Dear Dr. Crippen

Dr Crippen had to call an ambulance for one of his patients and he wrote it up here.

I've already left a few comments on the post, but I thought that it might be interesting to answer some of his points on here. All on the basis of understanding each other. I invite Dr. Crippen to do the same.

This isn't an attack on Dr. Crippen, but I do think that there is a bit of a misunderstanding on the role of the ambulance worker. So this is an attempt to show the situation from the other side. Also blogs are all about the conversation.

Dr Crippen starts,

I know, I know, it seems melodramatic, but I can’t take the risk that Andrew might have another attack on the dual carriageway. So I call the ambulance service. A very friendly operator answers on the second ring. I give all my details, my code number, then all Andrew’s details, his address, date of birth and then I am asked “the question”. The same glorious question I am always asked read, as always, from the protocol.

“Is there a medical need for an ambulance?”

I resist the temptation to say “WTF do you think I am phoning” and merely say, “Yes.”

Well, it might be that someone is calling for an ambulance to take a non-ambulatory patient to hospital, so it's not a silly question. Maybe I'm being churlish but 'WTF' Means 'What The Fuck', which isn't a nice thing to say to one of our call-takers, they hear it quite enough from 'civilians'.

Even now, I know that there is about to be a problem. What is your provisional diagnosis? The word “provisional” is irritatingly gratuitous. “Unstable angina”. Silence. Operator switches to a different protocol. Do you want an immediate ambulance? Well, I certainly do not want to wait two hours, but this was not dire enough for me to have dialled 999. “Yes, please, but you don’t need to arrive with sirens and flashing blue lights”.

A lot of GPs call an ambulance to take someone to hospital because they aren't sure what is wrong with the patient – a lot of GP letters that I read end with something like “?Angina ?MI ?PE, please do the needful”. This isn't a problem, that's why the patient is going to hospital, for further investigation. Were the call-taker to ask for the diagnosis and you were unsure, would you be annoyed by having to say “I'm not sure, that's why he's going to hospital”?

There is no such option on the protocol sheet and so my request is ignored. I am switched to the 999 “pathway”. I am told that the ambulance is on the way but I have to answer some more questions.

“Are you with the patient?” Of course I am.

You'd be surprised at the number of GPs who sit their patients out in the waiting room, sometimes when said patient is near death. More than one patient put out in the waiting room has been 'blued' straight into resus by me.

“Is the patient conscious?”. Yes, of course he is, if he was not, I would have dialled 999. In fact, he is sitting in front of me smiling. “Is he breathing.” “Has he changed colour.” And so it goes on. These are the 999 protocol questions for the layman. They are not questions for experienced doctors but they are always asked and have to be answered. By the time I get to the end of the ludicrous questionnaire I can hear the siren and soon I see the flashing blue lights through the window.

Ah, the wonders of AMPDS, or Automated Medical Priority Dispatch System. Designed so that an ambulance trust doesn't have to employ expensive medically-trained call-takers. It was designed in America and so it's biggest selling point is that no-one has successfully sued a trust because of it. There are not Doctor specific versions of it.

If the call-taker doesn't follow the 'script' then they get marks against their performance, too many marks and they get disciplined or passed over for promotion. they have no power to change this, or to use common sense when talking to a caller. See Nee-Naw for more details on this.

I go out to meet the paramedics. Two very keen young men. I give the history to them, and tell them the important things. Andrew is pain free, stable, in sinus rhythm, with a normal blood pressure. Then we have to play the ECG game.

“Have you done an ECG, doctor.”

Reasonable question for a patient with chest pain. The hospital A&E department will do one as part of the diagnostic process, if the GP surgery had the time/staff/equipment then there is no reason not to do one.

“No”.

“Do you have an ECG in your practice?”

Tempting to say mind your own business, or ask if they have oxygen in their ambulance. We have both an ECG machine and a defibrillator but neither has been needed, thank God. It is not possible to make paramedics understand that it is not necessary nor even helpful in this situation to do an ECG.

“Why on earth would I want to do an ECG?” I ask

The paramedics look at each other and back at me. “To see if he has had a heart attack, and to see what rhythm he is in.”

