The Crippen Diary - 2008 : January (2)
What do you want to do when you grow up...January 2008 (2)
Once again, the best and worst of the modern NHS.
Last Thursday I arrived for work at about twenty to eight, to find Andrew and his wife, Mary, already waiting. Andrew is 71, retired, in good general health though he has (well controlled) hypertension and (well controlled) hypercholesterolaemia.
He looked well, and smiled as he sat down. He gave a history of three attacks of severe indigestion, two during the night and one whilst having breakfast this morning. Andrew is an intelligent man. He knew this was not indigestion. The history was the kind of text book angina that makes one want to run out and find a medical student and say “listen to this.” Andrew was now free of pain, with a normal heart rate and blood pressure. He is already on aspirin and had indeed taken it that morning with his BP pill.
This was classical unstable or crescendo angina and Andrew needed to go into hospital. He was not surprised. Mary was, but started fumbling for her car keys. The local hospital is three miles away. Now one of those taxing general practice moments which we all dread.
“I will get an ambulance” I said
Mary looked shocked and panicky. “But we have just driven down here and have been sitting in the car park for fifteen minutes”
I know, I know, it seems melodramatic, but I can’t take the risk that Andrew might have another attack on the dual carriageway. So I call the ambulance service. A very friendly operator answers on the second ring. I give all my details, my code number, then all Andrew’s details, his address, date of birth and then I am asked "the question". The same glorious question I am always asked read, as always, from the protocol.
“Is there a medical need for an ambulance?”
I resist the temptation to say “WTF do you think I am phoning” and merely say, “Yes.”
Even now, I know that there is about to be a problem. What is your provisional diagnosis? The word "provisional" is irritatingly gratuitous. “Unstable angina”. Silence. Operator switches to a different protocol. Do you want an immediate ambulance? Well, I certainly do not want to wait two hours, but this was not dire enough for me to have dialled 999. “Yes, please, but you don’t need to arrive with sirens and flashing blue lights”.
There is no such option on the protocol sheet and so my request is ignored. I am switched to the 999 “pathway”. I am told that the ambulance is on the way but I have to answer some more questions.
"Are you with the patient?" Of course I am. “Is the patient conscious?”. Yes, of course he is, if he was not, I would have dialled 999. In fact, he is sitting in front of me smiling. “Is he breathing.” “Has he changed colour.” And so it goes on. These are the 999 protocol questions for the layman. They are not questions for experienced doctors but they are always asked and have to be answered. By the time I get to the end of the ludicrous questionnaire I can hear the siren and soon I see the flashing blue lights through the window.
I go out to meet the paramedics. Two very keen young men. I give the history to them, and tell them the important things. Andrew is pain free, stable, in sinus rhythm, with a normal blood pressure. Then we have to play the ECG game.
“Have you done an ECG, doctor.”
“No”.
“Do you have an ECG in your practice?”
Tempting to say mind your own business, or ask if they have oxygen in their ambulance. We have both an ECG machine and a defibrillator but neither has been needed, thank God. It is not possible to make paramedics understand that it is not necessary nor even helpful in this situation to do an ECG.
“Why on earth would I want to do an ECG?” I ask
The paramedics look at each other and back at me. “To see if he has had a heart attack, and to see what rhythm he is in.”
I know what heart rhythm he is in (well, OK, he could be in steady atrial fibrillation or even compete heart block but it is not likely) and you cannot exclude a heart attack at this stage by doing an ECG so, whatever it shows, he needs to be in hospital. Might as well just take him. We are not on Dartmoor. The paramedics do not carry clot busting drugs. The hospital is only a few minutes away.
The paramedics huff and puff.
Andrew refuses to get on a trolley and insists on walking to the ambulance. The paramedics do not like this and huff and puff some more. I keep a straight face. Not a sign of schadenfreude from me.
The ambulance then sits in the car park for eleven minutes (just over). I timed it. Stay and play. Do an ECG. Follow the ritual. The ambulance service insisted on sending a blue-light ambulance which, all power to them had it been needed, arrived in less than five minutes. They then waste eleven minutes doing unnecessary tests. Stay and play probably killed Princess Diana. Fortunately it did not kill Andrew.
