The Story So Far (Or, how to keep the bank manager in suspense)

It’s been a little quiet round these here parts. I mean the blog, not Israel. Below, I explain a little as to why this has been the case. This isn’t really my normal blogging style, it’s just a chance to vent a little, so feel free to skip this one if you so desire. I promise to not be offended.

To say that the last few months have been an education is somewhat of an understatement. Almost ten months since I stopped working in London, I seem to still be some way off from getting my paramedic qualification recognised here. The key word, as you may have gathered either from previous posts or from twitter, is bureaucracy.

Even prior to our arrival, I’d made contact with the right people, presented documents, certificates, qualifications and all manner of related material, and was promptly promised that after a short conversion course of sorts, that I’d be a fully qualified paramedic. There are, like many other places around the world, many roles for a paramedic in Israel, within multiple different organisations and healthcare providers. However, the issue of paramedic qualification belongs to only one – the original (and still main) Israeli ambulance service – Magen David Adom (MDA) – a subsidiary of the International Red Cross. As an organisation, MDA has a pretty good reputation around the world. Many an ambulance service has come to study its mass-casualty treatment system and they lead the way in some of the treatments they provide. Yet at the same time, I'm discovering that it is overly burdened with tape the same colour as its well-known emblem. And I thought that London was bad.

I’m a little wary of accusing anyone of lying, but I think that the phrase “terminological inexactitudes” is a fair one. The information I provided wasn’t passed on. Claims (false or misinformed remains to be determined) were made that they had never had a paramedic who had qualified overseas want to move here, nor that there was even a protocol in place for such an eventuality. The relevant authorities weren’t informed. When they were eventually informed, there was another delay when the head of the right department seemed to leave under something of a cloud. Nothing to do with me, I hasten to add.

Then the plan changed a little and was to become a two-pronged attack on the system. Whilst I was waiting for the right courses and exams to come up that would eventually give me my paramedic license, I’d also work through the other side of the system to be recognised as an EMT and ambulance driver. Unlike the UK, not all road staff need to be able, or required, to drive the ambulances here. The idea was that the driving element should be easier and quicker to complete, the EMT certificate more of a formality, thereby giving me employment, at least as an EMT.

Plans are often foiled, sometimes by man, sometimes by machine. Sometimes the two combine to make life as difficult as possible. It’s meant that whilst I’ve been able to volunteer on the ambulances, I still have no actual employment. Other jobs that I’ve gone to look at, even temporary ones, both related and unrelated in any way to the medical world, have been kiboshed by the fact that someone, somewhere would tell me that there’s no point, as the bureaucracy will be sorted within a matter of days. There are three people particularly upset by this situation. The wife and I are the obvious two. The third is our bank manager.

There have been moments where I have thought about giving up altogether. That the effort I’ve been putting in and the hardship my family is enduring is just not worth the final outcome, assuming we even get there. I have sat through courses, taken exams (one of which, thanks mostly to my own stupidity, but partially to the ambiguity of multiple choice questions, I have to retake next week) and pushed on through the reams of paperwork, often feeling that it is a never-ending cycle leading me to nowhere and back again.

Then I’ll look back at the last decade, think back to the hundreds of shifts both in London and the few that I have here, and remember what it’s all about. What it is that I love about this job, which is so much more than just a job. Think back to the patients where I know I made a difference, or where they made a difference to me. Think back to the simple patients who only wanted someone with whom to talk. Think back to the patients who left no mark on my life, but who years later still remembered the difference we made to theirs, and who took the time and made the effort to come back and tell us so.

I know that I want to continue doing it. I know that I can’t throw it all away. I know, that if only they’d let me finally do it, that I still have so much to give. To give to my patients, to my colleagues, to myself. But for each step forwards, there seems to be at least one step back. Sometimes two. To say that it’s been frustrating is yet another one of those understatements. I have known for a very long time that Israeli bureaucracy is a menace that each person has to fight at one time or another. It’s frustrating that I have the skills and the knowledge, not to mention the experience, just sitting at home and waiting. It was frustrating during the recent war that I’d hear reports of volunteer paramedics arriving from overseas whilst I wasn’t allowed to join them despite sitting on the doorstep.

I am determined to beat the system, even if that then means I become a part of the very same. Perhaps once there, I can do something to prevent the next person crazy enough to want to do the same, from having to go through this chaos. In the meantime, I’m waiting for this chaos to end, just so that I can go and face chaos of another sort altogether; one that I can hopefully do something to treat.

And hopefully make my bank manager a little happier, too. 

Unsung Heroes

Heroism is a term bandied about all too lightly. Teenagers describe the latest pop-sensation as their hero. Sports fans describe the latest world-class footballer, baseball-player or sprinter as their hero. And every so often, a short note in the media, or a new internet-based meme will try to portray unlikely people as heroes, including paramedics, nurses and other medical staff. 

Whilst I agree that all are undervalued, the stretch to the point of heroism is a little bit far-fetched. I've written about it before. The fact that EMS finds itself at the bottom of the heap of the medical world is unfortunate and not a little unfair. Yesterday, I saw a tweet that described it thus: "Whether EMS is part of the health system, or public services, it seems as though we will always be treated as the red-headed step-child." From my experience and understanding, through either virtual or actual meetings with EMS providers around the world, the feeling is mutual across the globe. And this is coming from a (albeit balding) red-head. 

Still, I feel that to reach the point of hero-worship, as some seem to feel should be the case, cheapens the meaning of the word as well as the act of heroism. 

Overnight, as the fury of Hurricane Sandy hit the eastern shores of the United States, a hospital in New York City had to be evacuated after both its regular and emergency supplies of electricity were cut off. According to reports, 215 patients, from the youngest to the oldest and in all manner of medical conditions, had to be moved to other hospitals. 

Staff ventilated patients manually, keeping them alive. They changed mains-powered machines to battery-powered back-ups. They climbed down and up flights of stairs to the ninth floor to rescue the tiniest of neonates, as brittle and dependent as it is possible for a human life to be. 

Ambulance crews braved the weather conditions and risked their lives in a manner which the rest of the population had been ordered to avoid. Not just advised - ordered. 

That, to me, is heroism. It isn't the constant calls, it isn't even the life-saving calls. That doesn't make paramedics into heroes; it makes them damn good at their jobs, as they should be. It's the paramedic who, despite everything he has learnt, despite the awareness of the risks he is taking, jumps into a dangerous scene because he knows he can make a difference. It's the hospital staff who, when faced with the most serious possible crisis, don't walk away, but run towards it, armed with knowledge, skills, awareness and, no doubt, no small amount of fear. 

It's occasions like these that show the world the reality, the true meaning of heroism. 

I certainly didn't see any footballers or pop-stars there. 

Stay safe. 