I know what heart rhythm he is in (well, OK, he could be in steady atrial fibrillation or even compete heart block but it is not likely) and you cannot exclude a heart attack at this stage by doing an ECG so, whatever it shows, he needs to be in hospital. Might as well just take him. We are not on Dartmoor. The paramedics do not carry clot busting drugs. The hospital is only a few minutes away.

“He could be in steady atrial fibrillation or even compete heart block but it is not likely”, not likely but I've been surprised by patients having unusual things happen to them. I've no problem with GPs not doing ECGs but there is a reason why we do them. Actually a few reasons.

1) We diagnose ST elevation MIs – heart attacks, and take them to the 'gold standard' cath-lab rather than to the A&E department. It's one of the real success stories in the NHS.

2) We are told by our management and training to do ECGs on chest pain patients. If we take a patient like this to hospital without an ECG, the hospital will look strangely at us. If we don't document a *very* good reason for not doing an ECG then we can expect to be asked some pointed questions by our management.

3) In most cases it doesn't hurt – and can turn up something like complete heart block, or an asymptomatic MI.

The paramedics huff and puff.

Andrew refuses to get on a trolley and insists on walking to the ambulance. The paramedics do not like this and huff and puff some more. I keep a straight face. Not a sign of schadenfreude from me.

Then I shall not have any schadenfreude over any of your patients. The reason why the paramedics didn't like this is because it is a disciplinary offence to 'walk' a chest pain. We can lose our job over it (and I personally know one crew that has lost their job over walking a chest pain). So yes, it makes us nervous.

The ambulance then sits in the car park for eleven minutes (just over). I timed it. Stay and play. Do an ECG. Follow the ritual. The ambulance service insisted on sending a blue-light ambulance which, all power to them had it been needed, arrived in less than five minutes. They then waste eleven minutes doing unnecessary tests. Stay and play probably killed Princess Diana. Fortunately it did not kill Andrew.

You have eleven minutes to spare? The tests are not unnecessary if there had been something wrong with the patient at that moment in time. They probably did a blood sugar measurement (as per our medical director's instructions). Actually all the clinical procedures and policies have been created by doctors, JRCALC and the individual trust Medical Directors. This includes doing ECGs on chest pain patients.

If he had another bout of chest pain while in transit the crew would have given him a spray of GTN. To do that safely you need a recent blood pressure. And no, we don't always trust the GP's measurements. You've mentioned yourself the weirdness about writing 120/80 on a referral letter, and how it implies that the blood pressure has been made up.

So, much of the problem you have with the ambulance crew is because of things we have been told to do by doctors. It's just that you don't understand the policies, guidelines, pressures and culture of us ambulance workers. It's not a problem, I'm not an expert on QoF targets or how to get through a thorough assessment in twelve minutes. It's one of the reasons why I read your blog.

What I would remind you is that ambulance workers have a lot less power than doctors, we don't have the letters after our names to go toe-to-toe against MPs, even though they know less than us about medical matters. We do as we are told, we use common sense when we aren't told what to do and we learn from other professionals and from our experiences.

Sometimes we are told to do silly things, but we have no way of changing this. Like you have silly things thrust upon you by your masters, so are we.

Oh and do stop going on about Diana – it was doctors who 'stayed and played'. Any crew I know would have splinted, C-spined, stuck in a cannula and ran to the hospital.

UPDATE:Garth has also entered the discussion


On a more serious note, the police and us work together closely, so it's always sad to hear when one of them is having trouble. I would ask you to go and have a read of the difficulties that one particular police family are having because of a very sick child.

What is curious to me is that there is apparently a treatment for the child's illness, but that the NHS don't offer it. If it's due to the cost couldn't we do with a few less NHS pen-pushers and box-tickers? How about MPs having a below inflation pay rise like the rest of us? Or how about claiming back the money on the awful 'Connecting for Health' fiasco?

40 thoughts on “Dear Dr. Crippen”

  1. Very interesting post! I have looked at the other sites involved – should be a good discussion! We are moving to not doing ECGs on scene but getting them on route if no Paramedic is available for thrombolysis as there is not a lot we can do about it as Techs if they are having an MI. I do agree though, hospitals often want to know if there is elevation and where when the courtesy call is put through and always ask for an ECG when you get there. I've nearly fallen over several times after doing a 12 – lead just to confirm that the pt is not having a heart attack only to find a raging barn door – tombstone style – MI going on…… Always get nervous without an ECG me!

