on the skills and procedures carried out, so that they can be honed further.

Be safe.

Back to the nights

I completed my first tour of night shifts since my unfortunate period of illness and trauma last year. It took me a few shifts to get into it again, and my sleep pattern was erratic at best to begin with. Nevertheless, I enjoyed the run and actually dealt with some genuine (and genuinely nice) patients.

However, my first night kicked off with a call I'd rather not have gone to. A 1 month old baby with respiratory failure. She'd stopped breathing due to a genetic condition, and her mother and sister were taking care of her when we arrived. There was a motorcycle paramedic (MRU) on scene and we got the story from him when we entered the little flat.

The baby was breathing again (albeit inefficiently) but had stopped several times prior to the 999 call. She is in such poor shape that it is unlikely she will have much of a future, if any at all. This type of call always makes me feel very down, especially as I am a parent myself. I have a lot of admiration for people who struggle through with very unwell children and still manage to keep a smile on their faces.

We took her to hospital while supporting her breathing all the way. We had been diverted to this from a nonsense call way out in the opposite direction; if it hadn't been for the common sense and good judgement of whoever was despatching us at the time, we'd have been attending a fully grown up woman who was 'not talking' instead.


Tonight was all about alcohol for a good few hours. In fact, our next patient - a drunken female at an underground station, had such strong alcoholic breath that I could still smell it on my uniform hours after we'd taken her to hospital for her own good. This was swiftly followed by a 40 year-old man, found lying among the rubbish bags in the street. A MOP had called us because he was worried about him and he was right - the guy would have been left all night and ignored for the most part, until he was finally taken in unconscious with hypothermia.

He was drunk of course, but he was a gentle drunk. A man with a learning disability and no clue where he was or how he ended up on the pavement. This made him vulnerable but he knew that and when I spoke to him later, when he was in his hospital cubicle and sobering up, he agreed.


It was almost certain that I would get assaulted at some point during this weekend; the number of aggressive drunks and angry people around made it inevitable if we were to get involved with them at any point. So I wasn't really shocked when I was punched a few times by a fist-swinging patient who'd allegedly taken 60 codeine in an attempt to kill herself. I got hit on the way down the stairs of the hostel, as police officers attempted to keep her off me, and hit again in the ambulance as a reward for trying to sit her down safely.

It was the first time I'd ever been assaulted by a six-foot transgender patient.


In the early hours of the morning we set off, on blue lights and sirens (because it was an emergency call) for a 90 year-old bed-bound man who woke up and realised he hadn't switched his TV off! Incredibly, we were allowed to go all the way there before it became clear (even though it was to us) to everyone else, that the call was about switching off his TV for him and no more. To add insult to injury, there was a 24-hour concierge on the front desk of the apartment block when we arrived. So he was tasked with the job and we returned to whatever normality we'd be allowed to resume...


...Until a drunken 25 year-old female fell down steps in a night club and split her eyelid open, deep enough to reveal the bone of the orbit. She wasn't knocked out and she was lucid enough, so she went for cleaning and closure.


The last call took us a long way out to tend the needs of an old woman who was 'vomiting'. She lived with a strange man in a strange, unkempt house. In front of a fully-functioning three-bar electric fire, she retched her way through explanations of illness as the man stood over her, patting her on the back in that 'I really don't want to touch you' way that you sometimes see when people are trying to be sympathetic but either don't have the practice or don't know what else to do.

She continued to retch and cough, but never vomited. And when she was preparing to come to hospital with us, she requested her teeth, and the strange man duly obliged, fishing them out of a cup with his fingers. Then he lost them on the grubby carpet for a time and they had to be retrieved by the FRU paramedic who had arrived ahead of us. He gingerly picked them up and handed them to the woman. Now she could smile if she wished, and her carpet debris could smile with her.

She retched all the way to hospital and stopped as soon as we arrived.

More to come from this tour...

Be safe.