DVT Confusion

When is a DVT, or deep-vein thrombosis, more dangerous to an ambulance crew than it is to the patient who's had one? Consider the following conversation:

Medic: "Does your husband have any medical conditions?"

WifeOfPatient: "Yes, he's diabetic and has high blood pressure."

Medic: "Any medications?"

WOP: "Oh, lots, I'll show you the list." A list is promptly produced. On there, alongside medications for the ailments already mentioned, is warfarin.

Medic: "Why is he on warfarin?"

WOP: "Oh, that's to thin the blood."

Medic: "Yes, well we know that bit. But why does he need his blood thinned?"

WOP: "Oh, he's got that thing, you know, the thing that's like a video or television thing."

Medic: "Pardon? What's TV got to do with blood thinners?"

WOP: "You know, that new-fangled thing they use to watch films now!"

Medic: "Nope. Still confused."

WOP: "Oh! I remember now. It's that thing in his leg. A DVD! Told you it was like a telly..."

Just so you know, it's a little difficult to treat your patient when you and your crew mate are having fits of the giggles...

Simple

It's a question I get asked on a fairly regular basis:

What makes a good medic?

In my simple mind, it's a simple answer.

Here's the test:

Would I be happy with you treating a member of my family?

If the answer's no, then in my eyes, you've some work to do.

If the answer's yes, then in my eyes, you're a good medic.

The test works when I look at myself in the mirror and check on how I treat my patients too.

Simple.

Medics are from Mars...

Transcript of a recent conversation with a patient:

"Do you have any chest pain?"

"No. Not pain as such. It just hurts." 

"Have you ever had any heart problems?"

"No. Never. Had a heart attack once, but never any problems." 

"When was the last time you had an ECG?" 

"An ECG? I've never had one. But they did check my heart last month with all those sticky labels on my chest." 

"Have you ever had palpitations?" 

"Never. Every so often I feel like my heart wants to jump out my chest, though." 

"Any other medical conditions?"

"No, no. Take medicine for blood pressure and diabetes, but no medical conditions." 

Patients are from Venus. Well, some of them, anyway. 

Bystander

I decided to try something different, and write this post from the point of view of the bystander. Sometimes it's easy to forget that they might be more affected than the patients...

__________________________________________________

They came thundering in like a stampede across the savanna, bags on their shoulders and equipment in their hands. I directed them upstairs, and told them the same thing I'd explained to the gentleman on the other end of the phone. I think it's too late.

It was the first time I'd ever had to call for an ambulance, and I only called because I didn't know what else to do. Lily and Ted had been my neighbours for as long as I could remember. I never really left home, visiting regularly throughout my university years and even the first few years of my marriage. They adopted me as their own, and my children were the grandchildren they never had. When my parents died within weeks of each other, we renovated the house, and instead of selling my childhood home, we sold our house and moved back in.

"Uncle" Ted and "Aunty" Lily were family, whether they were related to us by blood or not. My kids adored them as much as I did. We ate together, spent days at the beach together, celebrated birthdays and anniversaries together. So when Lily knocked on my door early that morning with tears in her eyes, I knew.

They came rushing in, four of them, their green uniforms and tired eyes showing signs of another night shift nearing its end. And yet, the speed and energy with which they came bundling through the door, well, it was as if they had only just started. All the while, I knew deep down that it was too late, but just for a minute, watching the paramedics running up the stairs, I dared to hope that maybe they knew something I didn't.

Moments later, the first of them came back downstairs, empty handed and sullen faced.

"I'm sorry," he said, genuine regret in his eyes, "there was nothing we could do. I'm afraid Ted's died."

He went on to explain that Ted had probably passed away during the night, and probably just drifted painlessly away in his sleep. I was glad to hear that. Small mercies are all we have to grab on to when there is nothing else left to do. Lily was sitting by the table in the kitchen. She knew too, but somebody had to tell her. I didn't have the strength to do it, so I asked him if he would. He put a comforting hand on my shoulder, nodded gently, and walked towards the kitchen.

"He's died, hasn't he?" asked Lily, her voice as broken as her heart.

"I'm afraid he has. It's probably been some time, and it looks as if he just fell asleep."

He was so kind, that paramedic, I wish I'd asked his name. In fact, they were all so kind, but I could hardly remember any of their faces, so I'd probably have forgotten their names too. Once they'd cleared up, they each came in to make sure Lily and I were OK. One of them made us tea, the sweet, warm liquid slowly thawing our numbed minds. It's the drink that cures all ills, at least temporarily. For Lily, and thinking back to my own parents, I feared that this might be the beginning of the end. She promised to stay strong - she meant it, too - and I promised that I would always be there for her. From the day Ted died, six weeks ago today, I checked in on her at least once a day, even though I knew that she had carers twice daily, morning and evening. 

Then, tonight, the carer knocked on my door. She couldn't get in to the house. Lily wasn't answering the door, and the key was still in the lock. As soon as I walked up to the house, I knew. The police broke the door down, and once again the green uniforms went rushing in. Once again I hoped I was wrong. Once again, as the first paramedic came back downstairs, I knew that I wasn't. He put an arm on my shoulder, told me what I already knew, and that he thought that Lily had obviously decided that she couldn't live without Ted, and had chosen instead to join him. 

As I looked at him properly for the first time, I was surprised, but relieved. This was the same paramedic who'd been here when Ted died. At least he understood. At least he knew. He knew that I was not just a nosey neighbour, that I was more than a simple bystander watching it all from the sidelines. It wouldn't make a real difference in the long run, but at that moment, as I stood there engulfed in sadness, it just felt right.

Two Seats

A pair of expensive-looking trainers adorned the feet that stuck out from behind the bush. It was the only part of Jacek that was visible from the street. A concerned member of the public walking home late at night called the ambulance when he thought someone must be lying dead. It's a good thing he waited, because we'd never have spotted the shoes from the road.

"He's in there. Not sure if he's breathing or not, didn't want to get too close."

At five in the morning I had to ask what he was doing walking around the streets.

"I was on my way home from work. I do funny hours too."

"Oh really? What do you do?"

"I'm a nightclub bouncer."

I should have guessed really. Six feet four in every direction, close cropped hair, and a badly fitting suit - a perfect stereotype. The fact that someone who intimidates people for a living was a little nervous about approaching a pair of shoes, or at least whatever or whoever was attached to them, seemed a little ironic. I shook the patient's legs and one of the shoes fell off, making our bouncer friend visibly recoil.

A groggy mumble of "Go away!" from deep inside the bush only added to his discomfort.

"Do you still need me here, or am I alright to go home?"

"Yeah, sure. We're OK here. Thanks for your help."

He practically ran away from the scene.

After a few more attempts at waking up our patient, he finally relented and climbed out of the branches, hampered slightly by the thorns of a lone yellow rose. His face appeared last bearing a five o'clock shadow, but at the wrong five o'clock.

