I Am NOT A Doctor

Just to remind you all – this is my own personal view, not that of the LAS or any other authority.  I have no official capacity to evaluate government policy or to pass judgement on it beyond that of a ‘civilian’.  I’m a taxi driver in a truck.

 

Half of ambulance trips to hospital may be unnecessary as patients could be treated at the scene, a report says.

The NHS Confederation said the myth the ambulance service was a “patient transport” system must be challenged.

The report said crews were becoming more skilled and in the future nearly two thirds of patients would be treated at the scene in England.

Some 77% of 5.5m emergency calls each year end up with patients being taken to hospital.

But the NHS Confederation said this would change in coming years.

It warned the number of emergency calls had more than doubled in the last decade and it was essential patients accept more will be done out of hospital if the service was to cope.

And it said ambulances were increasingly being staffed by emergency care practitioners, who have a wider range of skills than paramedics.

They can prescribe more drugs, take blood tests and refer patients to GPs to reduce the number of emergency admissions

Full BBC Article Here

This leads on from Peter Bradley’s report to the government on the future of the ambulance service.  Mr Bradley is also the chief executive of the London Ambulance Service.  In the report it is stated that only 10% of 999 emergency calls require the trauma/stabilisation skills that we EMTs and Paramedics have.  The other 90% of calls do not have life threatening illnesses or injuries, but have ‘urgent primary (or social) care need’.

That word ‘Primary’, what it means is the sort of thing that General Practitioners are trained in.  Doctors who have to do a couple of years at university, then another five years or so working in teaching jobs at hospitals.  Remember that training period, It’s important.

Compare that with the training that you need to do in order to be an EMT.  You spend 20 weeks in training school learning anatomy, treatments and diseases as well as how to drive, how to safely move a patient and how to deliver babies.  A year of post-training experience and you become a fully trained EMT-3. It’s short but intensive – and at no point does it compare to the training of a doctor, instead it turns us into people who know our job and do it pretty well.

The report goes on to mention that only around 40% of patients are admitted to hospital, while ‘at least 50% … could be cared for at the scene or in the community’.

With revised education and training of ambulance clinicians, the number of patients taken to A&E departments by ambulance can and should be significantly reduced. Ambulance clinicians need to be competent, trained and empowered to do this and supported in making decisions for themselves – rather than feeling that they have to get a second opinion. Appropriate education, guidelines, pathways and clinical support need to be in place locally to enable and support this decision making process. 

So it is suggested that we can provide ‘primary’ (GP, lots of training) care to people by using ambulance people (taxi drivers with 17 weeks medical training).  Dr Crippen has a better breakdown of what this really means.  Now we do have some good skills, for example we are excellent at diagnosing STEMI (heart attacks) and transporting them safely to an angioplasty centre rather than a normal A&E.  But at no point does the ECP additional training does not turn these people into doctors.

So, how much extra training do you have to do in order to be an ECP?   In London at least you have to do eight modules of around five days study each.  You also have to do some hours of supervised practice (around 80 hours for certain modules).

Since the government removed the compulsion for GPs to provide out of hours medical cover the ambulance services have had to cope with the fallout – the patients don’t go away, they just go somewhere else.  If the doctor won’t come out then the patient will call out an ambulance and go to hospital.  The ambulance services/hospitals are getting overloaded, so the 40% of  patients who would not need hospital admittance need to be redirected elsewhere.

So do you offer more money to GPs to return to out of hours cover, or do you go the much cheaper route of training up ambulance staff?

The government reduces the pay of doctors who don’t provide out of hours cover by £6,000.  ECPs are not paid an extra £6,000 more than basic ambulance workers.

Money in the bank.

 

The ECPs that I’ve spoken to often feel that they are told to ‘get on with it’, but if something goes wrong they will be the first ones sacked – so, thankfully recognising the limits of their training, they also take most people to hospital.  No-one likes to take risks in the medical game.  Instead of an ambulance, they have become a people carrier for minor injuries.  Truly a ‘taxi service’.

