Read this or Die
NHS hospitals are filthy, dangerous places, to be avoided if at all possible. But sooner or later, when you can no longer afford the private health insurance on your stealthily-Brown-shrunken pension, you may end up in one. But first make sure you get there alive. To maximise your chances of arriving there safely, best call a taxi.And now, for my non-medical readers, a little education.
There is a blood vessel in your body called the aorta. It’s about the thickness of a large garden hose. As you get older, and the aorta hardens and calcifies, it will sometimes develop large swellings. Occasionally, the layers in the wall of these swellings will rupture. We in the know call this a ruptured aortic aneurysm. You can call it, “Oh shit, if I don’t get to a good vascular surgeon in 30 minutes, I’m dead.”
It is not difficult to diagnose a ruptured aortic aneurysm - provided you have popped into medical school for five years and done a few years post-graduate training.
Oddly, although patients are rapidly ex-sanguinating (that’s bleeding to death for you non-medics) because the blood is trapped in the abdomen, the increasing pressure for a while slows the blood loss down and blood pressure is maintained. Even more oddly, putting a drip up on the patient can make them worse.
God, the things they teach you at medical school.
“Hadn’t we better put a drip up?” said the young paramedic.
“No. Just put him in the ambulance. Put your little blue light on and get him to hospital as quickly as you can. The surgeons are expecting him.”
Albert was 73. He had had severe lower abdominal pain for several hours. The pain was getting worse. It was radiating through to the lower back and down both legs. He had a large, pulsatile abdominal mass. The only comfortable position he could find was standing behind a dining-chair, bending slightly at the waist, supporting himself with his hands pressed hard against and squeezing the top of the chair. The diagnosis was not in doubt. His aorta had been dissecting and was now ruptured.
"No it's not a slipped disc, no it's not sciatica" I shouted at the paramedic.
“I’ll just take his blood pressure and do an ECG.”
“His BP is irrelevant, but happens to be normal. He doesn’t need an ECG. There isn’t time for a drip and it won’t help. He’s ruptured an aneurysm. Please, pleae, please just take him to hospital. Now!” I said, probably rather curtly.
The ambulance left. Albert was accompanied by his nephew. The paramedics were not happy. I had insisted they deviate from their protocol. But not for long. Albert’s nephew told us that once the ambulance had got round the corner out of my site they stopped, did an ECG, attached Albert to a monitor and put a drip into the back of his hand. That took 20 minutes.
The old fashioned ambulance man was the Dixon of Dock Green of the health service: solid, reliable, calm and sensible. He never lost sight of his primary function, which was to get the patient to hospital alive and as soon as possible. The modern paramedic is a different beast altogether. He has been given a little training by doctors in white coats. He has machines to play with. He features in Holby City.
The paramedic may find his forte at the train crash or road-traffic accident. But the paramedic called to an elderly patient’s house by the family doctor brings protocols that may be embarrassing or even dangerous.
Albert collapsed as the ambulance arrived at the hospital gates. He was clinically dead by the time he reached Casualty.
Albert would have died anyway. Probably. But possibly, just possibly, if those paramedics had understood the implications of a dissection or had simply taken the word of a country-bumpkin GP, he might have had a chance.
I complained. Bitterly. The paramedics came to see me. They wished they had taken him to hospital more swiftly. But that was not how they had been trained. “We have our protocols!” The protocol gave no leeway to take advice from the GP on site. Lack of white coat, I guess. “You can’t expect me just to act like an emergency taxi-driver,” one said.
But that is exactly what was needed on this occasion.
The health service is dumbing down and is now being front-ended by under-trained, protocol driven, well-meaning amateurs. I shall be returning to this topic frequently over the next few months.
16 Comments:
I think you're being a bit rough on prehospital workers mate.
I haven't been in the ambulance service long, but I've already been to several cardiac chest pains sitting in the GPs waiting room (no GTN, aspirin, oxygen, IV cannulation or ECG).