He arrived at the local cardiac unit a few minutes later, alive and well, and still pain free. By mid afternoon he had been fully investigated, ECG, blood tests, angiogram and stent. He was discharged home the following day.
Click to enlargeAndrew has almost certainly been saved from a full blown heart attack or worse. He appeared at the Health Centre at 7.40 am and thirty six hours later was back at home, well, stented and pain free. Whatever one may think of protocols and government targets, this is an excellent outcome.
Criticisms? Well, a few.
Andrew was in and out of hospital so quickly that he did not really take it all in. I had to spend half an hour translating all the medical jargon on the discharge summary and explaining the medication to him. Mary was still frightened and wanted to wrap him up in cotton wool. And I hate doctors who are too frightened to use their own name. The “cardiology team” is not a consultant.
But, all in all, a good result. I wish they would treat psychiatric emergencies in the same way, but hearts are glamorous. The mentally ill, apart of course from Stephen Fry, are not.
34 Comments:
As part of our portfolio of clinical experience we have to go and speak to patients on the ward and write them up as sort of a practice clerking, we also have to take down their CHI number (unique NHS number) ward no, their consultant and the date and time when seen- so the med school can verify the patient actually existed.
If we are being taught to take down all these details why is it acceptable to write to a GP under the guise of cardiology team- surely you would like a name of a doctor to verify your patient actually saw one.
A thoroughly absorbing post as usual Dr C.
One question: do you have a view on the policy to perform a pre-hospital ECG on ALL patients with symptoms suggestive of angina, since increasingly this will determine if they so straight to cath lab, [and not A&E] if there is ST elevation on the 12-lead ?
The Trust I work in offers angioplasty (24/7) so ambulances often bring patients from slightly further afield on the basis of the intial ECG - these cases are taken literally from the back of the ambulance into the cath lab [A&E no longer routinely provides thrombolysis for MIs, and we only tend to see patients who collapse/arrest en route].
Some ECGs are misinterpreted by the crews [high take off, widespread ST elevation because of pericarditis, etc] in which case they are taken to the medical assessment ward]
But this approach is being hailed as a great success where I work, and thrombolysis for CVAs is also dealt with in "special suite" [but stroke patients do go to A&E first, then for a C/T head, [which according to the dreaded protocol] must be organised within 30mins - it's all part of Darzis great plan I'm told ;o)
How irritating to have to deal with such peasants on a daily basis - how tiring. I can tell you how tiring and irritating it is to patients who present with symptoms that require more than the usual - 'probably nothing' response. My husband is now waiting for a scan, which is being chased by his consultant - our GP interpreted his blood test results as being 'normal', when they are anything but. Symptoms dismissed two years ago are part of a bigger problem, and I am very ANGRY and UPSET that he has had to spend time CHASING and being assertive, just to get further investigations that were paid for by his company insurance.
There are bigger issues to get upset about - if the local Ambulance service has a policy of doing an ECG before taking a patient to hospital than either accept it or complain to them. Personally I wouldn't've wasted time in seeing how long it took them. Surely you have bigger fish to fry??
Dr Crippen,
It's the misunderstanding of (a) Ambulance culture, (b) Ambulance policy and (c) Other policies.
As you are expected to do things by the PCT (TWR springs to mind) likewise as ambulance types are expected to ECG all chest pains, otherwise we get disciplined.
As A&E Charge nurse says, this is partly for the redirecting to Cath lab - I've done it with a local GP myself, GP wanted patient to go to hospital for angina, turned out he was having a STEMI so we took him to the Cath lab.
It's also because if we *don't* do an ECG with a chest pain and the patient dies - it'll be me up before the Coroners court.
I'm easier to fire than a GP. So I make sure everything is done how my bosses want it done.
The computer system that you are put through sounds like the one in London, designed in America to stop people from suing ambulance services.
It is daft, it is useless and it is mandatory for the calltakers to follow it to the letter. Otherwise...yep, they get disciplined.
So there you go - the reason why we do things (and again, 'walking a chest pain' is an offence that could lose me my job) is because we are forced to. Unlike doctors we have very little ability to fight back against silliness from the people above us.
