Nee Naw

Most of you are probably aware that drinking laws have been changed in England and Wales so that clubs, pubs and shops can apply for licences to sell alcohol at any time of day. Previously, most pubs closed at 11pm, shops stopped selling alcohol at the same time, and most clubs only served alcohol until 2am, even if they were open all night. People have been asking me what I think about this. Well, from a personal point of view, as Mark Myers, 20-something lad about town, who always wants “just one more drink” at kicking out time, I think it is absolutely marvellous and I can’t wait to hit the town and guzzle to my heart’s content without gluing my eyes to the clock and listening out for the bell. However, as Mark Myers, Nee Naw Dispatcher Extraordinaire, my views are a little more ambivalent.

There’s no doubt that more alcohol leads to more accidents. On the average Friday or Saturday night, I would say that at least 90% of the calls we get are alcohol related. The most common theme is fights, followed by people who have drunk too much and made themselves ill, followed by people who have drunkenly accidentally injured themselves. There’s also a lot more suicide and self harm going on. Even when the ailments aren’t alcohol related, the people calling are often more than a little tipsy, which often makes them rather belligerent and not easy to tell what to do. It seems logical that alcohol will make all these problems worse. But will it really? Taking these points one by one:

1) Fights. Most fights seem to occur after the pub has shut. Squabbles break out over cabs and kebabs and before long, blood is shed. While the pubs are actually open on a weekend, Nee Naw Control is dead quiet. I think people get grumpy because they want more alcohol and are denied it. Let them carry on drinking until they are ready to stop and they won’t have that problem. (Assuming people *are* ever ready to stop… I can imagine some people would never be). Also, if the pubs are all kicking out at different times the kebab/cab queues won’t be as big and there will be less opportunity for fight-picking. The call taking queue always leaps up at around 11pm when the pubs shut, and there’s always a long wait for ambulances at this time. Spread out closing times, and that problem will be eliminated.
2) Drunk-Too-Much Syndrome. Speaking from personal experience, the times when I’ve ended up “worshipping the porcelean god” haven’t been when I’ve drunk for too long but when I’ve drunk too much in a short space of time. If I knew I had as long as I liked to drink, I’d be less inclined to guzzle high strength drinks at a rate of knotts. So perhaps there will be less unconscious drunks.
3) Drunken Accidents and Mental Health Problems Exaceberated By Drunkeness. I guess while the pubs stay open, these will keep on happening. So while everything quietens down at 3am at the moment when everyone goes, they may well keep on going all night, meaning we don’t get to doze off in the ten minute gap between calls at 5am any more. Management will probably say this is a good thing, though.
4) Drunk People Ringing For Ambulances and Being Rude. Will probably get worse now more people have the opportunity to be drunk.

Anyway, I’m reserving my final judgement until I’ve worked a weekend nightshift and seen how different it is. I expect tonight will be a nightmare because everyone will be taking advantage of the laws and overdoing it, but I’m not working tonight, so I don’t have to worry about that! I will report back with my findings when they have them and until then… I’m off to the pub!

Ambulance crews, I’m told, really hate getting called out to women in labour. They must do, to be inspired to write touching poems such as this about them. In the words of Big White Taxi Service, “you are not ill, you are in a condition you got yourself into. You should have made proper arrangements like the 160,000 mothers each year”. Don’t get me wrong, of course sometimes being in labour can turn into an emergency, when something goes wrong or things happen a little faster than the mother-to-be anticipated, or if you already know that there’s a problem with your pregnancy and that you need to take an ambulance to hospital when you go into labour. But going into labour in the normal way is not an emergency, and you should NOT plan to call 999 to get to hospital. In those exciting eight months of preparations for the new arrival, between buying miniature booties and popping folic acid, you should also be putting aside a taxi fare and/or getting your friends and relatives on standby to get you to the hospital.

We get a ridiculous number of calls for women in labour, most of whom don’t need an ambulance. Sometimes I even hear a relative on scene saying they won’t go in the ambulance, but they’ll follow in the car. So why don’t they just drive the patient to the hospital? I have no idea. I have a feeling, though, that it’s not all the fault of the callers — often they tell me that the midwife has instructed them to call for an ambulance when the contractions reach X minutes apart, and unless pregnancy turns women into compulsive liars, I suspect midwives have indeed been telling patients this. I think someone should educate the midwives against this.

