Question from a friend of my sister-in-law at lunch recently:
You're a doctor, can you answer a question for us about paramedics. I think paramedics are doctors with special training in emergencies, but my friend thinks they are nurses with special training. Which of us is right?
We are having lots of problems with paramedics being put under pressure not to take people to A&E. They 'advise' patients that they would be better off seeing their GP. When we then advise them to phone 999 again as the paramedics were talking bollocks, the patients say "the paramedics are professionals and we believe them".
And why not? Paramedics are, after all, highly trained specialist doctors or nurses and we are just general practitioners. It' not as if paramedics are just pulled off the street with a clean driving license and given three months training....
Oh, and when the patient subsequently dies guess who the relatives complain about? I'll give you a clue: it's not the people with the flashy van.
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28 comments:
An appropriate response would be have been: Paramedics are not doctors or nurses. They are first aiders who have a year of intense training and advanced life support certification. Their training allows them to provide extensive first aid and pre-hospital care. They attempt to stabilize and transport a patient to doctors and facilities equiped to handle the patient's problem. They keep the patient alive until they can get him to a hospital and try and troubleshoot problems on the way there. They can communicate with and take orders from a doc via radio.
EMT's have a few months training and provide basic life support during a transport to a place that can handle a patient. If a patient is a minor they get EMT's and if it is major paramedics are sent out as well. Is it different here in the UK?
I have to deal with a ward where there is one nurse and 11 support workers with no accountability who do fuck all whilst the patients look on and think that the ward is well staffed with nurses. People are ignorant. I am getting used to it.
I am a nurse and have worked as a paramedic in the past. I have seen nurses and paramedics shopped for doctor fuck-ups whilst the doctor gets away with it. It is easier and cheaper for a facility to shop a nurse or paramedic or whomever rather than the docs. When I get around to another blog post I may make a list of cases such as this.
Last year the London Ambulance Service received 1.2 million calls and made 865,000 responses.
http://www.lond-amb.nhs.uk/helpweoffer/other/other_main.html
One individual has been brought by ambulance to our A&E more than two hundred times since the beginning of the year [sometimes arriving in A&E on x3 seperate occassions within a 24hr period] - complain of chest pain, shortness of breath or vomiting blood [as this serial chancer usually does], and a blue light is mandated to arrive within <8mins.
The LAS recently produced a poster campaign with the slogan "only one of these is a taxi" - but call outs continue to rise inexorably [costing us £165 each time].
God forbid that we should have a triage system so that paramedics can sort out the piss takers [certainly >30% of their punters].
Meanwhile resources are deflected away from "genuine" emergencies because crews have no choice but to play the game each time they get a maternitytaxi call, for example.
That true A&ECN
What gets our goat as GPs if when we do a home visit, diagnose a serious condition, spend 10 minutes waiting on hold at the hospital switch board in order to give some snotty nose prepubescent fresh out of medical playschool the hard sell in the hope that they might be gracous enough to take the patient that is possibly going to die......
......only for the ambulance crew that eventually turn up to decide that the pateint doesn't need to go to hospital.
It has happened.
I'm sorry, but If I say the patient needs to go to hopsital, the ambulance IS a taxi service and certainly not a second opinion.
Ggggrrr!
i liked the interview with the health trust where the interviewer was being assured how safe it was to close a & e near a major centre of population, and that the extra ambulance journey would be safe cos "the paramedics are so well trained", was hilarious when they were asked "so what % of ambulances are staffed by qualified paramedics then"... not many as it turned out
i love u all by the way
no one
oh and at least proper paramedics do have some training
more than can be said for the average GP receptionist who often makes decisions which risk patients life!
i wish GPs would sort their own fucking house out
Not many receptionists are called out to decide if young people with neck injuries need to go to hospital. One of my nearest and dearest had a fracture dislocation at C4/5 and was eventually allowed an ambulance by a grudging first response paramedic who told him he was lucky that there was one free that day. He conveyed quite clearly that he thought said nearest and dearest was whingeing about the pain in his neck as he could move both hands and feet OK. Mercifully, subsequent care including neurosurgery was excellent or he wouldn't have been able to move them for very much longer.
Probably kill less people than your average GP.
Anon your just turning into an annoyance.
Go peddle your crap elsewhere.
mamma doc - as you probably know, diagnostic errors by doctors have been estimated to be around 15% [for the profession] - no system is ever be risk free.
The case you hightlight is clearly an example of extremely poor judgement [given the forces required to inflict a spinal fracture/dislocation].
In my experience paramedics usually have a very low threshold for boarding and collaring suspected neck trauma [especially when distracting injuries or alcohol are involved].
I agree entirely with Dr Mustard that any further assessment by paramedics [after GP examination] should not in any way impede rapid transfer to A&E.
There is no doubt in my mind that a significant [but growing] minority of punters are abusing ambulances - there is a lot of stuff on the net about how crews have been called out because a man had a problem getting his trousers on, for example.
It was this, rather than the very poor practice highlighted by your friends experience, that I had in mind when suggesting the possibilty of paramedics declining to transport patients to A&E because they had verucca, and so on [because this sort of stuff does happen].
