Category Archives: Ambulance

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.

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.

Knickers

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

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'Woman in Labour – outside newsagent shop'.

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

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

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

“Erm… That's our patient”, I say.

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

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

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

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

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

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

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

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

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

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

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

I take another look and see a bulge…

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

“What?!”

—–

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

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

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

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

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

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

—–

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

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

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

Blokes With Bandages 3 – Continuing Training

Continuing training

Medicine and the paramedical sciences are constantly developing, there is new research and new products that we need to learn about. We also need to refresh skills that we might not have used in some time. For example, I don't believe many babies, other crews deliver loads. I don't have many calls that could be classed as 'trauma' other crews are 'trauma magnets'. Meanwhile there are crews that perhaps don't have the same number of 'social care' issues that I do.

So it is essential that we have continuing training in order to learn new stuff, and refresh ourselves on the stuff we don't do that often.

Until very recently there were essentially no continuing training courses for road staff, at least none that I have ever been made aware of (and in this instance, not knowing about something is as bad, if not worse, than there not being any provision in the first place.

There is a 'training prospectus' on our internal website – let me give you a flavour.

Applying for Promotion, Communicating Assertively and with Self Respect, Effective Verbal Communications, Effective Written Communications, Equality & Inclusion, Getting the Most from Your Job in the Service, Giving and Receiving Feedback, Making the Most of Meetings, Minute Taking, Office Suite Training, Presentation Skills, Report Writing, Time and Workload Management.

You will note that lack of clinical skills.

It is a part of the Agenda for Change that we are continually learning, yet this doesn't happen.

However, things are changing slightly.

Our station now has five days a year set aside for training. So far this has mostly been for things like the new 'trauma tree', a new (and vaguely pointless) new bit of kit we are getting and my Personal Development Review. Nothing on delivering babies, CPR and ALS, trauma treatment, social care pathways, mental health issues….

The list goes on.

It is supposed to be 'protected', but already on one of those days I have been told to man up on a vehicle because there is no-one to train us (although the day was postponed, not cancelled).

This training is provided by our Team Leaders, who aren't actually trained to give training (although on our group of stations our AOM has put them through an instructors course – I wonder how widespread that will be).

So it is a fair bit of a shambles at the moment as there are many groups of stations that will not have any set training days.

My crewmate's instruction on the administration of Morphine? A sheet of A4 that had to be read, signed and returned.

Solution

Mandated training days, outside inspection of our training programmes, specific trainers who are educated to be trainers. A yearly prospectus of what each role in the ambulance service must have a refresher on each year. Standards that are set and must be reached.

Clinical Governance

Clinical governance is, at it's simplest form, a way of making sure that your staff are doing the right thing. It is a way to make sure that I'm not wrapping BP cuffs around someone's throat. It is a way to make sure that I'm following the latest medical evidence and guidelines and it is basically a way of making sure that I'm not doing anything wrong.

At the moment this is done by looking at my paperwork and 'marking' it in comparison to an ideal.

What my managers don't know is that I could make up everything on that paperwork and they would never know. As long as there is a tick or number in a box on my paperwork then I'm doing the job fine.

At the end of your first year on the road you have a 'ride-out', where an officer does a shift with you to make sure that you are doing things right.

Seven years ago I had this ride-out. It was the last time I was ever supervised in my work by anyone other than my crewmate.

(And crewmates will cover for crewmates – it's in out culture, not least fostered by an 'us vs. them' attitude towards management).

Solution

It's obvious really, regular ride-outs, regular checking of skills during refresher courses and a 'no-blame' culture. A person that a road staff can go to to ask questions or check their own skills without be judged or without fear of being disciplined.

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Unfortunately with both of these problems, in fact the problem with everything that I have written so far, it's not in the LAS best interest to squander our few resources on them. Instead we panic about hitting the eight minute target (and the 19 minute target for amber calls) and so all the focus is on that rather than on a well-motivated and well-trained workforce.

For example, a nearby complex has no training days. Yet their AOM has seen fit to install time tracking devices into local hospitals so that crews are under more pressure to 'turn around' jobs quicker.

i.e. We don't have enough ambulances, so we need you to see more patients, so don't spend as long at hospital as you have been doing.

This is where the resources are going, into trying to eek as much performance out of existing staff as possible. No extra ambulances, no extra staff, ignore training. All that matters is the time targets.

For this I blame the government – although there are some mumbles that some of these time targets are going to be scrapped. Hopefully the ambulance service will be one of these.

But there also needs to be blame laid at the feet of the ambulance trusts, there seems to have been a severe lack of action in trying to get these (clinically inappropriate) targets flagged as clinically inappropriate and instead bring in standards that actually reflect on patient care rather than on how quickly we drive.