Unless the woman is having problems or is about to give birth on the spot, most “maternataxi” calls turn out as Green, the lowest priority (or at least they are supposed to — as Reynolds of Random Reality often laments, there is a bug in our software which keeps churning out Reds for calls that should really be Green. But that’s a whole different whinge). This means that a lot of women in labour have a long wait, during which some of them wise up and get in a car, and others ring back every five minutes shouting at me and saying things like “Do you want me to have my baby right here??” to which it is very difficult not to reply “Well, yes — at least then it would be a proper emergency!”

The other day, however, there was a call from a woman who used a special technique to get an ambulance to ferry her to hospital in the early stages of labour. This technique is known as Telling Porkie Pies. As you may remember from a recent post, we have to ask a series of questions that we have already guessed the answer of to ensure that we haven’t missed anything. In the case of a maternity, one of the questions is “Can you see, feel, or touch any part of the baby yet?”

“Yes,” replied the woman — the woman in labour, the woman in labour who was talking calmly with no sign of pain or panic in her voice — “I can feel the head.”

Thinking that she had probably misunderstood the question, I rephrased it, using the word “vagina” and everything.

“I told you — the head is out!” said the woman.

This put me in a difficult position, because from my (admittedly limited) experience of women giving birth I can tell you that they generally cannot talk calmly on the phone whilst the head is emerging from their vaginas. On the other hand — never disbelieve a caller! Expect the unexpected! So I got the caller to summon her sister from the next room, and got the sister to check the vagina, hoping that she would tell me that there is definitely no sign of the head, but instead she told me the same thing: “Yes, I can see the head.”

There was nothing much I could do except take their word for it and press on with the birthing instructions. I sent the sister off to fetch towels, and she returned to the phone after a suspiciously short length of time. I told her to get the pregnant lady on to the bed in the correct position and stripped off, and she told me that she was already in that position. I then told her to place her palm against her sister’s vagina as the baby delivered, and she told me she was doing it. I knew she wasn’t. Don’t ask me how - we don’t have video phones - but I can tell if instructions are actually being followed or if the caller is pretending every single time. Then I waited. And waited. Of course, the head didn’t get any further and during the whole time the mother to be made not a grunt nor a moan. She showed no evidence of having contractions, let alone giving birth.

Then there was a buzz at the door and the man from the FRU burst in, no doubt expecting to see the baby taking his or her first breath, and instead was greeted by a heavily pregnant woman sitting fully clothed on the sofa*.

“I thought you said the head was out?!” he said incredulously.

“Oh no!” said both women in unison, “we said that the labour had just started!”

Cue noise of, once again, call taker banging head on desk…

*(I am using my imagination here — like I said, no video phones…)

As of a couple of weeks ago, Nee Naw Control is no longer officially known as Central Ambulance Control but as the Emergency Operations Centre. I am not sure of the logic behind this change of name since Central Ambulance Control bears far more relation to what actually goes on in there than the new name. Emergency Operations Centre sounds rather like we are whimsically whipping people’s tonsils out when the hospital is full. I think it’s another step in moving away from the word “ambulance” since we also have Telephone Advice, the HEMS helicopter, Emergency Care Practitioners, FRUs and other non-ambulance ambulancy things. We’re already not supposed to mention the word “ambulance” on the phone because it “increases the callers’ expectations that they are going to get an ambulance”. Whoever made up this rule has obviously never spoken to any of the callers — the second they pick up the phone, they already think that an ambulance will be knocking at their door within the next five seconds. Their expectations are already at ceiling.

You will also notice that the word “Control” has also been removed. I don’t know why this is. Perhaps we are no longer controlling the ambulances; the ambulances are controlling us.

This is another of those posts that I’m writing in the hope that next week’s 999 callers will see it!

