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.