What we need is for all our Chief Executives to band together and say 'No'. We need them to stand up and say, 'This is where we fail our patients, and it's all because of this target – no more. We refuse to having you harm our patients any more'.

We need people to fight for what is right in the media so that the public can see that we have their best interests at heart, rather than follow an illogical, outdated and irrelevant target. Instead that we need targets and standards that result in better patient care.

But I can't see that happening any time soon.

Blokes With Bandages

On this blog I've often moaned about things that the government does that makes our job more difficult, less effective and worse for patients. A large part of this being the clinically irrelevant Orcon target of reaching a large number of our patients within eight minutes.

This target chasing has led to what I consider to be a number of very bad decisions from our upper management which has resulted in low staff morale.

However, I've endlessly banged on about these problems and I'm yet to see any change.

What I haven't done is look at the role that us road staff have to play in this situation.

Our own personal morale is crucial in our own development, without some 'get up and go' we are happy to remain where we are. Turning up at the start of the shift, doing twelve hours work, and then at the end of it going home with no thought to the larger picture or how we can change things for the better.

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A large part of our problems are, I think, brought on us by ourselves.

For a fair number of the road staff workforce our job is essentially 'blokes with bandages', and that includes the women. They see themselves as largely taxi-drivers with a few other skills. On occasion I'm certainly guilty of thinking the same way myself.

It's a side effect of 80% of our jobs not needing any emergency medical intervention at all.

There is almost a 'reverse snobbery', where it is culturally desirable to not be clinically well trained. Where knowledge of medical issues outside of the 'pick them up and take them to hospital' is seen as being a swot or a boffin.

We hamstring ourselves by reducing clinical knowledge to a 'nice to know' rather than a 'need to know' basis, and by almost being proud of our lack of knowledge.

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What has led us to this? Why does such a large section of road staff have this attitude?

I can see four immediate causes for this, and a lot of it isn't our fault.

  • Our pay.
  • Our initial training.
  • Our continuing training and lack of clinical governance.
  • A lack of development opportunities.
  • A lack of role models.

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Our Pay

A vast number of road staff, myself included are on the 'Band 4' payscale. That is the same sort of level as a care assistant in a hospital. A starting nurse is Band 5. My salary is £21,798 and it's not going to get any higher as that is the top of my banding.

Actually that is not strictly true, I could move up a band by training to be a paramedic, but then I would lose my crewmate and probably my station – and some things are worth more than money. If I became a paramedic my pay after six years of paramedic practice would be £27,534.

I'm not complaining about the pay particularly, because the median wage is £23,472, meanwhile the median 'Health Professional' wage is £49,488. (Numbers from that link, multiplying a weekly rate by 52. The median wage is the wage where half the people in the country are being paid more than you).

So, at the moment I'm earning a bit less than the median wage.

In that case, is it at all surprising that we don't see ourselves as healthcare professionals when we are getting similar wages to medical secretaries or HCAs?

One of the comments that I regularly hear is 'I'll do that when I'm paid to do it' – referencing that our pay is supposed to be related to our job role, and yet the role keeps expanding but our pay doesn't. For example – we now recognise and treat appropriately heart attacks, yet our pay hasn't changed. We now give morphine as an analgesia, yet our pay hasn't changed. We are being encouraged to leave people at home, yet our pay hasn't changed.

As an aside, 'leaving people at home' is an almost perfect example of this blokes with bandages attitude, and one on which I'll return later.

One of the fears that I've heard both on station and online is that the removal of intubation from the Paramedic training is to keep them in Band 5, thus keeping pay down.

If you believe that you are only worth the same wages as a 'man and van', then you are probably going to content yourself with doing a 'man and van' job. Pick up the patient, do the mandated checks and take them to hospital.

So the problem is, we aren't paid enough to care about the big picture.

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The Solution?

I'd love to say that the solution is as simple as throwing money at us, perhaps even just enough to make our worthwhile job seem worthwhile. But it's not going to happen – there is no way that the public is going to swallow the idea that the NHS pays it's staff more for a better service when the NHS is already having trouble paying for cancer drugs or even for beds.

It's not even that we can improve our initial training for an increased wage. A newly qualified nurse with a diploma is earning the same as a degree level paramedic. Because apparently we on the road, on our own, have the same supervision as a nurse in a ward.

No-one ever said that the Agenda for Change banding would be fair, just or right. And the ambulance service is the proof of that.

So, we aren't going to get more money, especially with the government constantly talking about big, huge, and painful cuts – what is it possible for us to get?

A bit of respect.

Respect isn't given, it's earned. We need to start demanding respect for our profession, and start proving that we are worth that respect.

We need better representation in the media, we need more innovative practice and we need for our concerns to be discussed on a national level.