I’m also told that a lot of the patients that they go to, while happy to see an ECP, also want to go to hospital, ‘just to be on the safe side’.  So once again the ECP is used as a taxi service.

I’d trust all the ECPs I know personally to deal with my family, they are all good people who know the limits of their training.  But how many ECPs will start thinking that they are a doctor?  With over-confidence comes mistakes.

The plan for the ambulance service boils down to this – Keep the number of ambulances the same, but increase the number of ECPs as they will reduce hospital admissions.

All the while call rates are increasing.  And in this litigation happy society we seem to be turning into, it doesn’t do us any favours to start leaving people at home.  It’s why I take everyone to hospital – I’m not a doctor, so who am I to decide who needs proper medical treatment.

As Dr Crippen puts it, “…consider this. If Elizabeth or Phillip, Charles or Camilla, Harry or Wills, or even Tony or Cherie have an acute medical problem, do you think they will see an ECP?

14 thoughts on “I Am NOT A Doctor”

  1. Reynolds, I read your article twice thinking I'd missed the bit where you proposed a solution to the problem. Truth is its not there. I guess the inference is that we should just supply an endless quantity of ambulances and GPs, I've not noticed a polical party prepared for infinate investment in the NHS but given the taxation required I think its fair to say it'll never happen. So I guess we'll stick with trying to improve situation as best we can. Most people who call 999 don't need to go to hospital, lets give them what they want! We've spent the last 50 years taking them to hospital and it doesn't work. I say lets try something new!Sorry for the rant but frankly its hot and if I'd wanted to read whining without any sense to it I'd have popped over to the BWTS. I thought better of you Reynolds

    DSO

  2. nice to see both of you are letting off steam.something needs doing, is it back to force out the GP or update the ambo service remit.

    I dont know the answer to that.

  3. When an ambulance is called to me because I've collapsed in the street or whatever, but am conscious and talking by the time they reach me, then it's gone like this:-Quick once-over (taking pulse, checking eyes and so on), asking me a few questions, then asking if I think I can get to the truck for “a proper check-up without everyone gawking”.-Into the truck, sit down, various checks for blood pressure and blood sugar levels and a brief medical history and all the other bits for the form.- The Hospital Question. This varies. Sometimes it's “do you want to go in?”, sometimes it's “we'd like to take you in”, but since the hospital won't cure me I say I'd prefer to get a taxi home on the basis that home will be quieter and more relaxing.- After a greater or lesser degree of promises to take it easy and make an appointment with my GP, I sign a form saying I refused to go to hospital, they give me a copy of their report to give to my GP, and job is done.I don't really see what's wrong with that as a system, except for it being clogged up by those members of the public who insist on going to A&E in a big white taxi for every stubbed toe.Indeed, most of what puts me off going to my nearest A&E hospital is the fact that unless I'm actually spraying blood everywhere, I will be seen by a qualified doctor QUICKER by simply making an emergency appointment with my GP's surgery, and I'll get to sleep in my own bed in the interim!

  4. I think alot of it comes down to Public Education. We bang on about it all the time, but do we really ever get anywhere?At home in Ireland we have the situation where folks having an MI will ask that the ambulance parks away down the road as they dont want the fuss/their neighbours seeing/or better still dont come at all and I'll get a cab…. Whereas here folks call an ambulance (on their mbl as they are passing by, not even stopping to wait with the pt whilst they give their details) for Trampy Lou in the street who is simply sleeping!

    If the Public dont know when it is appropriate to dial 999 then things like the “I need an ambulance for my kids broken toe” are simply going to continue.

    I want to be an ECP, and when I get there I will make damned sure that if I get to a call and it wasnt appropriate for them to have called us, they'll know!

  5. If I had the solution don't you think I'd patent it and make tonnes of money?The point is one to the government explaining why I don't think that this idea will work, and highlighting perhaps the (financial) reasons why they would want it to work.

