Wednesday, 16 January 2008

Unconvinced

Dr Crippen is back and an interesting discussion has begun already, as a result of an initial post on the events surrounding a patient with chest pain. To me it looks like that ambulance staff took far too long mincing around with a patient who clearly needed to get to hospital asap:

"The ambulance then sits in the car park for eleven minutes (just over)."

Dr Crippen also highlighted the nonsensical protocol driven aspect of getting an ambulance to a patient, it appears that the people who have the job of prioritising the transport have very minimal medical knowledge, this can result in very sick patients waiting at the expense of much more trivial problems. I have certainly experienced this first hand on several occasions, as transfers from one hospital site to another seem to carry a low priority for these protocol driven automatons, meaning that patients in extremis can be left on a knife edge for much longer than necessary. In fact Tom Reynolds, in his response to Dr Crippen points out yet another example of how managers with minimal medical knowledge are able to put an unfair pressure on events, an unfair pressure that then results in unnecessary delays in sick patients reaching hospital:

"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."

Tom Reynolds does make a strong argument for doing ECGs on patients with chest pain which I do tend to agree with, however the explanation of merely 'doing an ECG' does not explain some of the obstructive delaying tactics used by a increasing minority of ambulance staff. I have heard of several cases where patients with unstable angina with normal ECGs have been very inappropriately managed by ambulance staff, in one case instead of being taken to hospital the patient was dropped of at the GP's surgery and another ambulance had to be called. I have lost count of the number of stories, several of which I have had first hand experience of, in which ambulance staff have dangerously questioned the opinion of experienced GPs, resulting in patients nearly dying or having their arrival at hospital dangerously delayed. A pregnant woman with severe abdominal pain which turned out to be an ectopic, a man with an MI who had to drive himself in as ambulance staff refused, old ladies who were unable to weight bear with fractured necks of femurs left at home having being given a single dose of morphine; these are all examples of shocking bad practice that cannot be defended. I therefore think the problem of arrogance does not lie primarily with GPs. Of course GPs are not perfect by any means, however medico legally would these ambulance staff have a leg to stand on in court if they were found to be questioning the medical opinion of GPs? I think not.

I found the next two quotes particularly revealing, as they showed up some rather gaping problems in the ambulance service that should be addressed:

"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."

"The only other observation I would add is that when you were transferred to the 999 'pathway' with a patient presenting with chest pain then your call became an "A" cat response: we need to get someone to your surgery within 8 minutes (doesn't matter who - the station cat will do provided he can press the 'at scene' button) . Trouble is, in my service at least, you end up with me; the good 'ol solo responder. Once I arrive, the clock stops and we could all be waiting for hours for that 'back-up' ambulance. You remember, the one you actually needed in the first place. So to kill time (and to avoid being disciplined) I'll do an ECG and fill in the paperwork and we'll probably have time for a game of cards or two while we wait. At the end of which you'll be hopping mad and well behind with the surgery list. I usually suggest that the GP might like to complain."

"If you want to get an ambulance person ranting just mention ORCON, it's the '8 minute' target that was dreamt up by the government based on an out of date bit of research concerning cardiac arrests. A lot of the problems in the ambulance service, in my opinion, are based around this 8 minute target. Think of it as a QoF equivalent, only it causes more life threatening mismanagement of resources. Like sending out the station hamster, or leaving #NOF on the floor for three hours..."

Again we see how a target, based on out of date evidence and implemented by idiots with no medical knowledge and no ability to foresee how the target will result in changes to the dynamics of the system, can result in ludicrous acts of fudging the system with patients being no better off, if anything they are frequently worse off. The vast majority of ambulance staff do a very good job under exceptionally tricky circumstances, however the increasing empowerment of management with no clinical knowledge has definitely resulted in unfair pressures being applied to try to prevent hospital admissions, and this puts ambulance staff in an impossible position at times. If they disobey management they risk censor, but if they try to prevent appropriate admissions then patients will suffer, it would be an impossible job even with a medical degree and years of medical practice.

It's a hallmark of our Stalinist regime that instead of doing the work that needs doing and treating the sick, the government is instead putting it's efforts into bullying staff into making decisions for which they are not adequately trained, in an attempt to reduce the workload of the system. I just wonder if a patient had chest pain following trauma, would the ambulance staff still be obliged to do an ECG? If they were then it would show the ludicrous nature of these blanket rules, as this patient would simply need to be shifted to hospital as damn fast as possible, an ECG would add precisely nothing.