The Royal cushion

Every now and again in this business, we treat individuals of high stature or fame, or both. A call to an 81 year-old woman who'd fallen in the street didn't allude to anything more than an average call to an average person. However, when we arrived, we saw that armed police had settled and comforted the lady and that a decoratively dressed man was also in attendance. It was clear from a distance that they were helping someone who was regarded as a little more than ordinary.

The woman had stumbled over her walking stick and fallen hard onto her arm and hip. Her upper arm was giving her a lot of pain and we controlled this with Entonox, whilst establishing what had happened. The lady's husband is an employee of the Queen, and she was on her way to Sunday church service near the Palace, when she misjudged her step and fell onto the pavement.

She was helped to a sitting position by the cops, who'd been close by, and the decorated man, who is also in the employ of the Royal Household, appeared shortly afterwards, to render moral support and to provide a beautifully embroidered cushion that belonged to the Queen Mother.

Every patient is an individual, regardless of their status in society. Every patient feels pain and deals with it in their own way. But it is nice to treat people that you know, with absolute confidence, will not abuse you. They won't swear at you, spit at you, or cause you discomfort whilst carrying out your job.

I will probably never meet the Queen (I'm sure my medal for contributions to blogging is in the post however), but it was a pleasure to come into contact with people who work closely with her. I was expecting to be commanded, rather than allowed to do my job. I was expecting to be excluded from the conversations the patient and the decorated man would have in the ambulance. Neither happened. The decorated man praised the LAS in fact, citing how wonderful the service was and how well we all did our jobs.

The patient, although in a lot of pain, was animated and humorous in conversation. It was an unexpected pleasure to be with them. So many high-ranking people forget to consider who we are and what we do, day after day. It was refreshing to be reminded that, when it comes to the crunch, they are just people, like everyone else.

I don't know what the outcome for this lady was - I suspect she had a broken Humerus - but it made me smile to think that my handover was initially rejected.

"I have two VIPs with me", I said to the nurse. "Members of the Queen's staff".

"Yeah, in your dreams", said the nurse with a grin.


On the other hand...a call to a 32 year-old man who'd had a witnessed seizure in the street, jolted me back to reality. A cycle response (CRU) paramedic was on scene and the man was still dazed and confused after his 5 minute fit, during which he'd bumped his head and cut his hands.

There was a single can of extra-strength lager in a carrier bag next to him. It was safe to assume it belonged to him, that being the nature of many of these calls. Nevertheless, we took him into the back of the ambulance, where he was initially calm and fairly compliant. The police accompanied us. They had been called to help and had decided to stick around.

It took a long time to get the man's first name and no other details were forthcoming. Post-seizure patients can be very vague and seemingly uncooperative, but that's part of the recovery process, as the brain resets itself. It can take an hour for a patient to fully recover and start talking sense.

As this man began to recover, he became extremely aggressive and abusive towards me. In fact, he made it very personal with me, which angered me. I am not a diplomatic person. I will not allow anyone to abuse me or insult me without a response, but while on duty and representing my profession and my employer, I simply cannot indulge in my instinctive reactions, so I had to sit there while he dealt me one threatening insult after another. He was no longer post-ictal and seemed lucid enough to know better.

I, like many of my colleagues, have had years of this type of abuse. Somehow people think it is acceptable. People think its just 'part of my job'. Well, it is NOT part of my job. It isn't in my contract and it isn't in my professional guidelines.

Unfortunately, there is very little or nothing we can do about this, so it really comes down to how long you are willing to accept it yourself (as part of the job). For me, time is running out. After a decade of abuse and insults and physical assault, I'm seriously thinking of a better life.

This guy was eventually taken off the ambulance and allowed to walk away. The police could do nothing (well, they could but it'd change nothing), so he staggered off, with his can of lager and his hateful soul.

I had to consider the huge contrast between this job and the last one, and it depressed me somewhat. The first call had lifted my spirits and made me feel like the job was worthwhile. This call had reversed all of that in an instant.