    The problem is that ECPs won't make a huge difference, not the 40% of non-travellers that the government wants. We aren't stupid and won't put our jobs on the line just to help government targets.

    Education is what is needed. We need to find out how it became acceptable to call an ambulance for 'crap' and change that social thinking.

    I'm working on a post where I propose some solutions.

    But yes, a fairly negative post, but then it's my opinion and I'd love to be proved wrong – just that working in EC I _really_ can't see it working, esp. when ECPs take just as long writing up their notes as we do taking people to hospital.

    And there wasn't enough swearing to be a BWTS post…

  6. Hi TomBrilliant post, if I may say. Now I do not do any on call, I was able to read it lying on the chaise longue, supping claret, wondering how to spend by 250,000 a year.I think I start by saying that one of the things I hate most about medical training (and I am as guilty as the next man) is the way the all people in health care, but doctors in particular, are trained to shit on colleagues.You soon learn the hierarchy at medical school. The physicians and the surgeons are at the top of the table, and shit on all below. And on each other. We move down the hierarchy to the rheumatologists, the dermatologists and so one and then, as we pass the salt we get to the serious pond life, like the GPs. Below them come the psychiatrists, the epidemiologists (what?) and so on.Further down the food chain we come to the nurses, the EMTs, the paramedics, the ambulance men, the St Johns people and the first-aiders.One of the signs of maturity of anyone working in healthcare is knowing their own boundaries. This is my big big problem with midwives. They do not understand their boundaries. And the nurse specialists in general are getting as bad.I am an experienced GP. I am pretty good at diagnosis, particularly diagnosis in the very early stages of illness. But lets imagine there is a train crash. Or a bomb. Or a multiple RTA. I would be hopeless. For starters, I would panic. I know all the theory of ABC, of neck stabilisation, of the recovery position, and so on. Indeed, I give lectures on it, and when I am asked about the innervation of the diaphragm (very important for breathing) or the interpretation of ECG I am pretty hot. But dont, please God, ask me to do it outside a hospital or health centre. I dont do trauma. And I dont want to do it. This is where you need paramedics. Or EMTs. Or whatever New bloody Labour is calling them today. Why could we not just stick with paramedic. We all know what that means. They are very good at this sort of thing. I am not.So I am deeply suspicious of BASICS. In theory a laudable organisation, and not totally without merit. But it is still a group of well-meaning GPs who have banded together to form an instant response traumatology service. Hmmm..Traumatology in the UK is not good, but this is not the way to do it. I would prefer the paramedics to stabilise the patient and get them to hospital.Now I am very good (I know that sounds cocky) at diagnosing hot poorly children. I can sit in my health centre or in a Casualty department or a walk in centre and I can do it. And I can do it efficiently and safely. It took about 10 years training before I got to the stage that I felt reasonable confident about it, and I still find it stressful at times. But then I learn that you dont need to train for 10 years to assess sick children. You can do it three days. Really. In three days. http://www.practitionersassoc.co.uk/three_dayIf this is true, you do not need me. You do not need a doctor. You can put an ABC or a CED or a PMT or an ENT or whatever in Casualty to do it. Its cheaper than me. This is the best example I can give you of the reasons why I get cross with dumbing down, and cross with the government undervaluing the skills of professionals trained to do jobs properly. It is lunacy.You cannot become a paediatrician in 3 years, never mind in 3 days.And the craziest thing of all is this. If the paramedics are all in hospitals doing my job, who is going to arrive on the M1 when there is a multiple pile-up? It will be ME! I have more free time under this system. More free time to spend some working for BASICs where I can explore my areas of ignorance.Madness.I wish the government would let us all get on with doing what we can do.John

  7. I feel I have to just pass comment here. I'm a paeds nurse, working in a paeds a&e, while I love reading Dr Crippin, I do worry he doesn't appreciate that with experience comes knowledge for nurses as well as for dr's.In our dept medically we are staffed on rota by the sho's doing their 6 mth (soon to be reduced to 4 mths) A&E – normally on their way to a career in surgery or medicine (v v rarely paediatrics) who often haven't even touched a child with a barge pole since they did about 2 mths of paediatrics during their medical training.