  2. This is difficult. Chest pain in itself is a stressful clinical encounter because of the number of differential and scary diagnoses it may represent.To be honest both the doc and the ambulance men did a credible job on this patient's behalf.

    As a doctor we're trained to think laterally, if tests and investigations in 'the field' are not going to change the patient's subsequent management at hospital we shouldn't waste time doing them and try and ship them off to their definitive treatment as soon as possible.

    I do understand that in some hospitals the gold standard PCI is indicated for STEMI's but not every hospital has this facility and quite often they come through A&E and get the ECG and then are transferred quickly to the cath lab or 'clot busted' .

    I'm not sure that a consultant cardiologist or specialist reg would open the cath lab until they had seen the ECG via fax or had the story corroborated by another medic out in the cardiac ambulance but anyhow.

    I understand why the amublance men were nervous especially about following protocol as quite often these said protocols have saved lives but I don't think we should get ratty about a GP who was looking after his patients interest and nor do I think the GP should get ratty about the ambulance men who were looking after the patients best interest.

    To cut the rambling short….it's all about the patient's best interests…and in this story both teams (not sides) were most admirable in looking after this patient. They've just got to step away from the bigger picture and realise that they are both playing for the same side.

    God sorry, that's an awful post but hopefully the sentiment is conveyed.

    (Just another junior doc hoping to remain employed this year.)

  3. I'll bear Dr Crippen and Garth's comments in mind the next time I attend a GPs referral at surgery and find the pt sat in the waiting room, no aspirin, no GTN, no pain relief, no cannula, no 02, no ECG and a scrawled letter and then have to spend more time that I'd like doing all the above in their car park, transmit the ECG to the CCU and then have to thrombolyse the PT too.Self righteous prigs (yup, prigs, I wanted to put something else though).

  4. This is an interesting topic, and Im going to chip in my 2pence worth.This all comes down to one principal, one that we are taught in medical school and again and again throughout our careers as doctors:

    Will the results of your investigation (in this case an ECG) change what you do to your patient? If the answer is NO, then the investigation is a waste of time and should not be done.

    So, whether you think he is arrogant or priggish or whatever, Dr Crippen is absolutely right in not doing an ECG at his GP practice. He would have called for an ambulance whatever the ECG showed. It would be totally negligent and unacceptable if didnt call for ambulance even if the ECG was normal.

    Regarding the ambulance crew, whether or not they should do an ECG depends on the local circumstances. If the ECG decides whether the go to cath lab, CCU or A&E; or whether they thrombolyse at the scene or not then, they too are absolutely right and correct to do the ECG.

    If they are going to take the patient to A&E REGARDLESS OF WHAT THE ECG SHOWS, then they are wasting time and potentially endangering the patient by waiting to do one.

    The point is that protocols arent sensitive enough to allow people to make clinical decisions like this.

    Btw, all those who said I remember a patient who looked fine but the ECG showed a big MI, therefore they are always worth doing are missing the point.

    The point being that even if it does show a big MI, are you in a position (in an ambulance in a GP carpark) to do anything about it? If the answer is no then the patient needs to go to place where there are people who can do something about it as quickly as possible. Simple, really.

    Bear in mind that EVERYONE admitted to hospital with chest pain gets an ECG on arrival. The question here is how useful is a pre-hospital ECG in this scenario?

  5. It's that kind of attitude from doctors that annoys me about them.I used to work in a GP surgery and found most of the doctors to be ok, but one was particularly funny.

    (this was before my nurse training so I don't remember what rhythm he was in!)

    On the one afternoon that there was no clinical staff, a member of the public not registered at the surgery came in asking for some help as he was complaining of chest pain – I knew that this wasn't something to twiddle thumbs about so called 999. The crew arrived and I asked if he was ok – I was told he was having a heart attack.

    Thinking I'd get a pat on the head and a star from my bosses, I was cornered and asked why I hadn't called the GP in from home (15miles away) as he would have been able to assess and diagnose!

    Looking back now since my training, I can see that the Dr was on another planet!!

    I hope that Dr who's blog you read, reads your side and opinion and takes note of all the red tape that has to be covered, to cover our arses as well as the said GP's!