14 comments:

Tom Reynolds said...

To be honest, when paramedics are being hauled up before the HPC for being unable to stock an ambulance (because there are no such drugs in stock) crews that give morphine to a #NOF and leave them at home should be pulled up.

I can't imagine any of my workmates doing this, but if there are poor GPs, then there must be poor ambulance people as well.

Just don't tar us all with the same brush eh?

Garth Marenghi said...

I don't mean to and apologise if I do, I am a big fan of paramedics and the cases I mention are obviously a very small minority.

The problem is that the unfair pressures on ambulance staff from a conbination of management and government, mean that more cases like the above are likely to happen. I think the unfair pressures may result in even good man being pressured into bad decisions. The massice majority of the blame should go the the government for its short sighted and dangerous policy.

It's all part of the government's drive to shift more and more care to the home, the problem is that the more that this is done then the more a minority of patients will suffer.

You can get away with it most of the time, however when it goes wrong the results can be spectacular, that's why the pressures on ambulance staff should revolve around getting patients into hospital asap and not trying to avoid admission.

Part of the problem is that AE in this country does not have the capacity to deal with the amount of work out there, hence the pressure on ambulance services to reduce the workload passed to AE.

The government has also rrodgered OOH care in many areas meaning that even more strain is being placed on short staffed AEs.

The solution is simple. Scrap politically driven targets. Invest in increasing capacity so that AEs can cope with the workload.

The problem is that this would be more expensive that trying to avoid doing the work. Money talks after all.

Baby Blue Pyjamas said...

I work in an A+E/ ED department. We do ECGs on everyone who comes into resus, trauma, cardiac, pleuritic etc etc. I don't know if the ambulances do ecgs on trauma patients, i guess they try and get them to us ASAP, so we can mess around with ecgs.

kingmagic said...

As Tom has pointed out...if a Paramedic had given morphine at home and left the patient there then they should be taken to task.

But it sounds like only half a story...or a story that has had an attack of the "Chinese Whispers".

I personally cant see anyone doing something so stupid...but then I suppose there must be a few idiots out there!

The reason Ambulance Staff are being given the option to follow a differnt "Care Pathway" as regards to patients is simple....the vast majority who call 999 do not need to go to hospital.

If we took every single person that dialled 999 to hospital the system would collapse!

Again as Tom states, Ambulance Staff use common sense and experience with every job. We come up against appalling GPs all the time who manage their patients awfully.

The good GPs are brilliant and will manage the patient properly and give a good handover to the crew.

Dr. Crippen is right in his thoughts on requesting an Ambulance from control for transport to hospital. It can be quite baffling and somewhat patronising talking to control.

But he is wrong to not do an ECG and his excuses are lame. Going on his reasoning then the patient did not need an Ambulance but could have got a lift to hospital from someone else!

We as Ambulance staff know when to get a patient into hospital "ASAP" and we also know when to redirect a patient.

And we dont do it lightly...because if we get it wrong then we get the sack! We dont get a light rebuff (if at all) like doctors do!

I work with some great doctors and some great paras and techs. And we all agree that there is a lot of ignorance and very old fashioned ideas out there about emergency medicine.

One more thing...I agree with a lot of what Dr. Crippen has to say on matters health wise...but when it comes to someone questioning his actions then he reverts back to the sterotypical 1950s doctor that thought he was God and should not be questioned.

Mini rant over...

Garth Marenghi said...

Good rant,

I am inclined to agree with a lot of what you say,

I have worked in AE a few times and completely agree that a lot of 999 calls are very trivial indeed,

There is a problem area when ambulance staff choose to overrule a GP's decision,

I know there are crap GPs out there but I think one is getting onto very dicey ground in this area,

We are however all managed by the same bunch of power crazed numpties! I just wanted to point out that the pressures on ambulance staff are not fair.

Ambusam said...

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?

Garth Marenghi said...

Just to make sure there is no misunderstanding:

"Tom Reynolds does make a strong argument for doing ECGs on patients with chest pain which I do tend to agree with.."

I have made my opinion clear.

What I have tried to get across is that a minority of ambulance staff are being slightly obstructive when GPs want to get sick patients into hospital.

Anecdotally I have heard of some rather shocking cases, just as there are shocking cases of GPs mismanaging patients.

The point I am trying to make is that GPs are properly trained to work out when a patient needs admission, even though a minority are substandard.