"Go away! I'm sleeping!"

There's gratitude for you.

"You can't sleep here. People will think you're dead and call ambulances!"

"Go away! I'm sleeping!"

"Where do you live?"

"I live here. Go away."

His clothes, other than the odd branch and a few green leaves, were clean, maybe even new. Not exactly the attire of a long-term homeless man. 

"Do you have any family in the area?" 

"No. They not live here." I guessed by his accent that he must have left his family in Eastern Europe somewhere. 

"And friends?" 

"My friend he is here." 

"Where's here?"

He turned round and looked back into the bushes.

"Here!" He points aggressively at the broken branches. "Don't you speak English good?" 

I looked at him, looked at my crewmate, shrugged my shoulders, and climbed half way into the bushes looking for a drunk friend. 

"Jacek, There's no-one in here!" 

"He is there! You not see him!"

I look again.

"There's definitely no-one here!" 

"He is there! Only I see him. You no see him!" 

I climb back out of the greenery, and look much the same as our patient with leaves and bits of broken branch all over me. 

"You mean to say I've gone looking for an invisible man?" 

My crewmate takes one look at me and tries to stifle a giggle. We help Jacek into the ambulance and as I'm about to take my seat, he suddenly shouts. 

"You not sit there! Friend - he is there!"

All of a sudden, the trolley seems a much better choice of seat. At the hospital, the waiting room is busy, and I take a minute to look around.

"What are you waiting for?" asks my crewmate.

"Just trying to find two seats together." 

Natural Wastage

We're in the media... for all the wrong reasons.

The news has hit the mainstream news outlets shortly after we heard about it internally.

Almost nine-hundred jobs are to go at the London Ambulance Service.

Two thirds of them will be front-line.

There are tough times ahead.

Possibly tougher for our patients than for the staff, if the "natural wastage" policy is adhered to.

I just hope I'm wrong.

Reflections

It's that time of year again. A year ends, a new year begins. Everything changes, and yet nothing does. It's a time to reflect on all that has passed, and then resolve for the future.

Reflect on the year in general.

Reflect on my achievements. Have I achieved all that I set out to do?

Reflect on my students. Have I taught them the best practices? Have I taught them anything new at all? More importantly, have I learnt anything from them, as they probably have more to teach me than to learn from me?

Reflect on my studies. Did I attend all the classes I could? Did I spend enough time studying of my own free will?

Reflect on my skills. Did I use them well? Did I learn any new ways of using them? Did I improve them?

Reflect on my attitude to patients. Did I treat the patient at the beginning of my shift the same as the one at the end when I'm tired? Did I treat all my patients with the respect they deserve?

Reflect on the way others see me. Did I give people the need to criticise or praise? And what did I do with either? And when they talk behind my back, are they armed with the sword or the shield? 

But for me, the most important of all the reflections I look at, is the one that looks right back at me.

And for now, as I stand in front of the mirror in an ironed uniform and polished boots, a star-of-life proudly hovering over my left breast pocket, the reflection's looking happy.

Happy New Year to you all.

Breathing Again

They came in their masses. Call after call, day after day, week after week, for well over a month. In that whole period I don't think I saw a single person who genuinely needed an ambulance other than a few elderly fallers. Coughs, colds, three-week old ailments that suddenly needed immediate attention at four o'clock in the morning. It was infuriating and demoralising. And to top it all off, in the midst of this lull, before the days when I only worked nights, there was the dreaded "office week". A week of shifts that runs from Monday to Friday, nine in the morning until six in the evening, just like being back in an office.

I used to despise that week. It came round every three months or so. It meant fighting the traffic on the way to work and on the way home. It meant being left with the least suitable vehicle with the least amount of equipment. It meant, more often than not, coming in, taking the ambulance to get fixed, spending hours making sure it was working, ready, stocked and cleaned, seeing one patient, and then going home. Late. It meant always, always finishing late. And it meant that after spending a day making sure that the vehicle was fixed and ready, that someone else would come in and steal it, and you'd have to go and do it all over again the following day.

All in all, it left me frustrated, angry, and burnt out. Office week had finally destroyed the enthusiasm that I'd harboured since the day I joined several years previous. It was just a straw, but the camel's back had been well and truly broken. I had never before taken a sick day when I wasn't actually sick, but I was very close. The end of office week brought, as a reward for surviving its arduous torture, a long weekend. I wasn't due back until the Tuesday morning. Monday night, I picked up the phone and called in sick. Or at least I tried to. Three times I tried, and three times I hung up the phone as soon as someone picked it up. I slept even less than my normal two or three hours that night. Tuesday morning came, I had an ambulance that worked, it was equipped, and there was even a crew mate I was pleased to see.

Although not thrilled to be at work, I was determined to fight through the lull, and go back to enjoying my job. Whatever it may throw at me.

The first call came in seconds after the clock struck seven. The call was more routine. Abdominal pain. A young man with a tummy ache. The MDT updated with more details as we approached the address. A fortnight of pain now culminating in an ambulance being called. My hopes and determination lay in ruins once again. Normally I'm exuberant to the point of irritation. Ask any of my colleagues. Nothing at work really gets me down. Patients who called for inappropriate reasons would be fodder for venom only within the confines of my brain, whilst mostly I'd be all sweetness and light to them, as though they were the most important patient I'd ever had. But now, even I had lost my positive outlook. One minor abdo pain too many, and I was completely and totally fed up and burnt out.

I sat in the front of the ambulance after we'd dropped him off, another one ticked off on the list of the multi-drop delivery van-driver that I'd turned into. As I filled in the paperwork, I wondered how much worse was it going to get. I pressed the green button to tell control we were available and ready for the next call. Barely had we pulled away from the kerb, when the MDT rang again. Just an address appeared, no details as to what was happening. Another waste of time, probably. 

Less than a minute away from the address, and the details popped up on the screen. A lady in her 50s, asthmatic, breathing difficulties. In the extra information it mentioned about the husband who was making the call was difficult to understand as he sounded distressed and that he was possibly crying. We pulled up outside the house, took out the bags of equipment, and as we stepped over the threshold into the lounge where she was lying, she took one last, deep breath, and then stopped.

There was a blur of activity. We requested an extra crew, or at least another pair of hands. We plugged the mask into the oxygen bottle and started breathing for her. We added the kit that produced a cloud of steam containing salbutamol, a drug that would hopefully help to reopen her airways. Needles in, drugs administered, and more and more oxygen pumped into her lungs. Her heart still worked on it's own, whilst her lungs went on strike, but even that wouldn't last much longer if we didn't help it by taking control of the lungs. Another ambulance arrived, making the removal and treatment just that little bit easier and smoother.