    Bex

    Ps Looking forward to your next book 😀

  6. Well said Tom, this is the second GP blog i've read having a go at Ambulance crew, rather than the procedures. Any sympathy I had with the doctor went out the window when he decided to take it out on the people that are forced into such narrow pathways of action, not through choice, rather through legislation. GPs seem to think that their word is law and should be followed to the letter. Might be nice to see them try and work with the system rather than bypass it.

  7. It seems to me that some doctors feel threatened by other health professionals. I admit that when I feel annoyed when a health care assistant calls herself a nurse I may be displaying the same fear but I think it's because they are lying. They haven't done the training.A good doctor is grateful for all the help he/she can get and appreciates another expert in their own field.

    Mind you, we're getting there. I've certainly seen a change in the last 30 years.

    When you stop to think about the logistics of calling an ambulance you realise that protocols must be followed by control,especially if there is going to be any chance of reaching the dreaded 8 minute target.

    Come on Dr Crippen, read this blog and then maybe you'll understand. Maybe.

  8. Re: WTFHe *did* say he resisted the temptation so it's a little churlish to pick on his language when he didn't use it. In fairness, the question he's responding to could be better worded; “is there a medical need” does tend to elicit the “Doh!” response until you made it clear what the question really was intended to be.

    Re: AMPDS

    It really IS stupid to have an alternative route into the system for doctors and then make them trawl through a script intended for laymen. Hell, I get frustrated when I get dragged through the script if I call in because of my asthma when I could sum up the whole thing in 20 (very breathless) words; for an experienced doctor it must qualify as some sort of torture.

    What I find notable is that there apparently isn't a doctor/specialist path though AMPDS but it contains a question like “is there a medical need for an ambulance” which implicitly calls for a medical judgement.

    Re: blues and twos

    It's frankly irresponsible to have a system that can't take account of the assessment of a doctor on the scene to grade a call into anything other than “blues and twos” response or “whenever”. Generating a blues and twos response puts other road users and ambulance crews at risk. This is acceptable when life is, or might, be at immediate risk, but when a doctor says “it's urgent but not that urgent” there ought to be a way of grading the response appropriately.

  9. “Well GP called ambulance for a patient with chest pain, ambulance then went to patient's home and did an ECG which was normal, hence dropped the patient off at the GP practice!In the end GP called another ambulance and it turned out to be an MI.

    Not saying this is typical behaviour, but there are increasingly frequent stories from GPs who are coming up against a lot of resistance, from people who are significantly less qualified than they are, when trying to get patients into hospital.

    I know of several cases of late directly. One MI and one ruptured ectopic that the ambulance crew argued with the GP that they didn't need to go into hospital.

    You are frankly living in cloud cuckoo land if you don't think this is a problem.

    The government is trying to save money by preventing people who need hospital from going to hospital.”

    Of course these examples couldn't be indicative of an increasing arrogance of ambulance staff? could it?

    I have posted a response on my blog.

    Doctors are concerned that HCPs with less and less training are being given jobs and responsibilities beyond their means, this is very different to feeling threatened.

  10. I'm not qualified to comment on most of this, but it does seem silly that there's no simple PIN system for doctors whereby they get, at least, a DIFFERENT script – including Ian's suggestion of the doctor being able to specify the speed that is warranted, based on the patient's state of health.Mind you, I have naff all trust in GPs, for reasons I don't feel inclined to comment about on the web, but there ya go – some must be okay.

  11. I'm a protocol driven automaton working for a provincial service, and it appears our way of operating when a doctor requests an ambulance differs substantially from the LAS. The AMPDS script that everyone appears to love so much is completely changed (the 'conscious' and 'breathing' questions are omitted for example), and the questions we ask take into account we are speaking to a professional.If the patient is in a surgery and there is a defibrillator available and staff trained to use it (I assumed this would always be the case, but sadly not), we don't send a vehicle that cannot transport the patient.

    As Tom mentioned above, AMPDS is meant to be followed without discretion when dealing with members of the public. It's far from perfect and often results in completely unsuitable responses because people blatantly bend the truth when answering the questions. I'm sure the 'A' stands for 'Advanced' by the way…

    “It's frankly irresponsible to have a system that can't take account of the assessment of a doctor on the scene to grade a call into anything other than “blues and twos” response or “whenever”.

