Friday, 29 June 2007

Trust me I'm not a doctor

Given that I am subjected to so much vitriolic abuse when I try to argue that being adequately trained for ones job is very important, I will keep my opinion to myself and provide you with two recent clinical cases kindly provided by clinicians working in the coalface:

"I was working a weekend out of hours shift recently, a call came through from an ambulance crew. They had a woman who had central chest pain but her ECG was normal. Could they bring her in for me to review? (The nearest acute hospital to the OOH centre is over an hour away by road and the ambulance crew bring people in to the centre all the time for review much to my chagrin). I reluctantly agree but make them wait while I check her over. Before we can repeat a 12 lead they pop their head around the door saying they have to go back to base. I say no they have to stay until after ECG. They say tough their ECG was normal so not MI so no need for hospital and leave. Two minutes later 12 lead done by myself shows ST elevation in several chest leads. Call 999. They crew arrive back and don't believe me til I show ECG. But how can that be our ECG (done about 30 minutes before) was normal!? Little lady gets a blue light ride in the ambulance after all."

"Demented granny in a residential home has a fall. Refuses to weight bear afterwards. Ambulance called.

Friendly helpful reassuring paramedics come out and check her over. Leg is not shortened or externally rotated so obviously can't be broken. Matron feels she needs an x-ray as she has seen old people hobble round on fractures in the past. But paramedics patiently and condescendingly explain to her that if it was broken, the leg would be shortened and externally rotated, wouldn't it? Matron made to feel an idiot. Paramedics leave, saying she should call the GP to visit to assess pain control.

I visit. Patient is too demented to say whether or where she has pain, but all movements of her R hip cause her to scream out. Leg is not shortened or externally rotated.

This is happening time and time again. It has become an almost daily occurrence in our large practice that we are called back to an address following a paramedics attendance.

When will they start taking responsibility for their decisions? Is anyone auditing the outcomes of patients left at home following a call to the emergency services?

Once again, the wrong outcome is being measured. Number of patients "successfully" managed at home by paramedics counts for nothing if they are later sent in with a more serious condition after a delay."

I do need to point out that just because there are no ECG changes it does not mean that a patient does not require hospital admission with their chest pain. Any orthopods amongst us will also know that just because a leg is not shortened and externally rotated, it does not mean that there is not a fracture that requires surgical intervention; the inability to weight bear is it itself a fairly significant finding to the skilled clinician.

I will leave the rest up to you.


adam james pringle said...

On the other hand.....

...have you never made a mistake?

Most crews, most of the time, seem (to me) sensible and helpful. There are times when they defer to us (medical illness, by and large), and times when we should defer to them (in the field, most of the time)

If the crews view differs from mine, then I explain my underlying logic, which they accept. If I cannot justify why my plan is better, then I am a poor doctor.

Case 1: The decision to review was wrong, if the history was one of cardiav pain - as need -ve bloods AND -ve ecg to exclude MI

Case 2: Clearly inadequate training/experience - but that is how people learn fastest.

I bet neither crew makes the same mistake twice.

Garth Marenghi said...

The point I intend to bring up is whether the non-medically trained should be given this large responsibility.

Of course we have all made mistakes, however doctors are specifically trained for this decision making and other workers are not trained to the same extent.

I don't think many medically trained staff would be happy trying to prevent patients coming to AE, these decisions are often very tricky indeed.

If even the medically trained struggle, then the less trained are bound to struggle even more.

Henry North London said...

Unfortunately this kind of thing happens all too often.