But, all in all, a good result. I wish they would treat psychiatric emergencies in the same way, but hearts are glamorous. The mentally ill, apart of course from Stephen Fry, are not.
Now I just KNOW I'm going get flamed for saying this.
That post you link to as a "psychiatric emergency" (from last week's diaries) is no such thing. It is a drunk bloke turning up in A&E with some superficial cuts on his arm that he did because he was pissed. By your own description, this is something he does regularly when he gets drunk. That is not a psychiatric emergency.
If the A&E had asked for a psych assessment then the psychiatrist would have immediately refused to assess him until he's sobered up (this isn't laziness - there's no way to accurately assess someone's mental state when they're drunk). By the time he's sobered up, he'll almost certainly have left the A&E of his own accord anyway - and with no indication that he's any risk to himself or others, there's no way to keep him there. Assuming he does stay until he's sober, then unless there's been a deterioration in his mental state then there's no way to get him admitted.
And assuming he was admitted, what would that achieve? It might have given him "a bit of a break", as you suggested (although that is not what acute wards are for) but it might just as easily distress and inconvenience him by yanking him out of his home and onto a ward.
So, with a patient who is (as far as we can tell from your description) expressing no suicidal intent and no psychotic symptoms (acts of deliberate self-harm are not necessarily in themselves symptoms of mental illness), the A&E were entirely justified in sending him home.
As for your question from the original post of "What is David’s curmudgeonly GP to do now?" Well, I would suggest maybe dropping a line to either his CMHT or the crisis team asking if someone can pop round and check on him. They can assess him in the cold light of day once he's sobered up and had some sleep. If he's becoming actively psychotic then they can further assess him for either home treatment or an acute admission. If he's not become psychotic and it's no more than something he did when he was drunk...well, maybe an alka-seltzer would be in order.
But of course, I'm just an ignorant nurse who doesn't know what he doesn't know....except that I showed the original response to a psychiatrist and, as I suspected, he pretty much said all of what I've said above.
The guy described would never have been admitted to an acute ward. Not now, not in pre-New Labour days. And that's not because of protocols or targets or nurse quacktitioners or anything like that. It's because an act of superficial, non-suicidal self-harm that someone did when he was drunk is not a psychiatric emergency.
Tom has, as usual, put the ambulance case succinctly. 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.
P.S. did the call taker at Ambulance control ask you to "put the dog away before the ambulance arrives" ? Its on the protocol sheet.
Dr C -
I have say as a medical reg that a baseline ECG helps an awful lot sometimes. We have to cover the what ifs and in this case there is an obvious and pretty common one. That is: what if hew gets more chest pain on the way to AnE or even in AnE? Then I really would like to know whether the LBBB or ST elavation are new since he saw you. It takes some of the uncertainty out of possibly killing the guy with thrombolysis. Not all of us have 24 hour cardiologists to finesse their way through the arteries. Most of us have an SHO or if they are a little luckier an SpR.
I would ask as a favour, please spend a few mins doing the ECG whilst you wait for the LAS etc... It might not help you, it might help me but more importantly it may help the all important health care consumer........
Dr Sniper
Magwitch, thank you, you said:
...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.
P.S. did the call taker at Ambulance control ask you to "put the dog away before the ambulance arrives" ? Its on the protocol sheet.
++++++++
to take that in detail:
(...when you were transferred to the 999 'pathway' with a patient presenting with chest pain then your call became an "A" cat response)
I did not ask, nor did I wish, to be so transferred. I was in control of the clinical situation and prepared to take responsibility for my decisions, and I don't want to be ruled by some telephonist following an "a" cat response protocol
(we need to get someone to your surgery within 8 minutes)
Too silly for words. Do you not have insight? You need to get someone to the surgery on a timescale that the clinician in charge of the situation determines appropriate.
And why 8 minutes. Why not 6. Or 9. Mechanistic botty wipe.
(doesn't matter who - the station cat will do provided he can press the 'at scene' button).
Ah...I begin to understand. You are taking the piss from the protocol too.
(Trouble is, in my service at least, you end up with me; the good 'ol solo responder.)