Even when I was just in lowly events I came across a collapse off duty, with a nurse and doctor on scene, and I was the only one to take a pulse.
There are ambulance officers who deal inappropriately with conditions a doctor has recognised and there are GPs who move onto the sore throat and leave the MI in the waiting room.
Our station is 45 minutes transport time from hospital - most officers in most cases apply Load And Treat En Route and minimise scene time.
[reposted for blogger]
I think you are being a bit generalised about Paramedics I,m sure you have a bad experiance with a new paramedic (or Paragods as I like to call them), But in general we (paramedics) have more than a smattering of appreciation for the predicament you found yourself in and certainly would not have delayed that patients transport. Don't tar us all with the same brush because we all have experienced problems with doctors in the pre-Hospital environment, but I certainly would not give them a public slagging, try getting involved with the Paramedic Training teams in your area and you will have a better idea.
Were you frightened by an ambulance as a child? Perhaps you'd prefer the sort of ambulance staff who wear caps and tap it in salute at every doctor they see.
This is the first time I have felt compelled to write anything on the web.My heartfelt sympathy extends to the family of the patient involved and I hope it is not disrespectful to suggest that the prognosis of such a condition is poor,even if diagnosed in theatre with all hands on deck. I can sympathise with the Dr`s annoyance at what he perhaps deems as`insubordination` by the ambulance staff, and that their actions were in someway `defiant` of his wishes.In this instance,with the facts ,as told by the Dr., and the unfortunate events that ensued, I do believe the Dr. to be correct in his diagnosis. I would like to remind him, however, that he is NOT a paramedic. He ,therefore, has little or no understanding of the social role performed by the modern ambulance service which, ironically, is stretching itself to the limits to absorb the role that all too many GP`s are `opting` out of covering; with, I hasten to add NO financial remuneration. He does, however, have some understanding of the protocols that must be adhered to. At the risk of adding credence to and indeed perepetuating the very public criticism of fellow NHS employees (that the Dr. in question seems to have little difficulty in commencing.) I would like to point out that in the first week of March
this year I encountered 3 AAA`s. One of which was treated as a PR bleed by a GP (with no haemorrhage!) and sent to a GI Bleeding unit,this was correrctly RE-diagnosed by the ambulance crew to a AAA (at which point they `put on their little blue light`)and redirected to A&E .Unfortunately, too late for the patient. The 2nd was left as an urgent call and not a 999 by the GP.(perhaps he was too considerate and unfamiliar with the call gradings). The ambulance crew arrived (some hours later) to a man in agony, alone. Fortunately, by the grace of his tenacious tunicae, he survived. The third, a collapse in a GP surgery car park where the patient was en route for an appointment to discuss the discovery of his aneurysm. Gp `columbo` at work (although flustered at a spot of trauma in his clustered car park) was spot on. Rapid removal from the scene was dutifully carried out.Unfortunately the patient died en route to theatres from A&E. The point I make is this. After briefly reading through the Dr`s blog, i find his awareness that (6th June)-`GP`s are universally hopeless in traumatological situations`. He elaborates quoting the BMJ "Doctors[no specification of role-Quoted in BMJ] have tended to overestimate the skills of Paramedics{in diagnosis}". I feel that many would agree that the contrary is the case, Paramedics skills are grossly underrated by GP`s and the skills of GP`s are quite overrated by Pre-hospital workers,initially. Perhaps `please take him to hospital now..` would be treated with more credence had GP`s (I hasten to add,thankfully not every GP) not routinely admitted every patient they could by ambulance to a medical receiving ward (with the family following the mobile patient in their car!) in order to protect their jobs, rather than actually doing their jobs.This detracts from the very reason of the ambulance service-namely dealing with trauma.Quote- "for my non-medical readers"-the next time it takes 50mins for an ambulance to arrive, you may well indeed ask`were you on a Dr`s call?" . An interesting study awaits for the AMAU admissions from GP`s that may easily be treated at home.