We need to promote ourselves as professionals. We need to stop putting ourselves down. We need to have our trusts stop bending over backwards to apologise when we have done nothing wrong. We need people who assault us to be put into prison, not let out because 'apart from beating up a paramedic they are actually a lovely person'. We need our PR departments to be more proactive and upfront about what we do.

More importantly, we need to have respect for ourselves and see ourselves as professionals.

—–

Next post will be about our training, and how it does us no favours.

Removing Intubation

As I was reading my Twitter feed before my shift started I noticed something. Loads of my fellow London Ambulance people were talking about intubation. I had no idea why.

It only took me a while to hear the rumour, then manage to get back onto station, then find on the internal website the bulletin that they were all talking about.

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Since the start of Paramedic training, one of the things that has been a main thrust of their qualification is the skill of intubation. Intubation is the passing of a plastic tube into a patient’s airway in order to breathe for them. This protects the airway from becoming blocked and, more importantly in CPR, prevents vomit from entering the lungs thereby buggering any chance of successful resuscitation.

The bulletin is entitled ‘The future direction of airway management in the London ambulance service’.

It mentions that in 2008 JRCALC looked at the research, which is mostly American, and made the recommendation that paramedics should not be intubating patients. JRCALC doesn't seem to have many actual ambulance people involved in it – but perhaps this is a cheap shot and I think this only because I can't seem to get much information when I Google the names that aren't obviously doctors, nurses or midwives.

What immediately leaps out at me is that if they are looking at American research you are comparing apples with oranges. From the research I have read, the success rate in America depends on the training and continuing education of the staff, something that varies across the different companies providing ambulance services and also that varies from state to state.

The consensus seems to be that you need practice, and you need regular refreshment courses and continuing assessment to be safe to intubate.

—–

There is thought that intubation can immediately reduce your chance of surviving a cardiac arrest, mostly because while someone is faffing around with a plastic tube the things that work – compression and defibrillation, aren't being done. But this is an issue that could take up a week's load of blogposts on it's own, so I'm not really going to touch on it.

In theatres, with a nicely starved patient undergoing an elective operation the airway of choice is something called an LMA – and this is great. It's easy to insert and it protects the airway. Unfortunately it doesn't protect against vomit very well. This is why you starve surgery patients, if there is no food in the stomach, no food is coming up your throat to then swill down into your lungs.

Rather unfortunately, most of our patients who decide to stop breathing and need CPR haven't had the foresight to starve themselves for eight hours. When you do CPR you often get vomit. Loads of vomit. Vomit that, if it enters the lungs will damage them in a really nasty fashion. As well as drowning you.

To protect against vomit going into your lungs, you really need proper intubation. And an LMA isn't going to cut it.

Unfortunately it's harder to train someone to intubate than it is to pop down an LMA.

Of course, if your patient isn't vomiting then you don't even need an LMA, most often a basic airway technique will be enough.

The next time I blue light a cardiac arrest into hospital, I'll ask the anaesthetist if they are going to use an LMA or intubate, and why they make that decision. That should hopefully highlight the clinical need for intubation.

—–

So, let’s look at London, and why I think that – while we are right to stop teaching paramedics intubation, it is just a symptom of a much wider problem.

To be good at intubation you need practice, you also need to have something called Clinical Governance. This means that someone or some policy will be in place so that your clinical skills can be evaluated so that it is certain that you are performing to your best.

One way in which this can be done is by having a clinical lead shadow you at work, watching you and making observations as to how your clinical practice can improve.

We don’t have this in the London Ambulance Service.

In eight years I have had one of these ‘ride outs’.

This, quite simply, is not good enough.

Imagine the simpler skill of taking a blood pressure – for the past eight years I could have been doing it wrong, placing it around the wrong part of the arm for example. There would be numbers on my paperwork, but they would have no resemblance to reality.

Unless someone complains, or another member of staff tells someone about my risky behaviour, I could be doing this for many more years to come.

Now extend this to intubation, a much more technical task that has severe repercussions if someone does it wrong i.e someone will almost certainly die.

Our paramedics do around 25 intubations during their training, which is under half the recommended number (57). Once they have done that they are given a tube and told to go and intubate people out in the wild.

Once the initial training is over that’s it. There are no refresher courses, there is no chance to go into hospital to practice (because in non-emergency situations other airway protection techniques are better, the LMA I mentioned earlier for example), and there is no way of knowing if the paramedic is even doing it right in the first place.

So, it is a good thing that intubation is being devalued and no longer being taught. But the reason behind it not being taught is purely because we don’t teach it right in the first place, and there is no system in place for paramedics to keep their skills fresh.

And that is just wrong.

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So, what does this mean for the future?

