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.
“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.
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?