I would like to reiterate that the case in discussion is not called into question nor is the diagnosis, but I felt personally compelled to contribute in order to facilitate a different, and very real perspective on these matters. I am reminded of the axiom told to heavyweight fighters by good trainers "Don`t brag about your last fight, `cause you`re only as good as your next one". One thing Medicine has taught me-is that you are only as good as your last diagnosis. Pride doth indeed cometh.
I would also like to give my gratitude to the Dr. concerned for remaining within the sinking ship that is the NHS!
Yours,
Concerned.
Well. Dr C clearly thinks along the lines of Kenneth Clarke the ex-Tory Minister who described Ambulance staff as "glorified taxi drivers". I find Dr C's comments patronising, insulting and ignorant. I have served 17 years with my local Ambulance service with 13 of them as a Paramedic. We now belong to a nationally recognised professional body which requires us to provide proof of continuous professional development in order to retain our licence to practice as a paramedic. Our role is also developing to include graduate-level Emergency care Practitioners, taken from paramedic staff within the service, whose skills and knowledge base equip them to make accurate diagnoses, prescribe appropraite medication, provide suitable treatment at home for minor wounds i.e suturing and liquigel skin adhesive, (when was the last time a GP sutured anything)? They can refer patients to clinics. They arrange admissions direct to appropriate wards or refer people to other care bodies such as social services. (Sound familiar Dr.)? This has all come about in response to a growing need for some of the out of hospital treatment the GP's used to provide, that they no longer feel inclined to. Trying to get a GP visit is well nigh impossible in this and, i suspect, many other areas, thus abdicating their responsibilty for the patient who, by being registered to them, is under their care. Even during surgery hours GP's first instinct often is to respond with "well, seeing as you're there, you might as well take the patient to hospital". Or even, as was said to me recently by a GP I have great respect for, "you guys are better than me at treating chest pain". I am not making the sweeping judgements about GPs that DR C is making about paramedics because I have the wherewithal to recognise NOT ALL GP'S ARE THE SAME... neither, Dr, are we. Dr C needs to be careful in his judgement of his fellow health care professionals as I doubt he sees much of what really goes on in the average ambulance workers life. Fair enough, there is evidence that, in a cardiac arrest scenario, the patient has a better chance of survival or at least regaining some cardiac output if CPR is carried out by technicians rather than paramedics because tech's have no responsibility to give ACLS drugs and therefore tend to scoop and run doing effective CPR in the back of a moving vehicle en-route. (No mean feat in itself). I would also like to point out that we are required to follow a nationally agreed set of guidelines and, yes, drug treatment protocols, known as JRCALC, (Joint Royal Colleges ambulance Liason Committee) which is our bible. Now, here's the rub, it was set up and is reviewed by a committee made up of a number of health care professionals including Consultants and GP's.
I am sorry the good Dr. has had a poor experience with the incident he describes but, let he who is without guilt cast the first stone.
P.S. Our blue lights are actually quite big!
The situation of mutual incomprehension here higlights one of the problems with relentless adherence to protocols, competencies, box-ticking, hierarchy etc etc in ANY profession (and I am including doctors AND paramedics). This is that "protocol-ism" tends to fossilize through misuse peoples' ability (an incredibly important but underestimated one) to tell - from what some other professional they are dealing with is saying - "does this person (i) know what they are talking about; and (ii) know more about this than me".
This is an absolutely key ability. As Dr C's column indicates, a paramedic crew who can't twig that the on-site doctor is a pro and thus second-guess him by rigid protocolism are not helping. On the other hand, a GP who never worked in A&E and who hasn't seen trauma in 15 yrs might sensibly defer to a clued-in and up-to-speed paramedic crew in managing an emergency scene.