Ah....you must be the "man on the motor bike. Can't tell you how glad I was when your alter ego rolled up after my 999 call when I was trying to treat a man in status epilepticus. I did write it up.
(Once I arrive, the clock stops and we could all be waiting for hours for that 'back-up' ambulance.)
Brilliant. I love you more and more. Just like the government protocols. As you imply above, you sent the station hamster, but as long as he is there, all is DEEMED to have been done.
(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.)
Excellent. I shall come out and have a coffee with you in the ambulance and write up some high earning QoF data describing how I have checked the cholesterols of all the 92 year olds in the OP home.
(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.)
We need to have a pint together. You are someone with insight. I have never complained about the ambulance service because, by and large, it is bloody good. But it is the protocols. It is destroying those of your colleagues who do not have your insight
(P.S. did the call taker at Ambulance control ask you to "put the dog away before the ambulance arrives" ? Its on the protocol sheet.)
Love it. I'll buy the first round.
John
Doctor,doctor, you are back! I am so glad!
Anya
A few quick comments John:
When I was a house officer we used to write The Cardiology Team on our TTOs (in fact I started the practice) as the firm was shared between 4 consultants. All 4 might have seen a patient during an admission. Possible explanation.
"Andrew was in and out of hospital so quickly that he did not really take it all in."
I know you're not suggesting we keep people in longer to explain things more clearly. Without PCI Henry probably would've stayed his requisite 5 days, but so often this is unnecessary after a small NSTEMI.
A&E charge nurse we also offer 24hr primary and 3hr stroke thrombolysis, but I find myself in agreement with Dr Crippen - the 12 lead need not have been done at the surgery. Tom I'm also aware of your protocols, but could the ECG not have been done early in the ambulance in this case? In my experience LAS traces are better than ones from GP practices(!) The med reg above is right, but surely as long as there are a series of ECGs over the course of ongoing chest pain that is enough to establish dynamic changes?
Rohin - I never expect a GP surgery to do a 12 lead ecg. They never seem to have the kit to do so. I;m reminded of a GP 'Chest pain' where the Dr. was querying an MI. I told the GP that we would ECG in the back of the motor and decide on 'nearest hospital' or 'nearest cath lab'. GP was surprised and impressed and came out to look at the ECG himself. A nice job. so, yes, I meant do the ECG in the back of the ambulance.
Crippen - 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...
Also "I did not ask, nor did I wish, to be so transferred. I was in control of the clinical situation and prepared to take responsibility for my decisions" - unfortunately our Control don't know that, and realise that we'd be the *first* people to get sued if it all went wrong - "I watched my mum die in GP Surgery while waiting for ambulance" would be the headline. So it's a case of covering our arses I'm afraid. Silly, but there you go. Not every GP is as willing to take responsibility as yourself.
Unfortunately we aim to cover for the lowest common denominator. Which is a real shame.
Remember - policy is set by lawyers, not by people who actually have a clue.
The point is that this guy had toi wait 11 minutes while something that didn't affect his management was done, this is stupid.
The ECG should be done en route and should not cost the guy minutes of mincing.
Most doctors have also heard of cases where paramedics refused to take patients in as the ECG was normal, even though the clinical situation merited an admission.
This is indefensible.
Here we have a case study of New Labour's crap policy and how stupid targets mean that patients get crap care.
Garth - You can't do an ECG while moving, the movement of the engine and the vehicle will make it worthless.
I'd also be surprised if an ambulance person refused to take a patient for *any* reason, not just GP sourced calls. It's not the way we think, we aren't stupid and anyone doing that would be out of a job quick-smart.
So, [Citation needed] please.
Also a lot of the targets come from governments previous to Labour (although they haven't helped things).
Dr C - your comments in response to Magwich's were unnecessary and unkind. He's as much a cog in the wheel as you are. As Tom points out, many of the practises you deride are part of the Ambulance service protocol, not dreamt up by the personnel who staff it. There are reasons for this protocol - if you disagree, maybe your efforts would be better channelled at challenging the policy makers not the delivers of the service you have requested.