A common source of frustration for ambulance callers is that bellowing “20 Albert Square, ambulance, NAAAH!” like they do on TV will not actually get you an ambulance, and that if you dial 999, you will actually be kept on the phone for about three minutes answering what can seem like stupid questions. I always explain to callers that this won’t delay help before I start, but unfortunately there isn’t time to explain to them how it works or why we do it. However, there’s plenty of time for me to explain here!

The first thing we ask is the nature of the problem, followed by the address. Hopefully, no-one will think those questions are pointless. Once they are in, the call is visible to the dispatchers who sit upstairs on various sector desks controlling various parts of London. They can send the call to an ambulance straight away. If there were more ambulances than calls, then we could probably dispense with most of the questioning, but there aren’t. If there’s no ambulance available to send to a call, or we’re down to our last one and the call is about something minor, it goes into a queue.

There then follows the “four commandments”, which are the age and sex of the patient and whether they are conscious or breathing. These are important because they change the questions that will be asked, the instructions that will be given and/or the priority the call is given.

Next follow the triage questions. These determine whether a call is high, medium or low priority and the high priority calls get an ambulance before the medium priority ones, who in turn get one before the low priority ones. In the good old days, calls weren’t triaged and were dispatched in the order that they came in. So a broken leg would get an ambulance before a baby who had stopped breathing if the leg’s owner phoned up five seconds earlier. These are the questions that a lot of people think are stupid, since they are fairly standardised and designed to check that a lot of things definitely aren’t happening, rather than to go into any detail about the things that are. Basically, we’re trying to be sure we haven’t missed anything. Callers do have a habit of dwelling on the most painful symptom and sometimes overlooking other life-threatening symptoms. I’ve had calls that have started off being about blocked catheters and have ended up being suspected heart attacks, because the patient has been so worked up about their catheter problem they haven’t bothered to mention that crushing pain in their chest and arm… or sometimes someone has fallen and broken a bone and no-one mentions they have also knocked their head and seem concussed until you ask… We have to ask every single question on the list, unless it’s obvious, and by obvious, I mean face-slappingly, already stated explicitedly obvious, not just logically obvious. So if someone rings with a dislocated shoulder, I still ask if there is any serious bleeding, but I do know that dislocated shoulders don’t bleed and have guessed that there isn’t — I just want to be 100% sure!

There’s usually between five and ten of these questions, and all the questions only demand one word answers — the vast majority of them are “Yes/No/Don’t Know”. It should take less than a minute to answer them all. Arguing about whether you’re going to answer them or not generally takes a lot longer. Answering them can speed up the ambulance too — the questions might yield some information which makes the call sound more serious. Not answering anything, on the other hand, might cause a delay — for instance, “Breathing Problems ” on its own with no other information is an medium priority call, but after asking the questions most “Breathing Problems” turn into category A, highest priority calls.

After the questions, there’s a few instructions. Obviously, if I hadn’t asked any questions, I wouldn’t know exactly what was happening, so I wouldn’t be able to tell anyone what to do next. So there’s another place they come in useful.

The final use for the questions is to give the ambulance crew a bit more information. While they don’t see the answer to every single question, we do pass them the most salient bits.

999 callers, if you still think the questions are pointless after reading this, and I hope you don’t, please remember that us call takers are under strict instructions to ask them and if you refuse, the call is going to turn into a stressful battle of wills and take far longer than if you just gave in and answered them. If you want to complain about the questions, our complaints department will be happy to listen, but our call takers will not. Believe it or not, call takers were not put on this earth to stand in the way of people getting ambulances and actually want the ambulance to arrive and the call to be over as quickly as possible too. It’s also worth pointing out that the call taker has no control over if and when an ambulance is dispatched; there is no big red button on our computers marked “SEND AMBULANCE”. So shouting “Just send the ambulance!” repeatedly when a call taker is trying to ask you something is going to have no effect whatsoever, except perhaps making the call taker bang their head against the desk and start losing the will to live.

“I’ve eaten too much, and now I feel really sick. Can you die from eating too much?”

Can you die from eating too much in one go? How much would you have to eat?

Tim Worstall has published a book about blogs. I am going to be in it, so I suggest you all buy a copy.

“Nee Naw Service, what’s the problem?”
“The vicar’s been stabbed!!”