New paramedics will no longer be taught intubation. More people will die from cardiac arrest from inhaling their own vomit, but perhaps we'll see a reduction in death from incorrect intubation – I suspect that in the long term deaths will increase, if only because you are more likely to vomit than suffer an incorrect intubation (and all the paramedics I've worked with are fastidious about checking that they have performed a correct intubation). However only time, and counting the gravestones, will tell.

Older paramedics will continue to be allowed to intubate, but any suggestion of a refresher course will be off the table as the skill is now devalued. I would also suspect that the ambulance service will just stop buying the tubes used in intubation. No stock on station means that you can't use the skill anyway.

It'll be interesting to see what happens should the newspapers get wind of this – that or the response to a 'My child died because…' headline.

I doubt the press office will admit that the reason this skill has been removed is because the London Ambulance Service cannot train, supervise or refresh their staff correctly.

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This removal of a skill because we cannot correct train, assess and update our staff ties in rather nicely to a series of posts I'll be publishing from Monday.

Chronicles of EMS

What do you mean you aren't watching 'Chronicles of EMS'?

It's a show about EMS, and it's by EMS people and it is really rather splendid.

And now there is a competition! For they are very close to being picked up by 'proper' TV.

(I'd enter but I haven't had an original thought in years… Also I don't like flying and I already have an iPad)

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So here is the big news!

We need your help.

Over the past few months our esteemed creator/director/producer and all round good guy, Mr Thaddeous Setla, has been meeting and pitching to TV Executives across many of the networks in America, and whilst they all really like what we are doing, they want to see a change to the name ‘Chronicles of EMS – The Reality Series’

What we need from you is your creative thoughts on a new name for the show. It will continue to be ‘The Chronicles of EMS’ but we need a new tag line instead of ‘The Reality Series’

It has to showcase what we are doing.

We are not just a fly on the wall TV Show – We want to challenge the status Quo and drive forward change in EMS

We are not an American only show – We are truly international and plan on travelling the world seeking out best practices and sharing them worldwide.

Just as important, we are an entertainment show that embraces it supporters and followers like never before.

We need something catchy and powerful, and for the one who comes up with the winning formula, there is an amazing prize on offer.

The person who provides the new name for the show will have round trip flights and 3 nights accommodation to a location of their choice where the Chronicles of EMS will be filming. This could be New York, San Francisco, Germany, Austria etc etc. If we are going there, the winner can come with us. They will also receive show credits and some ‘on screen time’ in a future episode too.

If thats not enough, they also get a 16GB Wi-Fi, 3G iPad.

If the winner is under the age of 18, they will win a top of the range 64GB ipad Wi-Fi & 3G.

The only requirement that we have to enter, is that you are a member of our Chronicles of EMS community. This is free to join and can be done by clicking here.

Full terms and conditions can be found here.

Submissions end on the 9th July 2010, when we will provide a short list of the top 5 entries which will then go on to the public vote from the 12th July up until the 6th August. The Grand Prize winner will be announced on or around 10th August during a live Tweet Up in San Francisco.

So what are you waiting for?? Get your entry in by using the form found here, and Good Luck!

Wakeup

For the past four or five months I have been coasting at work. It's not really my fault, it's just that none of my patients have been… challenging.

I've been going to a seemingly endless supply of patients who either do not need an ambulance because their 'illness' is so minor, or have had such simple problems that helping them doesn't require much in the way of thought.

I haven't had to 'blue light' a patient into hospital for this period.

And so I find myself settling into a fug of relaxed 'easy jobs'. Nothing much requires thought and, for many of my calls all I need to do is a set of basic observations and write down a name and date of birth.

It seems to last forever, being able to walk through my workday without having to think, without having any worry.

It makes the days go very slowly.

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And then…

Then I turn up to a patient, one who, to start with, doesn't seem too unwell.

But then he begins to get worse, he's getting a lot worse.

He starts sweating, he starts edging around collapsing, he asks me if he's going to die.

Suddenly, after months of sleepwalking through my day, I'm having to make decisions. I'm throwing drugs into him. Hell, I'm giving him drugs and I can't remember the last time I gave them.

We blue light to hospital and I'm eyeing up the ventilator, wondering if I'm going to have to use it when he stops breathing.

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We get to the hospital and the doctor there does a stunning save. No faffing about, just straight in there with the best treatment.

By the time I've completed my paperwork, cleaned and restocked the ambulance and washed my hands, the patient has turned the corner – we part company with him shaking my hand and thanking me.

Which, you know, is not a bad way to end the day.

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The trick is to be prepared for that worrying call. To not let the nearly endless stream of simple stuff blind you to the occasional, but important, serious job. You must not let yourself be caught out by it.

And lets face it, that's a lesson that works outside of the medical field.

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Now, I have a serious question for any ambulance people who read this blog, and I think the answer will say a lot about the state of the ambulance services in the UK.

Who is the top EMS educator in the UK?