I, like you, am extremely pricipled and will fight my corner to the bitter end - sometimes you need to suss out the battles worth fighting and those over which you will never have any influence, and save your energy for those you can win! :-) It's also much more satisfying!
Garth, like Tom I find that statement incredulous. I've done my time in A&E and never heard of a paramedic refusing to take someone to hospital.
I see what you mean Tom, thanks for clearing that up. I have heard of ORCON. These arbitrary figures make everyone's life hell. As you say patients can suffer, the hospital equivalent obviously being the 4-hour A&E wait which causes a lot of patients to be shifted elsewhere half-cooked, when they need to stay in A&E. Where did the 4 hour number come from? Probably the same place as your 8 minutes.
I think we're agreed targets can be stupid. But thinking further about it, what are the alternatives? I know the gut reaction is to say "everyone should use their heads" but as Tom says, sometimes there's not a lot in someone's head. Yes it's 1/1000 times, but it could happen. I hated the 4 hour rule with a passion, but I'm told by nursing staff that it put pay to people sitting in the waiting room for 12 hours. A target/protocol to do an ECG for a chest pain prior to departing may waste time, but it could alter outcome.
It's a tough call.
Citation?
Well GP called ambulance for a patient with chest pain, ambulance then went to patient's home and did an ECG which was normal, hence dropped the patient off at the GP practice!
In the end GP called another ambulance and it turned out to be an MI.
Not saying this is typical behaviour, but there are increasingly frequent stories from GPs who are coming up against a lot of resistance, from people who are significantly less qualified than they are, when trying to get patients into hospital.
I know of several cases of late directly. One MI and one ruptured ectopic that the ambulance crew argued with the GP that they didn't need to go into hospital.
You are frankly living in cloud cuckoo land if you don't think this is a problem.
The government is trying to save money by preventing people who need hospital from going to hospital.
It's a disgrace.
I've responded to this post on my own blog. Dr. Crippen, I welcome your comments.
http://randomreality.blogware.com/blog/_archives/2008/1/16/3468578.html
http://ferretfancier.blogspot.com/2008/01/unconvinced.html
my response
Dear God Doc, have you been appearing on a follow up to life on Mars? The Beatles have broken up and medicine has moved on. Many GPs are idiots who wouldn't know an MI from a chest infection. The ambulance service in your area has to deal with them as well as you, also many have their reception staff call for an ambulance hence all the questions. You booked the vehicle for a patient with chest pain symptoms, whilst an ECG cannot rule out an MI independantly it can diagnose one when combined with chest pain. Please understand that paramedics are medical professionals who know their job. They may be less qualified than you but they are the experts in prehospital care. If you don't like the systems set up by your local service then write to the medical director and wave goodbye to your arse as he/she masticates on you.
Ferret, your comments suprise me - surely the pre-hospital ECG does affect management ?
That seems to be the point (amongst others) that Tom Reynolds is trying to make.
ST elevation results in the cardiologist/cath lab receiving the patient directly from the crew (where such services exist).
Non-ST elevation, which of course does not exclude an MI, and the patient is taken to A&E, at least to begin with.
Presumably Dr Crippen did not think his patient was acutely infarcting, otherwise he would have simply called 999 for a blue light ambulance and administered first line treatment (aspirin/oxygen +/- GTN ) while waiting for the crew to turn up - but as you know 20% of MIs present atypically.
If a prehospital ECG reveals elevated ST segments then the case would certainly be blued in, and the A&E resus team armed with a thrombolytic can prepare to recieve the patient (assuming, of course that angioplasty is not an immediate option).
This sort of forewarning is incredibly helpful, remember, minutes = muscle.
You do an injustice to paramedics when you accuse them of "mincing".
I refer you to Mark Witbred and Fiona Moore LAS who i'm sure would be over the moon in discussing your feelings on the actions of this crew.
The paramedics do not thrombolyse in Dr C's area, a point he made clear in his piece.
The patient needed getting in asap.
The point Dr C was making was that it would have been much quicker to blue light patient in straight away and do ECG when possible. Sometimes those few minutes will make a difference.
A rhythm strip could also be done en route.