I analysed his anger and hatred towards me, simply because I was trying to help him as he bled onto the floor of my ambulance. I analysed my own anger, as I sat there wanting to lash out verbally at him in response, or simply ask him who the hell he thought he was talking to. But most of all, I had to analyse the possibility that he'd cracked his head hard enough on the pavement to cause a brain injury and that his response to me was the result of his slow post-seizure recovery, his alcoholism, or a bleed inside his head.

I could forgive only two out of three of those possibilities.

Be safe.

The root of all queues

THIS news story relays the current problems we are all facing but I have heard many times that this is fairly common with WAS. However, look at the story and read it carefully. The problem was caused, in my opinion, by the GP and the structure of the pathways set in place for such ambulatory patients.

How did the GP diagnose a fractured spine? He clearly wasn't absolutely sure but had suspicions, so he arranged for an ortho bed and an MRI to be carried out, to see exactly what the extent of the damage was to this lady's back. That is all fair enough. The GP has to act on his experience and knowledge and the given set of signs and symptoms surrounding his patient. But it sounds like he either used an emergency ambulance service, (which is solely for immediately life-threatening illness and injury), just to expedite his patient's journey to hospital, where other means of transport, such as A&E support or Patient Transport Services, were available (in other words he dialled 999 for a patient who was not being admitted for immediate life-saving intervention)... OR, as I suspect, there is simply no option available to him. There are no other transport pathways and so everyone ends up dialling 999.

The woman's daughter even stated to the Press "Admittedly, my mother was not an emergency case, but nevertheless during her long wait she was unable to go to the toilet and was getting increasingly tired and fed-up", before going on to describe the intolerable wait her mum had to endure, and the obvious frustration of the crews, even though they were professional and patient.

The irony is that if she hadn't been sent to hospital, essentially for a scan, by emergency ambulance via the 999 system by a health care professional, the queue would not have been quite so long, because they would not have been in it. The patient coming in behind them would not have had to wait even longer than they did, due to their presence, and the crew may have been saving the life of a seriously ill patient elsewhere.

Without alternative pathways; other means of taking patients to various different departments in hospitals without the need to call 999 and have them go through our already stretched Emergency Departments, this problem is only set to get much, much worse, until, soon I suspect, someone will die in the back of an ambulance because their undiagnosed triple A ruptures, while various GP referrals and District Nurse referrals - Health Care Professionals (HCP) using 999 as a means of transporting non-emergency patients - are brought in by exhausted and frustrated crews who will wait for hours outside hospitals with patients on-board who remain stable for hours. It's madness.

In my opinion, the problem is one of two things when it comes to HCP referrals. They either don't realise what they are doing when they take an emergency vehicle away from genuine emergency calls to transport stable, non-emergency patients. Or they don't have a choice, because there is no alternative.

This lady couldn't get herself to hospital and a car or taxi would have been a non-starter, due to her condition. A fractured spine is serious but it is not necessarily immediately life-threatening. A critical asthma attack, a serious head injury, unconsciousness, neck fractures, vomiting blood, central chest pain, cardiac arrest.... these are all 999 calls. But how do you get this patient to hospital for a scan if you have no safe means of transport? She needs an ambulance with a trolley bed (and a spinal board) and a crew that knows what to do.

The voluntary services offer non-emergency transport services, so what about them? Or private ambulance services... or the NHS Trust Patient Transport Services.

Here's the rub. Many hospitals have contracts with private or voluntary ambulance services but, when it comes right down to it, the HCPs who want their patients taken care of simply don't seem to trust these services and prefer to call 999 instead, knowing that they are going to get a professional front-line crew. I've even heard preferences for paramedics to take care of patients, even though there is no need because the patient did not require paramedic intervention of any kind. The transport services used by hospitals are usually the cheapest quoted and the contracts are decided by management, not necessarily clinicians.