    That isn't the case. The timescales do vary from emergency to whenever possible, but there is a within one, two or three hour option in between. Generally the only 'whenever possible' calls we take are transfers and discharges. Of course these timescales, much like ORCON, are not always met.

    “Generating a blues and twos response puts other road users and ambulance crews at risk”

    I took a call from a doctor recently wanting to book a blue light ambulance at 2pm, however there was no bed available until 5pm so he wanted it delayed until then. The hospital in question is in the centre of a large city and travelling into it at rush hour is not for the faint of heart at normal speed. I tried explaining that blue lights were not appropriate but was met with a garbled shout about whether I knew how serious the patients condition was. Luckily he saw sense eventually.

  12. Actually, what Dr Crippen is describing doesn't sound remotely like the protocol we use in London for doctors arranging an ambulance.First of all we do have a different set of questions for doctors (or any of a list of medical professionals). With the general public, the AMPDS system lets us prioritise patients based on layman's information (even then the question “is he/she breathing?” is sometimes met with screams of “I don't know, I'm not a doctor!”).

    With medical professionals, we simply ask what is the reason for admission?”, followed by “does this condition present an immediate threat to life”. We are then able (as in the trust Either/Or works for) to give an immediate (blue light) response, or one within 1, 2, 3 or 4 hours as required for a clinical reason (i.e. not because the GP wants to close his surgery in 45 minutes).

    The only time we use the AMPDS protocol for doctor's calls is when the answer to 'reason for admission' is on a certain list of conditions (a list that, as it happens, includes chest pain / ?MI). In this instance, we do not actually have to ask the questions on the protocol, just use it to generate the pre-determined response for the condition (although, before I clarified this with one of our quality assurance managers, I did once ask a doctor things like “is he changing colour?, is he clammy?”. Bless him for the patience he showed me).

  13. Guest Blogger,read my blog and look at our comments in context, throwing insults around as you do doesn't really take things forward does it

  14. The only problem with the Health Care Professional Questioning Protocol which is used in London, is that it has the unhappy knack of over-prioritising run of the mill requests for transport, and under-categorizing more serious matters.On the first day of it's inception I was working on Tom's sector, and spoke at length to a crew who had done a hospital to hospital transfer, which was given as a “blue light” transfer. It wasn't – it was an Out patients appointment. The following day – on my own sector – I received a request for transport for a doctors' surgery within 2 hours, for an 85 year old female with “a low pulse”. Having one of those “funny feelings” you sometimes get, I sent an ambulance immediately. Within 20 minutes the lady was being blue-lighted to hospital with a bradycardia of 30 bpm!!!

  15. I worked on reception at A&E and a colleague once asked a patient being admiteed via the gP to the Cardiology ward if he wanted a poter to take him up. The patient refused. We then got a very angry phonecall from the ward asking why we let the patient walk up! Nothing we could do, there were never enough porters, he could have been sat waiting half an hour in the A&E waiting room to be taken up.

  16. Sounds like the sort of GPs we get around here… I've lost count of the 'GP Urgents' that I've had to blue in.It's why I'll often drive under blue lights to certain notorious GP Surgeries.

  17. I do understand that in some hospitals the gold standard PCI is indicated for STEMI's but not every hospital has this facility and quite often they come through A&E and get the ECG and then are transferred quickly to the cath lab or 'clot busted' .I'm not sure that a consultant cardiologist or specialist reg would open the cath lab until they had seen the ECG via fax or had the story corroborated by another medic out in the cardiac ambulance but anyhow.

    I'm only going by how London operates, but here we do the ECG because if it's a STEMI then we bypass A&E and go straight to the cath lab. It's one of the real success stories of the NHS.

    The Cath lab is also superb, and are happy to see us and run a 24hr service. I can't praise it enough.

    (Case in point, I took in a patient who was borderline STEMI by ECG, it needed them to call in the Consultant and do some repeat ECG to confirm that the patient wasn't having an MI. They made it obvious to me that they were happy with my decision and that I should do the same thing again if I had any concerns – top folks).

    As for the getting ratty – well, I did try to not get ratty when I posted this. It's why I say at the start that it's not an attack.