Anonymous 6.17 says "Many GPs are idiots who wouldn't know an MI from a chest infection."
And what is your designation, pray tell? It is only fair that I know your profession or job so I can slag you off without any evidence. Where is your evidence?
Indeed Matt,
it's funny that this kind of statement can be written:
"Many GPs are idiots who wouldn't know an MI from a chest infection."
while often his kind of person is trying to justify the empowerment of people with much much less education and training than a GP
I sense a gap in the logic.
EKG shows acute MI -> Supportive care, transport to hospital.
EKG shows myocardial ischemia -> Supportive care, transport to hospital.
EKG normal -> Supportive care, transport to hospital (given clinical condition).
The decision process is affected by the EKG results HOW?
John
You haven't been reading the above posts have you medicine man ?
Pre-hospital ECG = ST elevation infarct ?
Then paramedics alert cath lab directly so the cardiologist can prepare to receive the patient for primary angioplasty (rather than wasting more time while the infarct extends in A&E, or while the patient sits in a holding bay until cath lab staff assemble) - remember a patient might arrive at 2 o'clock in the morning when the GP is still tucked up in bed.
If angioplasty is not available locally then a provisional (pre-hospital) diagnosis of STEMI is still incredibly useful since paramedics can alert A&E staff, thus allowing the resus team time to organise relevant drugs, etc, or pre-warn the cardiologist that a likely MI is en route.
Even boy scouts know that it is best to be prepared.
Having worked through most of the areas in this discussion, i would like to point out one or two things that everyone seems to have forgotten.
1) Unfortunately there is no standard professional - whatever medial profession you are in.
2)Correct me if i'm wrong Dr C, et al, but the professional in charge of said patient's care at that point in time has to do what they know and are told is the correct thing.
3) There are GP's who mis-diagnose acute cases. AS there are A&E docs, hospital docs, paramedics, and everyone who exists within a hospital. Surely you can't say (especially with Mr Medico-legal lawyer around) that everyone should take everything that's handed over to them for granted?
4)Government targets.. If you work for the NHS they rule your life. You can kick back against them, curse them, swear at people who adhere to them, but at the end of the day - you have to follow them. If you don't like the call centre, then don't shoot the operator. Unfortunately i have had many times i have talked to people who 'know best' and unless you are fully qualified to do someone elses job, you cannot hope to be as good at their job as they are. There's no way i know as much as Dr C about Gp'ing or Tom about Paramedicing, but i can guarantee - you dont know as much as me about what i do...
Medicine man - look at the post/comment from Ambusam......... for your information, so to speak
http://ferretfancier.blogspot.com/2008/01/unconvinced.html
Something that no-one has picked up on is...Dr. C wanted transport for his patient to hospital but not on a 999 basis but within the half hour/three quarters of an hour?
So why are some commenters banging on about "mincing" on scene and that the patient should be rushed to hospital?
We dont "mince" by the way...we walk but with a sense of urgency...when required.
Garth...where have you heard of Paramedics refusing to take patients off GPs? I think Chinese Whispers have a lot to answer for.
Interestingly the discharge diagnosis was ?MI, albeit ?NSTEMI. If there had been ST elevation then this would have been demonstrated on the ECG and, as many commentators have said, appropriate treatment initiated.
As a senior figure (who shall remain anonymous) in the BMA, I would be most interested to hear your response to Tom Reynolds.
Have you read his blog post here:
http://nhsblogdoc.blogspot.com/2008/01/crippen-diary-2008-january-2.html
?
kingmagic,
I have heard stories from people I know very very well indeed and it happened to them, they went through the proper complaints procedure etc and nothing was done.
To the A&E charge nurse.
Can you clarify - in your experience will your docs thrombolyse/catheterise someone with ST elevation who is otherwise well and *pain free*?
Thanks for your reply.
Dr C,
I accept that you are a Doctor and an ambulance technician is not. You therefore know more than the Ambulance person, but you forget one tiny thing - YOU ARE NOT THE AMBULANCE PERSON's BOSS - the ambulance chap has his own boss and management structure and whilst he ought to value you input you are not his boss. he cannot therefore disregard instructiosn from his boss just because you want him to can he!
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