Her lungs that were initially silent now had a harsh wheezing sound, a sign that they've opened just a little. Enough for us to be able to push the vital oxygen in just that little bit easier. Once in the ambulance, we warned the hospital we were on the way and a brief outline of what was happening. Half way to hospital things changed.

She took a breath on her own.

Then, after a few long, tortuous seconds, she took another. Still not enough on her own, but a huge leap in the right direction. We kept up our assistance with her breathing, arrived at the hospital, and handed her over to the team. As we stood watching, she took more and more breaths on her own, the regularity returning, the external interventions diminishing.

"Well done, guys", the doctor who'd met us with our patient treated us to a pat on the back. "You've saved another one." Another one maybe, but the first genuine patient in well over a month.

I was beaming as I walked out the department. A patient who not only desperately needed our help, but whose life we'd actually saved. A couple of hours later when we returned to the hospital, I peeked round the door to see that she was sitting up in the bed, a chest drain in place treating a collapsed lung. Her eyes were open and she was talking to her family.  

We breathed life back into her, and gave her another chance to face the world.

She'll never know that she'd already returned the favour.

The Mask

Patients;

Managers;

Ego;

Publicity;

Public education;

Anonymity;

Pride.

Go balance that lot!

I sent out a challenge, and dozens answered it, in comments on the blog, on Facebook, on twitter, in person. I have received suggestions, thoughts, ideas, humbling compliments, and on the whole, a strong recommendation not to reveal the face hidden behind the Insomniac's mask.

The main reason, although not the only one - an anti-management stance of mistrust. That in itself, is a sad reflection of the way social media is still perceived as foe rather than friend by the establishment. There is, of course, the potential to bite the hand that feeds you by blogging, but that was never one of the reasons for writing this blog. I'd like to take on the challenge of changing their view, but I'm not sure I'm up to that task.

Patients and their right to anonymity and confidentiality are clearly king. They are the reason we do what we do, they are the people who allow total strangers into their homes, their lives, and their vulnerabilities, with the promise that we don't then divulge their most intimate details to the world. To this end, as you all know by now, I change everything. Locations, ages, genders. I combine different calls to make one story, or divide one event into several different, unrelated posts. The tales I tell are effectively that - tales. Fiction based on real-life events. No patient has had their identity compromised.

And then there's the challenge of public education. Ideas such as the Chronicles of EMS, groups of visionary paramedics looking to advance their profession via open social networking and public media, could never work if we all hid behind masks. I'd love to get more involved, but at the moment, as an anonymous blogger, that's impossible. I could get involved in podcasts, as my face is probably more suited to radio anyway, but the options for exposing this to the public are limited, and therefore flawed as a plan for mass education.

Personally, my anonymity used to mean everything to me. It's still important to a certain degree, but every time someone guesses or knows outright that I'm the author of this blog, the pride I feel when they tell me they enjoy reading it, outweighs the shadows of anonymity that I crave. There's a voice that says I should be proud of what I have achieved, and that I should have no reason to hide, but then there's the other voice.

The voice that continuously asks "What if?".

What if there were repercussions from management? (Maybe one of them is reading this, and will have the courage or foresight to contact me? The email address is in the profile...).

What if I slipped up and did reveal a patient's identity?

What if I had to give the blog up all together?

For now, and I stress for now because this whole decision is finely balanced and on the brink of collapse, I'm staying hidden. It might well be the worst kept secret in the Ambulance Service, but for now, it stays a secret.

One day, hopefully, common sense, mutual trust, and pure, unadulterated ego will prevail.

When that happens, I'll lose the mask.

More on Change

Following on from my previous post - here's one of the changes that are going to be trialled in London in the very near future. The Evening Standard, a London daily newspaper, has titled it "UK paramedics sent to emergency calls without ambulances". Slight newspaper sensationalisation is evident in the title and may scare the public a little, so briefly - here's the plan and how it'll work. Single responders will be sent in FRUs (fast response units) to the calls that are deemed as appropriate. Having recently completed an 18-month secondment on such a vehicle, I see no problem with that.

As a single responder, you are in an emergency vehicle that carries pretty much everything that an ambulance does, except the transport devices such as trolley, carry chair, spinal boards and the like. FRUs up until now have been tasked to respond quickly, start treating the patient, and then hand over to a crew that is sent to back them up. The thinking behind it is that the FRU paramedic/EMT is then free to attend another call. Whereas a call turnaround time for an ambulance is somewhere around the hour mark, on the FRU it was often less than half that.

The difference with the new model is that a transporting vehicle will not be automatically dispatched at the same time (in theory) as the FRU, except in the most serious cases, but that those in control will wait for instructions from the FRU paramedic on scene who can give a better assessment as to what sort of further response is needed. This, to me, is a small admission that the dispatch system we use is somewhat flawed. Having said that, the system can only go by what the call-taker inputs, and the call-taker in turn can only go by what they are being told over the phone.

There are other flaws. Calls to serious RTCs and other traumatic injuries are very often not categorised in the highest banding, and could in theory leave a lone paramedic dealing with a multi-casualty incident. I understand that any intelligent dispatcher will take one look and send the ambulance anyway, but in an era where there is more and more intention to rely on computer systems, turning around and asking for human input smacks of a contradiction.

Despite all my reservations at this point, I'd be glad to be one of the first paramedics to trial it had it have been trialled in the area in which I work. I would, however, have certain conditions that I'd like to ensure were adhered to. The main one would be that if I turned up on scene and requested immediate back-up, that it'd be on the way there and then. Too many times as an FRU paramedic I've had to wait for the transport to arrive despite repeatedly pleading with the control centre to find me someone to take the patient.

It's not a lack of confidence in my skills or treatment abilities. It's not that I'm desperate to "get rid" of the patient and hand responsibility to somebody else. I like and accept the responsibility, I enjoy treating patients, and I thrive on the extra challenge that is often presented when dealing with a critical patient on your own. But I recognise when the patient needs more care than I can give them.

Equally, if I decided that a patient didn't need transport to A&E, I'd like to know that the system was in place whereby other medical professionals would recognise and accept any diagnoses or referrals, and I'd like the public to be aware that I'm trained and qualified enough to make those decisions. This was the idea of the Emergency Care Practitioner (ECP) role that has been running in London for the last few years, but was never fully put into successful operation. The staff that took on the role were and still are dedicated, motivated paramedics who undertook a large amount of extra study and training, and are now being left high and dry as the role is phased out. It just never had the understanding and backing that it needed, and was never fully accepted by external agencies.

I'd love to think that this trial is being undertaken at least partially from a clinical point of view. I suspect economics has had more of a say. I may be an optimist, but I'm not naive. I have my reservations about this trial, but am more than happy to give it a go. No-one yet knows a full job description or scope of practice for this new role (probably entitled Advanced Paramedic), or whether there will be extra training involved, more pay, or any other details. But we know it's coming. This is one of those things where front-line crews need to be involved in the decision making process, and as far as I know, they haven't been, certainly not to any great extent.