    As is, I have no problem with the actions of the crew or of Dr. Crippen – both had the patient's best interests at heart.

  18. OK. Before I start, I am aware Dr Crippen stated that “paramedics don't thrombolyse”. Whilst this may well be the case where he lives, after everything else he has written, I certainly wouldn't take that as gospel and he may be well counselled to check before he judges any further.In our area we do thrombolyse. I however am only a mere techie……the type our Crippen would doubtless wipe his boots on. I can think of a very recent job where we arrived on scene to find a patient with a cardiac history, short of breath but with no pain whatsoever who “just didn't feel right”. (Our Crippens patient was pain free I recall.) We took him out to the vehicle, in the carry chair……walking such a patient is not only a sackable offence but rather more importantly may kill him ……..did the ECG he considers so irrelevant, to discover he had raised ST. GTN, aspirin and O2 under his belt, with a 32 minute run to hospital we went through to control and established the nearest paramedic single responder was a mere 4 minutes away and was dispatched at once.

    On arrival he clarified our findings, asked a handful of more probing questions whilst we drew up the necessary drugs and thombolysed the patient there and then.

    At that point, we blued the patient straight to the cardiac ward, a 32 minute run, during which the gentlemans ECG reverted from a scarily raised ST to a near normal sinus rhythm.

    Clearly, if I had been at our Crippens surgery, he would have noted the double tech crew and sneered at our management of his patient (he'd not have walked to the vehicle if I'd been there, sneering doctor or not) and timed my treatment inside the vehicle (I have managers like him). However, my “stay and play” management of this case without doubt preserved the future quality of this mans life and may even has saved his life.

    Crippen. You are a GP. You are (I assume from the usual quality of your blog) not bad at it. I'm not bad at what I do. How about we be part of the same team eh?

  19. I can see the frustration from both sides.I would guess that whilst a patient is waiting in an area then should something have happened people were there to react and who had an idea of what had happened in the first place. Even with a porter, s/he has an idea of why they are being shipped to the Ward. If the pt. makes their own way and collapses en route then things become far more complicated. As per, not enough staff… well, not in the right places anyway ;0)

  20. So other than the fact he called yo a self righteous prig you would agree with every other point raised? I'm with the original poster on this.

  21. Fair comment… but then, us techs gotta stick together ;0)On more than one occasion i know of vehicles who've attended surgeries where no ECG has been done yet an AMI has been discovered by the attending crew. In one case, my own station, the chap had hardly a hint of an AMI but had actually had, what is referred to as, a barn door MI! (one glance at the ecg and it's as blatant as the wrinkles on the back of my hand)

    Like Sam, we have a long run to hospital so any advanced readings would always be most welcome.

    If the dots are already in place then attaching the ambulances' monitor is quick an easy but attaching leads and dots in the right places in a moving ambulance is bl**dy dangerous. Never mind that, as mentioned before, doing a reading on the move isn't worth the paper it's churned out on.

    Manual BPs should be taken for accuracy and, again, you try listening in the back of a bone-shaker.

    Never mind all the things a paramedic has to do there are plenty to keep a double tech crew occupied before one can consider moving.

    I do not believe in extended stay n play but once has to weigh up the situation for what it is and might be.

    In a very grey world with many black and white rules which colour is king?

    I should add that some surgeries in the area i look forward to attending as the GPs are cluey and courteous. And it works both ways.

    Bureaucracy seems to set brother vs brother some days!

  22. “The timescales do vary from emergency to whenever possible, but there is a within one, two or three hour option in between.”So by my reckoning there's still a gap. It's between immediate response and “within one … hour”.

    Let's take a concrete example. I'm an asthmatic and no stranger to ambulances, sometimes replete with full blues and twos onto the way to A&E. There have been times I've needed them here within 8 minutes and there's times I've needed them soon but not so urgently that I'd want someone running blues and twos on their way to me, but also not as far away as an hour.

    I'm sure that's not the only example of a situation where (when there's someone competent on-scene to grade the response) there's a call for a grade “on the hurry up, but not so much as to routinely call for blues and twos”.

  23. Appreciate what you're saying Jr Doc however doing an ecg there and then in the back of an ambulance shows what's happening/happened and then further ecgs illustrate potential changes.Even if no changes occur then the receiving hospital can see that. But, if you do not do an ecg then one can not see if there are/are not any changes.