We have a major problem. If this continues, not only will our system fail and patients start to suffer, but ambulance crews will begin to lose heart. They will also become unwell due to exhaustion, stress and frustration. This will have a knock-on effect and before you know it, we will be struggling to cope with the system as it stands.

HCPs aren't the major culprits though. The general public still attend Emergency Departments for the most insignificant problems. Everyone's emergency is personal, I know that, but when are we going to start educating people properly? First aid should be taught in every school - to school students, not just staff. And it should be taught by professionals who have actually done the things they are teaching you to learn. That way, a more realistic perspective is taught and kids might just start growing up taking ownership of their minor injuries and illnesses, instead of assuming that the health system is there to solve every little problem.

If you want an example of how bad things are getting, consider the 14 mile journey I undertook - on blue lights at a doctor's request, so that a patient could have a tooth replaced.

Xf

Dogs have feelings too...

Another cardiac arrest dragged me and my crew mate miles from base. An 83 year-old man had collapsed in front of his family. He was a known diabetic but had been speaking to his son earlier, with no problems reported at that time.

When we arrived, a FRU and another ambulance, crewed by an Accident and Emergency Support crew was on scene. We were told that a Physician's Response Unit (PRU) was also on the way.

The man was stuck in a tight space and the FRU Paramedic was in the process of resuscitating him, with the help of the A&E Support crew. It was clear that this was a messy and complicated job, and the presence of his family, in various rooms of the house, didn't help the situation. Emotional energy like that can hamper a resuscitation attempt - the task calls for an almost cold but certainly calculated demeanour; having family and loved ones out of sight is important whenever it can be achieved.

Before too long, there were too many cooks in that space. The PRU team had arrived, consisting of a HEMS paramedic and two doctors, so when they joined in to help, there were eight of us working on and around the poor man. However, once a few necessary skills had been carried out and we'd finally managed to get Intraosseous access (IV access proved to be impossible), only those directly involved with the resuscitation attempt were left with him. The A&E Support crew got busy with supplying and tidying away equipment, passing drugs and keeping the man's son, who was in a room opening directly onto the small landing area where his father lay, occupied and out of sight.

One of the doctors dealt with other aspects of the attempt, including communicating the process with the other family members upstairs.

Once again, despite what is said about the job and what we do, when it comes to this stuff, we all know it well. Teamwork and communication is vital during a life-saving attempt. Keeping calm and responding to the situation without allowing it to affect you personally, is what makes the difference, if there is to be one, between death and life. I'm still proud to work alongside my colleagues in situations like this.

Unfortunately, despite our best efforts over a long period of time, the doctor discussed termination of the resuscitation with us and we all agreed. There had been no change in the man's condition for almost an hour. It was futile to continue; the effect on the family was bad enough - to draw things out would have been cruel and unnecessary.

The man's body was left at home, appropriately covered and cleaned up as much as possible. The police were called (standard procedure) and the family was left to grieve in peace, with all of us waiting outside in our vehicles until the police arrived to take over the scene.

When we were tidying up, I walked into the small room that the son had been in, until he went upstairs at the end of the attempt. Inside, lying on the sofa, was a Boxer dog. He had his head on his paws and his eyes told me everything about how he felt. This was the dead man's dog and the animal was clearly upset and depressed about what had gone on around him. His eyes followed me without his head lifting, and this just made him look ever more sad.

I tried to persuade him to move into the little kitchen area, away from the sight of his master laying on the floor of the landing, and, at first he followed, tail wagging at the sound of a kind voice (up til then all he'd been hearing were the voices of control and procedure and they are not kind voices). But he turned and went into the landing area, where he bowed his head close to his master's face, before running up the stairs.

I love animals. I love dogs especially; they can be extremely intelligent and are famously  loyal, and I believe that what I witnessed at that moment, was a dog saying goodbye to his master.

Be safe.