It sounded like a screwed up episode of Father Ted, but I quickly realised it was no joke.

“He just turned up at my door. He’s got a huge knife sticking out of his chest…” continued the poor parishioner, who had probably been in the middle of watching Eastenders when this hullabaloo occurred.

“DON’T PULL IT OUT!!” I said. I had just been reading a copy of Chat Magazine where a clumsy DIYer had narrowly escaped death after inadvertantly shooting himself with a nail gun and attempting to remove it with a pair of pliers, and know from experience that when people see objects stuck in other people, their first reaction is to pull the object out. This usually does more harm than good.

From the quick run through of the questions, I could see this was Stabbing Proper, just like it is on TV. I take a lot of calls about stabbings, usually in Romford at 2am on a Friday night, and most of them are just a small flesh wound sustained in a scuffle. Those that are serious are usually rung in by someone running away as fast as their legs can carry them, or someone very drunk and abusive, so the amount of close-range help I have been able to give has been limited.

This was different, though. I have to give a firm pat on the back to the caller. In all the time I have been at nee naw control, I have never come across a more co-operative, sensible, quick thinking caller as him. There were a lot of things to be done before the ambulance arrived and he must have grown several extra pairs of hands to be able to do them. First, he did as he was instructed to stop the bleeding — taking off his shirt and wrapping it around the wound, avoiding the knife itself — then he got the vicar down on the floor, raising his legs (to treat for shock) and following the instructions to keep the vicar’s airway open as he was fast losing consciousness. He shouted outside for help, and some neighbours came in, which meant one could hold the shirt on the wound and another could keep his airway open. I asked about the location of the attacker (I wanted to make sure he wasn’t waiting on the doorstep to stab the ambulance crew!) and the caller managed to ascertain that he’d run away, and then went on to ask the vicar various questions about what the man looked like, which was very helpful from a police point of view and something I’d not even thought of as I always handle calls in an ambulancey kind of frame of mind. Unfortunately, the vicar was in no state to give much information, and three minutes into the call, he started to convulse. This, obviously, is not a good sign and I was relieved to look at the log and see that two ambulances, police and the HEMS cars were on way. The FRU pulled up on scene a few seconds later, and my job was done, so I hung up and felt very proud of a) the ambulance service for getting help there so quickly (four minutes from start of call to arrival of FRU) b) myself, for not panicking and remembering to give all the relevant instructions in the right order and mostly c) the caller, because it doesn’t matter what instructions you give or how fast the ambulance gets there, having a caller who has a grip on the situation is the most important factor in those first vital minutes after the incident.

Later I checked up on the vicar and was pleased to hear that he was doing well in hospital, after having surgery to remove the knife.

I went out to the messroom for my break last night, and there on London Tonight was a blurry photo of The Vicar, shots of the street where It happened, and best of all, an interview with the plucky parishioner. I have never been able to put a face to any of my patients before (except the baby whom I helped deliver in the Slug and Lettuce toilets, and she just looked like all babies do) so this was absolutely brilliant. He even mentioned in his interview that he took instructions from me, and I’m even prepared to overlook the fact that he called me the 999 operator as a concession to his bravery.

At time of writing, The Vicar was in a “serious, but stable” condition in his local hospital. Since then, he has gone on to make a good recovery, and a man was arrested and subsequently sectioned under the Mental Health Act in relation to the attack.

One of the things I love about this job is the way it allows you to practice being a total liar and sucking up to people you don’t like in order to get things to go your way. A man ring up because his girlfriend has “a nasty head injury”. A law of emergency medicine is that if someone tells you what is wrong, but not how it happened, nine times out of ten something dodgy has gone on (the rest of the time, they just can’t say it in English). I ask the man how it happened. He pauses, and his girlfriend can be heard whimpering in the background.

“We were having a bit of an argument, and, um, well I sort of pushed her, and she sort of, slipped, and hit her head against the, um, table and then the, er, door.”

Girlfriend in the background starts to cry.

“I see” I say, in a sugary, “it could happen to anyone” kind of voice.

“You’re not going to have to send the police, are you?” he says.