    Whether the run to hospital be 5 minutes or 50 minutes.

    And, yes a paramedic can do something parked in a GP surgery car park because they can thrombolyse IF the patient fits the criteria and consents to such a treatment. The only way to know is by looking at a 12-lead ecg. And, when living a long way from a hospital taking the time to do such a thing allows (conditions allowing) for the crew to call on the helicopter which will take the chap/chapess to hospital in less than 15 minutes.

    Any observations done by the initial practitioner (doc/paramedic/joe public) will be of great bonus not only to the attending ambulance crew but to the patient themselves. The more advanced the equipment the better.

    Wherever possible, crews will do what is possible in a moving vehicle.

    Aside from the jobs of the military, treating a patient in a moving ambulance is one of the riskiest jobs one can do.

  24. I've been reading this post and comments with interest. It seems to me that the Dr side of the argument has some logic but that logic is overshadowed by an arogant attitude towards other HCPs. HCPs are all in the same business – helping patients. Would it not be more sensible for Dr Crippen et al to stop complaining about the paramedics and technicians lack of knowledge and spend more time assisting them to increase their knowledge. I have not met a paramedic or tech who has not been keen to increase / develop knowledge, yes there are protocols to follow but these protocols, I am sure, can be developed to take in new practice IF the right people put forward balanced and logical reasons for that to happen along with sensible solutions.Pre hospital emergency care is a specialist area much narrower and with less training, but just as relevant as the wider GP medical knowledge. GP's need to recognise that and work with the system not against it. As pointed out, it is the patients interests that need to be met. I have known of many nurses and A&E staff going out on shift with the ambulance service but I do not think that this is something that GP's tend to do. May be an attachment to the ambulance service should be part of their training to try to help break down the obvious barriers? And just one more point, the use of the term “less qualified” sounds particularly derogatory. The ambulance crew may have less medical qualifications but surely experience and exposure to emergency pre hospital medicine counts for quite alot. I think these GPs maybe need to think “different, specialist” medical knowledge rather than “less qualifed”. Unfortunately in the real world, from a laymans point of view, the reputation of GP's is lessening – personnally I am inclined to go with the so called “less qualified” ambulance service if I have an emergency!

  25. I total agree with you EmT.If you're in a position to do something with the ECG result, like thrombolyse, divert the ambulance or call a helicopter, then, of course it is a valid thing to do and should be done as quickly as is safely possible, however, if you're not in a position to do anything about it, then it's a waste of time.

    A couple of points to remember

    1. Andrew had no chest pain when the ambulance arrived (would you really thrombolyse an asymtomatic patient with ST elevation on ECG?)

    2. Andrew had already seen a doctor who had diagnosed his condition

    Dr Crippen probably thought “this man is at high risk of having a heart attack but is unlikely to be having one right now. He needs an angiogram”

    And, like him or not, the letter shows that the GP was absolutely right

    – Michael

  26. Chaz,Your attitude towards doctors saddens me, and I don't think it's justified. You are absolutely right that it's the job of ALL HCPs to do what's best for our patients. That's why we give up our free time to study and go on courses, that's why we come into work early and go home late, that's why we grasp opportunities to learn things that will increase our ability to help our patients, that's why we work extra hours for free, i could go on… In my experience, the group of HCPs that do these things most frequently are the doctors. And we we do this preciesely because we care deeply about our patients.

    Senior doctors get frustrated when things aren't done properly. This is because they have the knowledge and experience to know what can happen when things are done wrong and what can happen if people insist on following protocols rather than listen to someone who knows what he's talking about. If people aren't told when they are messing up, how are they ever supposed to learn?

    On the whole though, I think doctors are far more likely to criticise other doctors than they are other HCPs. If you read the original post by Dr Crippen you'll see that he was pleased with the treatment that Andrew got and only criticiesd the cardiologists (other doctors) at the end for not taking the time to explain what happened to the patient.

    Protocols are incredibly useful and, in the vast majority of cases the correct protocol will bring benefit to our patients. However, they should never stop people from thinking about what they are doing. In my opinion, it is unacceptable for a HCP to cause harm or potential harm (eg by delaying definitive treatment) to a patient, even if the protocol says to do so. Really, in an ideal world, we wouldn't need protocols because everyone would know what they are doing.