More communication between the sides might surprise us all. The front-line staff might find that they want to be a part of the changes, even pioneer them, and management might find that they have willing partners, rather than unwilling subordinates.

Overall, change is a necessary thing for an evolving profession such as the one of a paramedic. Change breeds teething problems. These will exist at every level, public understanding, call taking, dispatch, front-line and external agencies. The trick will be to iron out these problems and turn them into a viable, working model, that will ultimately benefit not only the target-setters and finance department, but also the most important people.

Our patients.

Too Late

I see it... but I don't quite believe it.

Another shift with my new student (can you believe they let me mentor someone new?) and he's getting used to working the night shifts. We discussed things we've seen, things we'd like to see, things we'd never want to see. It's the crazy time in a night shift, the one where the wall of tiredness hits head-on, and where anything can happen. Minor hallucinations are a common thing in the dead of night. The tired mind plays tricks on its owner. I remember thinking once that I was seeing a baby crawling in the road at about 4am, only to realise that it was a plastic bag blowing in the wind.

As we drive over the brow of a hill heading to yet another call during this non-stop run of shifts, I think my brain is up to its old tricks again. We're two hours before the end of the shift, haven't stopped all night, and only eaten bits and pieces on the run. I'm sitting in the back, and looking through the front where the driver for the night and said student sit. Out of the corner of my eye, I see two little kids, probably three, four years old, running towards the road, then back onto the pavement, and then just up and down by the side of the tarmac.

"Stop! STOP!"

It's too late for kids to be up, let alone out on the streets.

The vehicle comes to an abrupt halt, and I jump out the back door. The blue lights of the ambulance illuminate the entire street, and it won't be long before the curtain-twitchers are out in force. The kids see me coming towards them, and head for an open front door. I follow them and as I peer in to the house, I see that there are several supposedly responsible adults there, awake, watching TV or just talking. Cans of beer sit on one of the surfaces, and empty boxes of takeaway food are strewn all over the floor.

"Did you know that your kids are running around on the streets at five in the morning?" The response comes in the form of raucous laughter and does nothing to calm me down.

"It's fine!", starts one of them. "They don't go far!"

"Well, one of them nearly got run over by an ambulance!"

"So we'll sue the ambulance service" they laugh. "They're fine. Leave them alone, and leave us alone."

With that, they slam the door in my face and carry on with their irresponsible parenting. Or partying, if you prefer. Furious, I turn on my heels, walk back to the ambulance, advise control of the cause of the delay and that they might consider informing the police. At least in the mean time, the slammed door might mean the kids stay indoors.

We continue on our way to the original call, not quite comprehending.

Hopefully we saved some lives on the way to that call.

We were too late for the original patient.

The Newbie

Those who can, do. And those who can't? Teach. Apparently.

I tried teaching once. Lasted all of a year and then gave up. Couldn't cope with the formality of educating in a school setting, probably because I was no good at it as a student.

Then I found a career I loved, studied hard for it, passed all the exams with flying colours, and have loved almost every minute of it since then.

Now, Lizzie, a newbie, is asking for help and advice. For the Handover Carnival, she asks a simple question. "What would you teach me?"

There's no better way to learn in this job than from those with all the experience. I've written before how learning to be an EMT or paramedic is a little like learning to drive. You learn to pass a test, but the real learning only starts once you've passed it. The wealth of information that is available is all there for the taking, there are blogs, websites, journals, research facilities, memberships of associations, and so on. If, however, I'm asked for one piece of advice to give a new recruit, it would simply be the following:

Keep an open mind.

This could be by not pre-judging a patient before you've ever set eyes on them. Not every unconscious patient lying on the ground outside a pub is a simple drunk.

Remain open-minded enough to question other's actions, even if you think that as they've been paramedics or doctors or nurses for dozens of years, they must know it all. We're all human, and all fallible.

Not every bruised or broken-limbed child has been abused. In fact most aren't. But keep your mind alert for the possibility.

The same goes for the elderly and vulnerable.

And keep your mind open for continued education. Every scenario you meet is a learning opportunity. Every patient you meet has something you could learn from.

Every new disease or medication you come across shouldn't just become another one of those long words on a list of things you don't understand. They should become part of your dictionary.

Every person you work with, has something to teach you. Many will be positive role-models. Some will show you exactly the type of medic you don't want to be. Be prepared to learn both.

Not every family model you come across will meet your expectations. Some may even break your heart.

Be prepared to be shocked and saddened, thrilled and delighted, broken and yet filled with hope, all in the space of one set of shifts.

Most of all, be open minded enough to know that you can't know everything. No-one can, and those who claim they do, usually know the least of all.

And be prepared to ask for help.

Oldies or newbies, sometimes we all need it.

Good luck!

Jealousy

Red 2, the second highest priority for a call coming in to the ambulance service. In the main determinant - the old favourite - Difficulty in Breathing. In the extra information the screen tells of a 40-year-old with a history of asthma. We race to the scene, find the front door open, and call in to find where the patient is hiding. We take in the oxygen bag, defibrillator, and all manner of equipment to deal with this life-threatening emergency.

A voice calls from the front room, and we follow the noise. The room is one of several in a large house, clearly now divided into several micro-apartments. A shared bathroom and filthy kitchen the only rooms with no external locks on the doors. The patient is sitting comfortably on the bed in the tiny room that is a bedroom, living area and laundry room all rolled into one.

Recently I've been charged with mentoring a student paramedic, (a brave decision by the powers that be...) and for most of this mentorship, he's in charge of the patients.

"Good morning. My name's Sash, what's your name?" Confidence is one of his strong points.

"Adam". A man of few words, obviously.

Adam seems to be having no difficulty in breathing at all, so Sash is a little confused.

"What seems to be the problem this morning?" Morning at this point is just after 5am, after another very long and busy night.

"I can't sleep." The words resonate well with your local friendly insomniac, yet at the same time grate a little.

"How long have you not slept for?"

"Since I woke up yesterday morning."

Whilst Sash is questioning, I'm checking his basic observations. A matter of course, and of course it matters. I think.

"So it's just been tonight that you've not been able to sleep?"

"That's right." I look up, just to make sure I heard correctly.

"Has this ever happened before?" Sash's perseverance is starting to show signs of frustration.

"No."

"So why have you called the ambulance? What would you like us to do?"

"Just take me to hospital. Maybe a doctor can tell me why I can't sleep."

Home remedies were suggested, a visit to the GP was suggested, an attempt to go to back to bed with a cup of cocoa was suggested. And all were rejected out of hand.

"I just want to go to the hospital. You're not doctors. I want to see a doctor."