    So myself and my colleagues are often ASKED for advice, support and practically a diagnosis by the dr's before they see the patient. I've now been there for over 4 yrs and know the dr's we work with often rely on our support and guidance.

    I would love to train as a paed ENP to see minor inj & illness, far from thinking its something I could do tomorrow, I'd see it more as building upon the foundations I already have from experience and practice. This wouldn't be a quick 3 day course, it would involve doing 2 pt/time courses (at uni at degree level) – while still working f/time obv, followed by at least 6 mths consolidation – being mentored by senior ENP's and Dr's in the dept and after that would always know that there were senior ENP's/Dr's to discuss anything I was concerned or felt out of depth with. Due to funding shortages, this isn't currently available to me.

    It does infuriate me though that you're always so down on nurse practioners – my experience of the ENP's I work with is that their often more cautious than our medical colleagues – I see far more reattenders who've seen our dr's than ENP's.

  8. I think that dr Crippen has the same probem I have with GPs, nursing homes and social workers.He only meets the bad ones.

    I'm sure that there are many competent Gps, caring nursing homes and effective social workers. The only problem is that they rarely call ambulances. If they rarely call ambulances then I rarely see them.

    I think that there are a great many good nurse specialists who know their subject and know their boundaries. It's just that they aren't the ones who'll ring up Dr Crippen and give a rubbish handover.

    So both Dr Crippen and myself have a badly skewed view of certain professions.

    (It's also why I've stopped posting about GPs who sit heart attacks out on the waiting room, or who have healthy patients that suddenly take a turn for the worse and need hospital treatment five minutes before the surgery closes).

    I think if we used the thumbscrews we'd jog his memory of the decent nurse specialists. I vaguely remember him praising his practice nurse, who *is* a specialist nurse.

    And to answer your main point I was also asked about things from Drs on their A&E rotation because I'd been there years and that it was often the first SHO post they had taken. Bit worrying when they asked me to take a look at a C-Spine x-ray mind…

    …And I did remind them that I was a nurse at that point.

  9. The real problem in all of this is the patients. If we'd just sod off your jobs would be so much easier…;-)

  10. From my end, the most competent professionals I've dealt with have been my current GP and a physiotherapist I saw for all of six weeks (who as you say, listened to the advice of my GP and knew his limits enough to work out there was little he could do for me except give me mild stretches to help me retain what mobility I have).The most incompetent ones have been at the sodding hospital. Doesn't matter which department – A&E, paediatrics, gynae, neurology, cardiac – they don't listen, they don't tell you what they're doing, they treat you like a piece of meat, they walk in and out of the cubicle (assuming you've got so far as a cubicle) without a hello or a goodbye, they write things down wrong, they say they're referring you to X and then don't… the best-staffed bit of that hospital is the cafeteria.

  11. Felt an urge to pitch in here. And yes I'm still working as an ECP and still wondering what the hell I'm doing.I remember reading the BBC article and having a little chuckle.

    …emergency care practitioners, who have a wider range of skills than paramedics. Yeah right! By skills they mean we can do a bit of minor wound closure (suturing, staples and steri-strips) and some male re-catheterisation.

    The other 'skills' are how to take a (better) history i.e. spend 10-15 mins rather than the 30 seconds the management want paramedics/EMTs to do, plus be able to write up copious notes on everything rather than tick the boxes on a patient report form.