However I don't think ambulance staff should ever try to overrule a GPs decision that a patient needs to go into hospital, they are not adequately trained to make this call.

This doesn't mean that sometimes they won't be right and the GP wrong, it's just about minimising error with sensible limits of safety.

Carl said...
This comment has been removed by the author.
Carl said...

I would beg to differ that 12 lead ECG diagnostics are contra-indicated in trauma patients. Whilst I would not advocate delaying transport to definitive care, there are certain specific ECG chages that raise the index of suspicion to thoracic trauma. That may then make the difference whether the pt is presented in a local DGH or a level I unit with a cardio-thoracic capability.

Garth Marenghi said...

Carl,

read what I wrote,

I didn't say that an ECG was contra-indicated,

I said:

"would the ambulance staff still be obliged to do an ECG?"

I was making the point that a protocol may state that any patient with chest pain must have an ECG done, however in certain trauma situations this would clearly be very stupid and dangerous.

Obviously there is a case for an ECG in some trauma cases, but I never said there wasn't, my point was different.

Tom Reynolds said...

Here's my take on the thought that we shouldn't question GPs about taking people to hospital.

I agree.

GP sees a patient and wants them taken into hospital, that's what I'll do - it's what I'm paid to do. I may inwardly roll my eyes if it's obvious that the GP is trying to 'dump' a patient because the surgery is closing, but at no point will I refuse to take a patient.

Hell, if a *patient* demands to go to hospital I'll take them, even if it means breaking another protocol.

A separate issue, and one you correctly put down to the lack of OOH cover is that of a Medic going to a patient and deciding that they shouldn't go to hospital. Even removing the problems that exist in the real world (lack of insurance, lack of backup from ambulance management, being really cheap to fire should something go wrong), I'm not sure why any seasoned ambulance person would want to do this.

This doesn't mean that I haven't left people at home if it's in their own best interests - but it still makes me nervous, and I have A&E nursing experience to back me up...

We now have ECPs who deal with minor injury and illness stuff - the ones I know I would trust completely, the reason being that they are very sure of what they don't know and will call for transport if they have even the slightest doubt.

What will be a problem is when ECPs and normal road crews start getting pressured to leave people at home because the trust gains £30 for ever patient not taken to hospital.

(Given the attitude of most ambulance crews, I think that we'd ignore any such 'pressure' and stick to what we do at the moment - which is take people to hospital).

Garth Marenghi said...

Well said.

Another big problem I have with OOH is this:

As services are more strecthed than ever, patients are now triaged over the phone without a doctor even seeing the patient.

I find this completely unnacceptable.

It would be very hard to defend oneself in court if one had never seen the patient in question, it is very very dicey ground indeed.

On the ECP issue, even the best GPs get caught out, I just fear for these guys, it's sometimes a very hard call indeed.

Also minor injuries can be very tough indeed, there are many small things that I think even pretty highly trained AE doctors get wrong a lot of the time.

It's a minefield out there.

the A&E Charge Nurse said...

Ferret - experts such as Dr Mortem are calling for protocols to avoid misdiagnosing meningitis in children.
http://www.thecnj.co.uk/camden/2008/011708/news011708_02.html

While the NCEPOD report 'Trauma: who cares ?' makes for grim reading - "almost 60% of patients in the study received a standard of care that was less than good practice", lack of experience during night shifts undoubtably contributed to avoidable deaths [p8].

One case study describes the gross mismanagement of patient with a head injury.
Admission GCS was 6, the patient suffered a tonic clonic seizure in A&E, yet it still took doctors 3hrs before he had a head scan and (incredibly) 5hrs before he was intubated - the patient died [p20].

The solution according to the enquiry chairman, Prof Treasure (chairman), yes, you've guessed it......... more protocols [p3].
http://213.198.120.192/2007report2/Downloads/SIP_summary.pdf

Maybe these luminaries are wrong and you are right ?

Garth Marenghi said...

AE charge nurse,

the problems you mention relate to either:

bad doctors

or

juniors being thrown in waters out of their depth

protocols don't fix these problems!

For example one place I worked introduced clerking protocols for all medical admissions. The good doctors' clerkings were made worse by the protocol and the bad doctors just left bit blank! The protocol did f*ck all of use.

The above problems would not be remedied by yet more protocols. If someone is running an AE dept on their own at night and they haven't a certain level of experience/qualificiations then protocols won't fix the problem!