At a loss for options, Adam was invited into the ambulance, took his seat, and we set off for hospital. We still can't refuse to take people to hospital if they're adamant they want to go.

I stay in the back of the ambulance to keep an eye on Sash and his ambulance aid, whilst our driver for the shift takes her place in the pilot's seat. We all know that there's not much to be said or done, yet I'm keen to see how Sash deals with a call that really shouldn't be.

The hospital is about a fifteen minute journey away. Sash starts to fill in the paperwork, name, address, baseline observations. Adam's not in any mood to talk, Sash has nothing to say, and I sit observing from the sideline.

About two minutes into the journey, I cough quietly. Sash looks up from his scribblings, and I mouth a 'Well done' to him. Confused, he asks me what for. I nod in Adam's direction and congratulate Sash on fixing the patient.

I can only stare at the patient as a strong feeling of jealousy starts to creep over me.

Adam's sitting there, held in place by his seat belt, quietly snoring and sleeping like a baby.

Shut. Up. Den!

They married the day after he was de-mobbed, seven years to the day after they had become engaged. The day of their engagement was tinged with sadness, as on one hand she placed the ring which betrothed them to each other, and yet with her other she waved him off, not knowing if or when they would finally exchange their vows. They didn't meet again for almost five years, whilst he spent that time at the request of His Majesty fighting in the war that followed the War to end all Wars. They marked their seventh anniversary with a new one, the start of sixty more.

"Sixty years we've been married", he tells us. "Not once has she listened to anything I have to say." His wicked grin was met with a sharp tongue.

"Shut up, Den!"

The pain had kept her up all night. The effects of the tablets she took wearing off before they'd even reached their peak effect. Eventually she could take the pain no more, and reluctantly agreed for the ambulance to be called. When we arrive, she's sitting in an armchair, trying for all the world not to show us that she's suffering. The colour of her face and the fine beads of perspiration on her forehead tell us more than we need to know.

"How long have you been in this much pain?" Seemed like a good place to start.

"Well", starts Den, "It's been getting worse all night. She didn't want me to call, but in the end I don't really think I had a choice!"

She glares at him. "Shut up Den! I can talk myself you know!"

"Oh, I know all right..." He mutters, just loud enough for us all to hear.

I try to hide the smile.

"It's not too bad now. It was much worse before. Keeps coming and going. I think I'll be fine if I just get some sleep."

"You've been like this all night, love, and I can tell it's not getting better. Why don't you let them help you?"

"Shut up Den!" she retorts. There's a clear theme developing.

"Lets have a proper look at you", I suggest, and reluctantly she agrees.

Her observations are mostly unremarkable, just an increased pulse suggesting once again that despite wanting to hide her ailment, the body will always give its secrets away. She can't help but admit it now. The pain is becoming just too much to cope with.

"How about we give you something for that pain then?"

"Good idea", ventures Den. "You could do with something stronger than those tablets!"

"Shut. Up. Den!" she growls at him, rests her head back on the trolley-bed and briefly closes her eyes.

"Maybe I could do with something. It is coming back a bit."

A few moments later, as the morphine courses its way through her veins and works its magic, the relief starts to show. Her whole body relaxes, the colour, so drained before, returns to her face, and the beads of sweat fade away.

"Feeling better?"

"Much better. Thank you."

"We're going to take you to hospital so they can find out a bit more about what's happened. Hopefully stop it from happening again."

"That's fine. Suppose I could do with a check up."

Den shakes his head, one part frustration to ten parts relief.

"One of these days, you'll realise that I do talk sense sometimes!"

"And one of these days", she shoots back, "you might just be right!"

Her voice softens, they smile at each other, and Den reaches across the ambulance to pat her on the hand.

"You know", he starts, "it IS my name on the front door! You would do well sometime to remember that!"

"Oh, do shut up Den!"

She rests her head back on the bed, and for the first couple of minutes of the journey there's a calm silence. I start the paperwork, and they look at each other, holding hands like they were still love-struck teenagers.

"You know what, Den? You're right. It is your name on the front door!" There's a sudden glint in her eye that wasn't there before.

"Just don't forget that the sign with your name on it is on the outside!"

Eating Habits

The famous adage, "You learn something new every day", is especially true if you have kids, or spend any length of time with them. Kids have a way of saying things, seeing things, questioning things, that we as adults seem to lose. It's a kind of honesty and direct approach that where an adult would think twice about the ramifications of what they are about to say, children just want to know. Their inquisitive nature is their no-holds-barred method to a greater understanding of the world around them.

This week, one of my kids found out that in a previous life I used to be a soldier. It's not a fact I hide, neither is it something I'm ashamed of. It's just never come up in conversation. She found a photo of me in greens, carrying a semi-automatic, and looking every part the soldier. She looked, digested, dissected, and then came out with the question that I could clearly see was troubling her 6-year-old mind.

"Did you kill anyone?"

Woah.

I didn't see that one coming. I thought about it for a minute, and told her about people not joining the army to kill people. Soldiers are in the army to care for other people. To secure their land. To safeguard their way of life. Forget the politics. Six-year-olds don't care about it. If she did, she'd have asked about the legal ramifications for the Iraq War, the troops being in Afghanistan, and what the new coalition government plans to do about it all. Clearly not very likely.

She wanted to know about her dad, and I answered her intended question.

All my kids know what I do now. Obviously. They're proud to say that their dad's a paramedic, and if you were to ask any of them what my job description is, they'd each tell you, in their own inimitable style, that I save people's lives, or I go and help the sick and injured, or something along the same sorts of lines. Sometimes, if I come home looking particularly harassed, said 6-year-old will ask if I saved anybody at work, or how many people did I look after, but she has never yet asked me if anybody died. Her question about the army taught me a little about how the little people around us perceive the confusing world around them. To my six-year-old, the following is her view of the world:

Soldiers kill, Paramedics save.

As adults, on the other hand, we look at the world through completely different eyes. Our vision is blurred by stereotype, cynicism, media portrayal, politics, and a small dose of reality. After the "army question", I was left thinking about perception in general, and of the ambulance service in particular. I sent out a tweet to my followers asking a very simple question: "What is the first question/reaction you get as a paramedic/EMT when being introduced to someone new?" A simple question, but the answer to which is probably reduced to a bare half-dozen similar answers.

"Wow, that's interesting", or "How cool", or "You must see some horrible things".

Of course there are the silly ones, like "Do you drive on lights and sirens just to get back for a cup of coffee?" I'd love to say yes to that one, but no. Unfortunately not.

I find that there's one more. Often not the first question or reaction, but is asked on a very frequent basis.

"What's the worst thing you've ever seen?"