I say a lot of things that don’t actually answer the question. I’m not the police, it’s my job to get your girlfriend’s injuries seen to, the final decision rests with the ambulance crew, the most important thing is that she gets help. This is all true, but at the same time I know the dispatch desk will have most likely sent the call straight down to the police as soon as they see what I’ve typed on the ticket (”30 year old female, fell after being pushed by boyfriend, head inj, ? domestic assault” — putting a ? before anything is a great get out clause, because you’re not accusing anyone of anything, merely stating it as a possibility).

I carry on speaking reassuringly and calmingly to the boyfriend and hope that his girlfriend isn’t going to have any more “accidents” while they wait for the police, I mean, ambulance, and then say goodbye in a way that conveys the message that I have in no way cottoned on to the fact that his girlfriend didn’t fall and quite obviously got those injuries when he punched her in the face.

My desert-island, all-time, top ten most memorably rubbish, pointless and waste-of-time 999 calls, in no particular order.

1. “There’s a bee in my front room!” (Had it stung anyone? No. Was anyone there allergic to bees? No. It was a straightforward case of Bee In Front Room…)
2. “I’ve stubbed my toe!”
3. “I had a dream my friend has been shot. I tried to ring him but no-one answered. Can you go round and make sure he is okay?” (It was 2am, I’m not surprised no-one answered…)
4. “My cat has scratched me!”
5. “I’ve just got a new SIM card, and I don’t know the number. Could you tell me, please?”
6. “My boyfriend has a boil on his bottom and can’t sit down!” (What made this one worse was the fact that the caller kept ringing back every ten minutes bemoaning the fact we hadn’t sent an ambulance yet.)
7. “There’s a rat in my kitchen!”
8. “My child has stuck a pea up his nose!”
9. “I think I’m going to get an abscess in my mouth!” (He hadn’t actually got it yet… I guess he was thinking that prevention was better than cure!)
10. “I had an accident last week and was taken to hospital by ambulance. I’ve just been discharged, and there is blood all over the carpet. Could you come round and clean it up?”

That said, these are not the calls that really get my heckles up. When I joined the Nee Naw service, I knew that some people make wildly inappropriate 999 calls. They are relatively few and far between, and rarely cause much inconvenience — they are highly unlikely to get an ambulance sent to them, and often provide a source of amusement to a dispatcher who was about to doze off during the early morning lull. (It is, of course, less amusing at busy times when there are callers waiting to get through, and I am certainly not recommending anyone makes this kind of call for our amusement).

But the calls that really get my goat are not these, but the far more common variety of timewaster who think it is appropriate to call ambulances out for stomach aches, migraines, toothaches, flu and other minor ailments that are really the remit of GPs or pharmacists, or maybe even of the variety that can only be cured by retiring to bed, calling in sick and waiting for it to go away. I remember clearly as a child being taught to dial 999 and being told it was only for life and death emergencies. I wouldn’t have dreamed of calling an ambulance for flu or toothache, and I am reliably informed that 20 years ago no-one else did either. Yet nowadays, “ambulance” has become synonymous with “mobile medical treatment unit” or even “free taxi to the hospital”.

These calls aren’t rare, either. I would estimate that 75% of calls on nightshifts and 25% on dayshifts are of this nature. The ambulance service does not have unlimited resources, and attending these calls inevitably means longer ambulance waits. While we usually manage to get to the immediately life threatening calls (heart attacks, etc) within 8 minutes, response times for lesser emergencies are not as good. It’s not uncommon for old people to lie on the floor with broken bones for half an hour because we’ve no ambulance to send to them. And where are the ambulances? No, contrary to popular belief, they are not all parked up behind St Thomas’ A+E eating sandwiches… they’re all out dealing with kids with stomach aches and students with the flu.