    You may be “inclined to go with the 'less qualified' ambulance service if you have an emergency” but aren't you forgetting that, if it really is an emergency, they'll take you to the feet of another doctor?

    – Michael

  27. I can't read Dr Crippen's blog any more because he posts such utter vitriol and nonsense about other HCPs but won't actually engage in a debate based on evidence or reason. He himself thinks that all midwives basically are unfit to do anything except wipe people's arses and that birth is only safe in a hospital with a doctor present and has slagged off midwives enough times; seems he's just moved on to ambulance personnel…

  28. I have to agree with London EMD – we have a much better system in place now for HCP and it makes our lives a lot easier as we don't have to ask the “layman” questions anymore.However at least on this occassion it was actually the Dr who phoned as more often than not it's the receptionist who has no idea what is wrong with the patient other than a very basic diagnosis. You ask if it's life threatening and they answer with “I don't know. Dr just asked me to call for an ambulance”. Before the new protocol came in for these types of journeys, you'd ask the AMPDS questions and you could hear the receptionist shouting over to the patient “are you clammy? are you nauseas? etc”

    Or on the switchside you get a Dr who expects you to be a consultant cardiologist and gives the latin medical term for everything that has happened since the patient walked in and all you really want to ask is “does that mean he's got chest pain?!”

  29. Junior Doc – protocols arise because of things like this:http://www.thecnj.co.uk/camden/2008/011708/news011708_02.thml

    Crews perform ECGs for a very good reason – depending on the tracing they will either;

    *Thrombolyse at scene (some regions).

    *Transport to the cath lab if ST elevation (some regions)

    *Blue into A&E – think of the 20% of atypical MIs that can be

    diagnosed pre-hospital.

    I'm sure you're very good at what you do – but so are the paramedics, we should let them get on with their job IMHO.

  30. Actually, I think that they have to have the same script is probably a good thing – everybody is fallible, and in the event of having failed to remember to check something, a list of things to check like that can't be a bad thing – even if they do have to put up with it for 99% of the time when they haven't forgotten to check anything.

  31. Now I understand fully that in different areas there are different protocols. Now all the LAS guys I talk to and people in my own service have similar guidelines to follow (yes I know guidelines are just that, but bear with me) It is a good thing to have to follow a set protocol, this enables us to make our clinical judgements, now I know we are just lowly techs, or paras, we don't have the years of training that the likes of Dr Crippen have (and I assume by your name, you will have in the future) however we are not stupid, we do however expect support from the medical professionals that we come across in our work, (the majority of docs round our way are superb, we have brilliant A&E consultants who are “pro” ambulance and very helpful, both when receiving patients from us and giving advice to us) Regardless of what the GP thinks, there are always exceptions, there is always a possibility of normal pain free patient that will catch you out. Now whilst I agree that the treatment we give the patient may not differ dependent on the ECG what we do next is quite important. While Dr Crippen and other GPs wonder why we are sitting in the car park doing nothing, we are in fact as medical professionals working as a team to decide the best route for us to follow. Are we happy that the ECG is ok for us to follow the GPs request to go to A&E? or do we want to follow our own “guidelines” and go down the route of a direct transfer to a cathlab, getting the patient the angiogram that The Junior Doctor speaks of.Now bandying about insults isn't going to change anything, whilst I think sometimes I would agree with some of them, we all have our opinions. What would be helpful is if the minority of GPs and Docs who for some reason feel threatened by us ambulance crews actually found out what we do. For this reason I think it would be a great idea if every doctor came out on the road for a few days with us and actually see what we do. We may not have the qualification of Doctor, but we learn everyday, we take advice from those that wish to give it, and we do the job that we love to the best of our ability. But as usual, we are the ones to be blamed….

    Wouldn't be nice if Dr Crippen had accepted that we have our own job to do too, we don't have the full weight of the Medical Council behind us when it arrives at coroners, in some cases we don't even get the backing of the trust. A very wise man told me once that if you deal with everything as a worst case scenario, the patient cannot loose, they will just receive the very best treatment that they deserve. If its alright with everyone else, I am going to do just that thanks….

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