Category Archives: Ambulance

L.A.T.E.R

Dr Crippen posts about the Princess Diana documentary and draws attention to the ideas of 'Stay and Play' or 'Scoop and run' in the ambulance service.

There is a discussion that has been going on for some time in medical research circles about the training of paramedics (and I would suppose also us lowly EMTs) and what we should be doing on the scene of an accident.

Let us imagine a young man with a stab wound to the chest – a nice 'trauma' job. Should the ambulance crew remain on scene for a long time, getting venous access (so that fluid can be given to prop up the patient's blood pressure), examining the wound to see where we think it goes (to determine the severity of the injury) and conducting a full physical examination by cutting off all their clothes (to make sure that there aren't injuries that have been missed). In America the crew would probably also immobilise the neck because the patient had fallen over*

Or.

Would it be better to load them into the back of the ambulance, do up the straps and rush them into hospital where there are doctors and surgeons and operating theatres?

It is complicated somewhat by the policies of the ambulance service. Unless there is a really good reason we have to record a full set of vital signs for every patient we pick up, that's blood pressure, pulse, oxygen level, rate at which they are breathing and blood sugar. We can also be expected to do 12-lead ECGs and measure the amount of carbon dioxide someone is breathing out.

So the option to just 'run' is fully out of the question – if the patient dies we would be up in front of the coroner and they would be asking awkward questions about our lack of vital signs.

So we have to stay on scene to check those signs. What else do we need to do?

Some stabbings are 'nothing' jobs, a little slice, or even a minor skin scrap have been reported to us as stabbings, if we were to 'blue light' these calls in we would be rightly laughed out of the hospital. So we need to do some form of assessment to determine the severity of the injury. To properly do this we would need to cut off the patient's clothing.

Gaining venous access would depend on the patient's vital signs and how close they are to the hospital – I am personally a big fan of 'scoop and run'. The place for a sick person isn't in the back of an ambulance.

But.

Here is where I consider myself lucky. I work in London, I'm never more than ten minutes away from hospital; if the patient is in the back of the ambulance then I can get them there really rather quickly (sometimes the trick is getting the patient into the ambulance, but that is a discussion for another time). I have that luxury of being a very short distance from a fully equipped hospital. If I were to work in the depths of Essex then I could be an hour away from hospital, then there is more of an need to stabilise the patient before transport (or doing such work while on the move).

Someone once mentioned LATER – Load And Treat En Route. Something that I've done myself with 'naughty' jobs – for instance heart attacks; if the ECG shows a heart attack then I'll get going and do the rest of my treatment on the way.

I don't know where Dr. Crippen works, but I would guess that if paramedics want to stay and play it'd be because he's a long way from a hospital. I may of course be wrong, I would guess that there are those ambulance types who see themselves as 'masters of trauma' and will fart around if it gives them something interesting to do – I don't know any myself.

Strangely enough, and tying it back into the death of Diana, we find ourselves 'staying and playing' when there is a doctor on scene (most often from HEMS). We all have stories of HEMS** turning up when really what we would like to do is 'scoop and run' with the patient. Of course they do come in handy when we have that delay getting the patient into the ambulance for example when they are entrapped in a car crash.

So while I don't think that Dr. Crippen is wrong in the treatment of trauma patients, I do think that he doesn't understand the mindset of your average ambulance staff. This may be a wild generalisation but we know we aren't doctors (even though the government is making us cover for doctors). We know where the limits of our education are, you won't see us trying to do things that we haven't been trained to do, and I'll tell you why – it's because we are scared of being sued. We like a nice easy job, pick someone up, drop them off at hospital, everyone is happy. We don't wear our pants on the outside, because we sure as hell aren't Superman.

I agree that the study and cover of 'traumatology' in this country is awful and I don't think that it will ever get any better.

Finally the good Dr. mentions his bad experience with paramedics – I've got to say that the last few disecting AAA patient's I've seen, all the ambulance crew present recognised it for what it was and blued the patient into hospital, doing the BP and such-like on the way. But if I may be cheeky I'll counter his bad paramedic experience with my own story of the A&E SHO who was convinced that the patient was having an asthma attack when every nurse in the department (me included) was shouting at him that the patient was having a disecting AAA.

(Apologies for a hastily scrawled blogpost, but I'm extremely busy today)

*I may be wrong, this is just the impression that I get.

**Talk of the devil the noisy sods are circling my house at the moment.