Why does the ambulance service send out ambulances to these calls? Well, two reasons. The first is that some callers — especially those who do it habitually — know the “right” answers to the triage questions. They know that if you mention certain symptoms, an ambulance will come blazing on blues and twos, whereas if you tell the truth, you’ll get a call back from Telephone Advice. The second is something I’ve mentioned before — the ambulance service are running scared from being sued. While Telephone Advice can and do weed out some of the inappropriate calls by pointing out a GP or a taxi to A+E would be more appropriate, some people insist that they only want an ambulance. You can imagine the newspaper headlines that would result if that “stomachache” turned out to be appendicitis, and resulted in a burst appendix whilst the relatives were trying to persuade us to send an ambulance, and you can bet your life that the papers wouldn’t point out that the patient refused to consult a GP (who would have authorised an ambulance straightaway), or speculate about what would happen if we sent ambulances to every child with stomach ache.

I am scared of this too — I considered writing a piece on “When not to call 999″ which people would hopefully stumble across when googling for “should I call 999 for…” type queries, but was scared that I might put off someone experiencing a genuine emergency. Instead, I’m going to list the four symptoms for which you should always call 999 for an ambulance:
Chest pain (better to be safe than sorry with this one)
Severe difficulty in breathing (eg. unable to talk in full sentences, gasping for breath. It does not mean having a bit of a cough or gasping in pain!)
Reduction in consciousness (”A bit drunk” does not count; if the person can tell you what day it is and recognise their own family they are what us dispatchers would call “alert”)
Serious bleeding (ie. spurting or pouring, cannot be controlled with a cloth or dressing)

If none of these apply, think about whether you really need an ambulance. Needing an ambulance is not the same as needing medical treatment. Can the patient get to the hospital without an ambulance? (Not being able to afford a cab is not a good reason for an ambulance!) Do they need to go right now? (If not, a GP can organise a non-emergency ambulance for them). Remember that arriving by ambulance does not mean you will be seen any quicker. Ambulances do take the sickest patients straight in, but ordinary patients still have to wait in A+E (and if a critically ill patient arrives by car, they still get seen straight away too). If a patient has flu or a stomach bug, waiting in A+E for four hours will make them really uncomfortable — they’d probably be better off at home in bed, waiting for an emergency GP or drinking a cup of Lemsip! If in still in doubt, call your GP (the emergency GP number will be on their answer phone) or NHS Direct (0845 4647).

On the other hand, trust your instinct. If you think someone’s condition is life threatening, don’t hold back from calling 999 because you are worried you might be wasting someone’s time. The ambulance service can deal with the odd genuine false alarm, and no-one will be cross with you. Just don’t use the ambulance service as a taxi service or an alternative to your GP. Remember that while that ambulance is ferrying you and your toothache to the hospital, it’s not available to send out to someone who’s having a heart attack or lying on the floor with a broken hip. That person could be your gran…

I like the first call of my shift to be something straightforward to ease me into it: perhaps a call from London Underground, an old lady fallen out of bed, or someone report that their father has chest pains. No such luck for me yesterday: the first call came through, and before the operator had even finished connecting the call I could hear a man ranting and raving.

“…dying! They’ve been waiting TWENTY MINUTES for an ambulance and he’s NOT BREATHING…. appalling… disgusting… RUDE WORD!… going to complain… sue…” was all I managed to make out of his diatribe. I calmed the man down a little and managed to piece the story together. His father-in-law had collapsed at another address and stopped breathing. His mother-in-law had called for an ambulance. A third, unspecified person on the scene had phoned my caller to tell him what had happened and that they had been waiting for an ambulance for this unreasonably long time.

So I looked up the original call. There it was: call received at 1958, details complete at 1959, ambulance dispatched immediately, well on its way, and sure enough, someone across the room was giving CPR instructions to the mother-in-law. What was the time now? Two minutes past eight. Yes, those twenty minutes were actually four minutes. I read the times out to the caller and he stopped in his tracks.

“Four min… oh, I’m sorry, yes, er, thank you, yes, sorry!”

I reassured him that the ambulance was nearly there and that the situation was in hand. I also told him it was perfectly understandable that the people with the patient thought they had been waiting longer. I’ve experienced this myself: a minute spent giving CPR to a patient can stretch on endlessly; sometimes I will look up at the clock at the end of a particularly dramatic call and be unable to believe so little time has passed. I’m sure the person who called him honestly believed that this horrible scene had lingered before them for twenty minutes, when really it was just the longest four minutes of their life.