I refuse to answer that one honestly. The adult in me forbids it. Anyone asking that question doesn't really want to hear what the worst things are to see, and I know they don't. I know because once upon a time when I was much newer, I'd answer with the truth. Except that after the first three words they'd cover their ears and yell for me to stop. "Stop! No more! I can't understand how you do it!" Now my answer tends to be about the latest delivery I assisted with, and the mess all over the place. It's enough for most.

There's an element in all of us that wants to hear the gory story, to hear about the trauma. It's what makes any person driving past the scene of an accident drive slower in order to take a look, but drive much quicker if there's any risk of actually finding out. The childlike curiosity that is in all of us often makes way for the cynicism of an adult's view of the universe. We really want to know, but not at any cost.

Children have a thirst for knowledge that we as adults have quenched by reality.

Children are on a quest, a treasure-hunt searching for understanding, whilst we as adults we want to rest at the starting line, ignoring all the clues and helpful hints.

As adults we always have much to learn, but not always the hunger to do so. We'd do well to look at the children around us, and learn a little from their hunger. And from their eating habits.

That's what helps them grow.

Rude

An ambulance, parked in the middle of the road, sometimes obstructs the traffic. We apologise, but if there's nowhere else to park, there's nowhere else to park.

An ambulance, parked up, doors shut, but lights on, probably has some dedicated staff inside tending to a needy patient.

That dedicated staff, it may surprise you to know, is not only dedicated, but skilled.

And that patient, despite the indignity of being in an ambulance that may be obstructing the traffic, is still entitled to privacy.

On the outside of the ambulance, on each of the doors into the treatment area, there is a notice. "Please knock and wait. Patient treatment in progress". It's printed in large red letters.

When a doctor is seeing a patient, in their own surgery, the door is shut. For privacy reasons. People knock before they enter, and wait to be invited in.

So why, Doctor, did you feel it was your right to swing the doors of the ambulance open whilst we were treating the patient?

"I'm a doctor!", you sneered. No knock, and no wait. "Do you need my help?" you asked.

"I'm important!", is what we heard. "And can you please get out of my way?", you must have added.

"I don't remember inviting you in", was answered. "And you certainly didn't knock", was added.

We don't barge in on your patients when you're treating them. Don't you dare presume that you're allowed to do it to us.

Rudeness and oneupmanship will guarantee you one thing, doctor. And it most certainly isn't that we'll clear the road any quicker for you.

No Answers

Saturday night, the scourge of all police officers and ambulance crews. These days, all nights are busy, but weekend nights are often like being in a war zone. Trust me. I've done both. Sometimes I think that it was safer in the other one. As I work only nights, my weekend night shifts come round more often than most, and without fail, I regret them.

A list of a weekend night's proceedings often resembles a list of the wives of King Henry VIII. Divorced, Beheaded, Died. Divorced, Beheaded, Survived.

A Saturday night on the street runs something like this: Drunk, Assaulted, Trashed. Drunk, Assaulted, Crashed. The last of these might only appear once a night. If that. If you work in the centre of London, there are probably even fewer. I work out in the suburbs, so there's a chance that once the pubs, clubs and fast food shops have shut, I may actually have to treat someone who genuinely needs an ambulance. By that time, I'm tired, cranky, and struggling to give them my best attention and care. That which they genuinely deserve.

Last night, I tweeted about treating drunks, by asking a simple question. Do you think that people who call ambulances because they've had too much to drink, should be charged?

All dozen or so replies were positive. Some just said "Yes". Someone said "Yes, without a shadow of a doubt". And one even went as far as saying "YES!! YES!!!! A THOUSAND TIMES YES!!!" It seems that I received some support for the idea.

It's a knee-jerk, almost default position by health care professionals, and even some who aren't in the medical field at all: You're drunk. It's of your own doing. You should know your limits, or suffer the consequences. You don't need an ambulance. You don't need to be in A&E. And we most certainly don't want to be the ones who have to clean up all the bodily fluids you emit in your sorry state. Therefore, we all want to charge you. I'm as guilty of it as the next person. Not so much the drunk bit, but the wanting to charge bit. But there's a problem with this thought, once taken to one of its logical conclusions.

We should charge those who overdose on drugs. The heroin addicts who should know their limits, but who take a little more than their normal amount, end up not breathing, and who we administer Naloxone to to get them breathing again, ready for their next hit.

We should charge drunks who wonder out into the middle of a busy road and get hit by the car whose driver had no chance of avoiding them. Or by the same account, charge the drunk driver who's hit the lamp post that's sat on the pavement for years, but suddenly jumped into the middle of the road.

We should charge the wrist-slitters, crying for attention at the age of 18 after being dumped by the love of their lives, and who next week will have another life's love.

We should charge drunks who we convey not for being drunk, but whose drunken state has led to some sort of illness or injury.

We should, therefore, charge anyone who should have had some degree of responsibility for their own presenting condition.

Smokers with emphysema? Charge.

Footballers with broken legs? Charge.

Diabetics with high blood-sugars? Charge.

So how far do we take this knee-jerk reaction, this desire to charge drunks? Is it a question of all or nothing, in which case we charge everyone, or do we continue as we are, charge nobody, and just have to keep putting up with it, whilst we all, as taxpayers, foot the bill? Once upon a time, drunks were taken to police cells, given a mattress to sleep on and sober up, generally ignored, and were then sent home in the morning. Just that cost money.

Now, they get an emergency ambulance, often accompanied by the FRU, as they are frequently supposedly unconscious or not alert. If they're in town, they might get the dedicated "booze bus", a multiple-patient-transporting, baby-sitting service staffed by EMTs and paramedics who are clearly a lot less averse to dealing with alcohol-induced vomit than I am. They get a hospital bed, an overworked nurse, a disinterested doctor, and sometimes a bag of fluids as well. All very often whilst abusing those who are caring for them. And that's if all they have is a serious case of overindulgenceitis. That's a lot more expensive, and a lot more frustrating, which is part of the reason we feel that we want to charge. But is it right? In the overall spirit of the NHS, free to all at the point of treatment, can we really justify it? And if we are going to start charging, who do we charge, what for, and how much?

I have lots of questions when it comes to charging drunks.

I just wish I had some decent answers.

What do you think?

Take Away

Take a deep breath. You're gonna need it.

As rumours go, this one has been floating through the ether for some time. When it was officially published the other day, I wasn't at all surprised, but I was, still am, more than a little disappointed.

Intubations are no longer going to be a part of the London paramedic's bag of tricks. The single most useful technique we use, the one used in the most critical of patients, is being taken away from us. Let's start at the very beginning.

Intubation (or colloquially "tubing") is a process by which a plastic tube is placed in a patient's airway to protect it. It's used when we need to breathe for the patient, and when we want to stop all manner of gunk, particularly blood or vomit getting into the lungs, effectively drowning the patient. It's used by paramedics mainly in cases of resuscitation attempts - or CPR. If ever there was a time that a patient is likely to vomit, it's when a paramedic is applying brutal repeated pressure to their chest at 100 times a minute.