The key thing is for people to recognise when they are on sure
ground and when they are at the limits of their know-how. If they all communicate and have enough insight to see whose experience is the more relevant, a lot of name calling could be saved.
Strange, I saw Michael Moore's "Sicko" and it seemed like NHS hospitals were clouds that broke directly off from heaven!
He also made our Canadian health care system seem like something I'd actually want to be treated in.
Good thing I know what it's actually like.
By the way, it's a shame that paramedics are bound by their protocol when in this case, obviously, following protocol could be what cost the patient his life.
It's also a shame that you're taking so much flak for suggesting the paramedics not follow their protocol.
Paramedics haven't been bound by protocols for some time now.
They just don't react very well to being spoken to like idiots and expected to take a patient over without checking them. There's a dead easy way of making sure that a crew will do exactly what you want them to do, get in the back and ride in, then you can take the wrath of the A&E Consultant as you explain that you haven't done any obs or secured IV access or given effective pain relief on someone at risk of blowing their aorta. It's so much easier to cannulate them while they still have a circulation.........
Several of the posts I've read recently by John and Garth have been so incredibly insulting to my colleagues that it's surprising that the backlash hasn't happened before. Constant use of 'Taxi', 'Ambulance Driver' etc is calculated to get a reaction and indeed they do.
If you want a taxi, then call a taxi. If you want an ambulance then call 999 and be prepared to have to give a handover that takes account of the fact that the crew are responsible for the patient while in their care.
SD
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We had a routine non-specific low back pain patient at the surgery recently. The abnormal pulsating in his abdomen alerted me. I got a second opinion, then a third - an acute need for a surgical opinion developed as I believed we had found a AAA prior to dissection. Paramedics refused to take the patient due to them thinking that the patient had 'gas'. After a great deal of 'discussion' they reluctantly took the patient whom, some hours later was having his AAA repaired.
It's not a difficult one to comprehend.
JH
I find JH's comments truly bizzare, the Paramedics 'refused' to transport a patient diagnosed by another medical professional with AAA?
I'm not entirely sure what it's like in the rest of the UK, but in my neck of the woods we can't refuse to transport ANYONE, including the local regulars who's get sloshed and complain of anything and everything that springs to mind - i've had to transport bloody conjunctivitis before now.
So I find it pretty implausible that an A&E crew would refuse to transport anyone for any reason from (presumably) a GP's surgery - and certainly not a condition such as AAA - and we tend not to question diagnosis either ....so....
Was the situation explained to the crew ?
Was it a Paramedic crew and not a double EMT crew ? (although even EMT's would understand the implications)
Was IV access established, was a basic set of baseline obs performed, was analgesia given ?
Was the job booked as 999 or an urgent detail? do you know the difference ? Did you assume it was OK for the patient to sit for hours for a crew like the 'Urgent' I took into resus yesterday?
Having dealt with an MI at a local surgery, I was mortified when getting on scene the GP asked me to walk the patient to my RRV, having done no baseline obs, or even a rhythm strip ...because she wanted to see her next patient
Needless to say, no oxygen on, no aspirin given, no BP and therefore no GTN ....pulse was an estimated 79 which was interesting because my estimate was 51 ...more plausible given the patient was on beta-blockers
I mean this GP wouldn't even do a manual pulse check and we're supposed to doff our caps whenever doctor incompetent has booked someone to an MAU because he's working on his golf handicap and can't be bothered doing any real work?
I wonder how many jobs that crew had been to where a GP had been so very very wrong it was embarrasing ...like the CVA at a nursing home last year which turned out to be a Hypo? GCS 15 and laughing and joking on arrival at hospital thanks to a bag of 10% dextrose.BM too hard after 6 years of med school?
Or the RRV and dual manned ambulance thrown at a GP's surgery several months ago for a girl with an STD?? It can be embarrasing for everyone when you have to ASK who's ill !!
I could go on, but I think the point is made, people in glass houses shouldn't throw stones
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