    They can prescribe more drugs, take blood tests and refer patients to GPs Again whoopie!! Drugs like paracetamol, gaviscon, co-dydramol, (stuff you can buy at the chemists) plus tablet versions of drugs that paramedics already administer in other forms (gtn, diazepam). OK we do carry some antibiotics as well but our guidelines are pretty clear about what we can us them for and, to be honest, most are for animal bites. Yes you read that correctly folks. We carry three different anitbiotics and about the only thing we can use them for are animal bites. I've only done 3 jobs in 11 years that involved animal bites and all were severe enough for the patient to require more than some anti-biotics. In the end, the vast majority of these extra drugs go out of date without ever being used.

    As for blood test. No, we don't do them. Even if we did they'd still have to be sent off to a lab for analysis so what's the point. We do 'do' urine tests though, but can only treat female UTIs (get quite a lot of those) as we do carry trimethoprim.

    As for refering to GPs. Well, most ECPs calls are Out of Hours. Which by definition means the GP is not around so a GP referral is not going to happen.

    Despite the claims from some of my colleagues (those with the big 'S' on their shirts and their underpants worn on the outside of their uniform) we are NOT doctors. I worked it out that adding together my EMT + Paramedic + ECP training the total comes to about 10 months full time. Compare that with the 10 years to train to be a GP. As the eminent Dr Crippen points out “we don't know what it is we don't know”. My medical knowledge is really no more advanced than a paramedic coz you don't really learn much more on the ECP course. The general rule of thumb is “is the patient BIG sick or Little sick”. If the former then they go in, if the latter then they can stay at home. Get a bit of advice from the duty doctor in Control and pack them off to their GP in the morning. Easy. Job done.

    On a positive note – yes I do leave about 40-50% of patients at home. They're not BIG sick, just usually need some re-assurance, some minor wound care etc; enough to get them through the night or over the weekend so that they can see their own GP. But Tom's right, it takes as long, if not longer, for me to complete all the paperwork; patient report form, letter to GP, clinical audit report etc, than it would to take them down to the local hospital. On the plus side though you often get offered a cup of tea and don't get hassle from control about why you're taking so long at scene.

  12. Interesting post but to take everyone to hospital reynolds “as I'm not a doctor” is a bit of a cop-out isnt it? Its been clear in my experience that many of our patients dont need to go to hospital (either they're simply not sick or spending many hours sitting in an ED is not in their best interests ie better to see their local doctor etc) and by us simply taking the easy route and taking them to hospital is only contributing to the problem of hospital/ED overcrowding. When I work with experienced ambo's I watch in awe as they sort the wheat from the chaff so to speak. Anyway, my two cents.

  13. Cop out maybe, but consider this. People call for an ambulance to see a doctor. I am not a doctor. I can however drive them to hospital to see a doctor.People become happy. Happy people don't try to hit me/complain about me.

    Sure – I *could* sort out the wheat from the chaff, I could tell the people with verrucas that they don't need an A&E. Then I get a complaint against me for 'refusing to take a patient'. Then I get disciplined.

    And that is without acepting that perhaps my training isn't enough to leave all but the most minor injuries at home.

    Besides – leaving someone in A&E for four hours might then educate them a little into going there inappropriately. Call it negative reinforcement…

  14. I thought you might be interested in this paper…..http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4123769&chk=YE6wNc

    This link takes you to a paper that is “in consultation” at the moment about the proposition in the UK to train the equivalent of the US Physician Assistants.

    Not a nurse and not a Doctor. Is there room for a third profession? There certainly is the work for them but is this the right way? The nursing profession is a very different beast than it was a decade ago and so indeed are paramedics.

    I am undecided about the MCP (or even the surgical equivalent – also proposed).

    It doesnt take a Professor to diagnose an appendicitis neither does it take a Doctor to diagnose/treat an infected in growing toenail. How much training/experience is enough? An SHO isnt as trained/knowledgable as a SpR but regarded as safe enough to treat most ailments. So how did this level get to be decided other than a general evolving acceptance? How much training is enough for a MCP to diagnose and treat and know when to refer?

    The Physician assistant has been working well for years in the States so perhaps if we follow/adapt their model we shouldnt worry?

    Sorry its a little off subject but its pertinent

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