It is used at other times such as massive trauma when the patient is unconscious enough to allow the intubation to take place. Yes, there are different levels of unconscious, and there are even different degrees of dead, but these are the subject of a completely different discussion.

Now, however, instead of training new paramedics in the skill of intubation, they are only training them up to use LMAs, or laryngeal mask airways. These are good when you need to breathe for a patient, but totally useless if the patient vomits. So in our case, frequently pointless.

These LMAs, whilst brilliant in the hospital setting, will fail to fulfil their purpose out on the road. The reason is simple. In hospital, when a patient is aware of the fact that they're about to be knocked out for an operation, they are starved beforehand. No food in the stomach equals no chance of vomit. The LMA is perfect. You can breathe for the patient without having to go the full invasive method and intubate them. If, however, someone ends up with an emergency operation, where there was no time to starve them first, guess which method of airway protection is used? Correct - the tube.

The trouble with emergency cases is that they are exactly that. Emergencies. The patient will never have starved themselves prior to collapsing or being run over. They will never be considerate enough to think that they'll hold off on having dinner because there might be the possibility of the cavalry in green charging through their front door on a rescue mission, and would really rather prefer that the patient didn't vomit, thereby endangering their own well being, as well as the ambulance crew's uniform.

The arguments for the de-skilling of paramedics are several-fold.

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

The first two I agree with - up to a point. A study, apparently carried out in the USofA, says that the minimum training requirement is a 90% success rate at 57 intubations. The numbers seem a little random to me - but I'm not arguing them. When I did my training, I had to successfully intubate 100% of 25 patients. At least. I think, if I remember correctly, I intubated 40. The only one I failed at was the first one I ever tried. I told the consultant that I couldn't do it. I couldn't see what I needed to see in order to ensure a successful intubation. He huffed and puffed, muttered something, good-naturedly, about these new paramedics, took one look at the patient's throat and found that it WAS an impossible intubation. Even for a seasoned professional. I'm not saying I'm brilliant. But I am saying that I'm honest enough to admit I can't do something. And that in itself is an important skill.

The problem with getting an intubation wrong, is down to what your mother used to tell you when you were a kid. "Don't talk with your mouth full, or the food'll go down the wrong hole." The trachea (air-pipe), and the oesophagus (food-pipe) are next to each other. Well, actually, one in front of the other. If you put the tube down the wrong "pipe", you pump air into the stomach and do nothing for the lungs. It's lethal. It's not a difficult skill to master, but it does need proper training. Not only in how to do it right, but how to recognise and rectify it if you do it wrong.

Training is apparently becoming a problem due to the increased use of LMAs in hospital. The number of intubations is steadily declining, so there are fewer patients going around for paramedics to train on.

So extend the training. Do blocks of hospital theatre training weeks. If it takes a year to get the prerequisite number of intubations, then so be it. Use all the skills you have, and wait with the intubations. If you're lucky and reach that number in two weeks - then off you go into the field and save lives - along with the tubes.

We definitely don't have enough refreshers. Certainly not on intubations. We have courses reminding us how to do CPR, how many compressions, what drugs, what's changed since the last refresher. But we never go back to theatres to intubate live people. A manequin is one thing. A patient is real and has a different feel and knack to tubing. I'd love the chance to go back, once a year, and intubate under the guidance of a consultant anaesthetist. By the same logic, I shouldn't be allowed to put a patient's arm in a sling either. I know one is not a life-changingly-critical as the other, but the logic is the same.

On average, a paramedic will intubate a 3-4 times a year. A few more if you tend to be a little like me and attract more trouble than the average paramedic. It's not a lot. There are pieces of kit on the ambulance I haven't used more than once in my career. Literally. That doesn't mean that I won't use them if I have to. I have the skill, I know how to use it, and use it I will. I feel it's also important for a paramedic to arrange their own refreshers on less-frequently used equipment. To take out pieces of kit they haven't used for ages and just re-educate themselves in it's purpose and function. Clearly this isn't possible with intubations. However, intubating only a handful of times a year does not mean that I lose the skill. It doesn't mean I don't know what I'm doing, and it certainly doesn't mean I forget how to recognise whether I've done it right or wrong.

We're lucky in London. We're one of the very few services in the country (as far as I have managed to discover) that uses a piece of kit called End Tidal CO2 monitor. I'm not going to go into the ins and outs of how it works, but very simply, when you attach this to the end of a tube, it is an almost guaranteed assurance of the success of the intubation. You get a reading - it's in, you don't get a reading, you've missed. Simple as that. If you get a very high reading, chances are that the patient's started breathing on their own. Good news all round. There are fail-safe methods of ensuring a tube is done right. Any paramedic worth their salt will know them, check them, double check them, and know that if they've done it wrong, that they start again. Or, in the rare cases of seemingly impossible or even very difficult intubations, recognises their own limitations and works with what they can.

I've only once out on the road seen a paramedic miss an intubation.

That one time, it was recognised very quickly and fixed. I don't know where the data comes from that we're not good enough at it. My personal experience, the only one I have to go on, tells me otherwise. There have been tubes that I couldn't get, only two if I remember correctly. I blame my legs for one of them. There was a smaller paramedic on scene who could fit more easily into the restricted area round the patient's head and intubated them with no problem. The other I just couldn't see what I needed to see to ensure the tube was going down in the right place. I stuck with an LMA and prayed the patient didn't vomit. I vaguely remember being lucky. That time.

The cynics amongst us will blame the doctors. They're trying, at least some of them, to regain their superiority and would love to see paramedics bounced back to the stone age where we literally pick a patient up, throw them on the back of a truck and race them into hospital quick enough for super-docs to save their lives.

Those same cynics will also say that it's nothing more than a money-saving exercise. Less training means less spending, both on the training itself and the kit that it entails once qualified.

The establishment will claim that as they cannot guarantee training and proficiency, that they are taking the skill away. Future paramedics therefore won't be trained. Current paramedics will be allowed to go on using it for now, but my suspicion is that the equipment will slowly be used up and never replaced. A de-facto de-skilling.

It's a backwards step for an organisation that aims and claims to be a world-leader.

To me, instead of striving to better at we do, and extend our range of skills, this is a move in the wrong direction, a move to limit our abilities further.

I think it's a mistake. A step towards those who see paramedics as nothing more than World-War-I stretcher bearers, and away from those with a vision of modern, skilled, experts in pre-hospital care.

I hope it will be rethought at some time in the near future.

I hope that lessons will be learnt, and I hope that as a Service, London will rethink it's training strategy.

Most of all, I just hope that this is one take-away that we don't all, patient and paramedic alike, learn to later regret.