Somewhat ominous that it's only the start of winter, and the ambulance crews are already stacking up outside my (well, ok, not "mine" as such) AMU. It's getting harder and harder to find places to put 'em.
I look at the steadily accumulating trolleys, the overstretched general/elderly wards, the ITU nurses "outreaching" left, right and centre - and I ponder (NHS Confed) Dr Gill Morgan's observation that people need to "abandon the idea that beds are sacred...they are just a piece of furniture, that's all."
Jesus, Its all getting a bit them and us. I like GP's, some are arses but most are considerate and caring. That goes for ambualnce staff as well. I work for an Ambo serice and we do get about 10 - 20 calls a day which are utter bollocks. "my doctor wont see me today" "he wont give me antibiotics" apart from wanting to scream "oi shit for brains try asking for an emergency appointment or thats cos its viral tonsilitis you dont need them" it gets very exasperating. Staff get the hump cos of being called out mostly due to the stupidity of the generel public. And yes we will always politley refer back to that stalwart of everything thats is not a hospital or a social worker the always there GP.
Dr Rant you attacks on ambulance staff are a little OTT. I think u can pinpoint the start of this problem from the Govt's poor OOH care. At least in the past GP's would provide a better quality filtering process (and manage minor things). Without this, the role has been shunted to overstretched A/E and the resulting spillover should be of no surprise. If paramedics transferred EVERYONE to A&E the whole system would grind to a halt (so in a way they are considering the bigger picture of patient-care in terms of maintaining the overall service, which is not their actual remit, but thats what happens...)
Fix out-of-hours cover and the rest should follow.
If you will allow me to respond to this post give that I am a service SJ john Ambulance member, the son of a paramedic and PTS ambulance driver, the executive committe member of an ambulance society/publication editor and the owner of my own (old) ambulance, allow me to begin.
Firstly, the term "First Aider" is not applicable to ambulance crews. Ambulance crews are trained in ambulance Aid which goes much deeper and has a larger remit of treatment.
As for "what are paramedics?" They are their own autonomous profession in the UK. Allow me to explain the development of the UK services which will make this clear. Until the NHS service started in 1948 under the use of City, County or Borough councils in England and Wales (the Joint St Andrews and Red Cross Scottish Ambulance Service in Scotland and the Northern Ireland Hospital Authority in Northern Ireland), ambulance provision was provided in a hap-hazards manner (in some area's, not at all!). Some area's had provision from hospitals, some from council run service's run under public subscription, some by police or fire brigade's, and some by the Red Cross, St John Ambulance, St Andrews Ambulance corps. Industrial sites such as mine's, or large factories/works operated an ambulance. In 1948, the coucils or organisations (country depending) took charge which gave people the right to a free ambulance for emergencies and out patient appointment. Until 1966 the only requirement was a knowledge of First aid, a valid first Aid certificate and a drivers liscence. This lasted until 1966 when the department of health under a board chaired by Dr Edwin Millar made several reccommendations which included the use of medical gases (oxygen and entonox) and more splinting equipment. This recommended a 6 weeks residential course. This was the norm until 1992 when the government announced the previous year that it wanted a Paramedic on every UK A&E ambulance. This gave more drugs to use (Adrenaline 1:1000 and 1:10000, Atropine 0.6mg, Asprin 75mg tablets, along with Dextrose, Gluco gel, Tramadol, metroclopramide, Saline, Salbutamol, Lignocaine, and Morphine is about to be introduced to my local service), along with the use of a manual defib, and intubation equipment for respiratory/cardiac arrest cases.
The complaint of leaving patient's at home Doctors: Your cases are set as an "Urgent" case. This should in the real world mean that within 4 hours of your call, the patient should reach hospital (I know reality is somewhat different). If it is an emergency, then you dial 999 and go through the quick route. It is a matter of priority. If you are with the patient, then you decide what response you want. However, I would not be so quick to fire off snide remarks of the Ambulance Service. There were rumblings re: use of medical cover at event's by the Athletic's Association which stated that it wanted a Doctor "Who regularly deals with cardiac arrest cases, simply having any Doctor turning up is not good enough". I know my St John Division has a Trauma Anaethetist to atend duty, which means that he deal's with trauma on a daily basis. A Urologist on the other hand, proberbly may not be as helpful.
Any medic should be able to deal with an MI...i think what you meant to say was an surgeon (probably orthopod) may not be as much use :)
Ok silly joke ... i even want to do Ortho...but it's still funny.
"Any medic should be able to deal with an MI"- Indeed they could, but the main problem is that outside the hospital, it can be limited what can be done (my local CCU does Coronary Angioplasty so pre hospital thrombolysis is rare to be done).
In my experiance though, I have seen stings, fracture's and abrasisons more then anything else. It's more decding which moron think's taking a serious casulaty in without using an ambulance is a good idea, and which one's dont. For any undecided, read the report on the Harrow and Wealdstone train crash (1952) and the dealing of casulties to decide.
"read the report on the Harrow and Wealdstone train crash (1952) and the dealing of casulties to decide"
Can't find the report online.
I'm unsure what you are trying to say in your post, Nursing Student.
Could you give more detail?
Certainly. I will have to paraphrase a bit.
Brief detail: In 1952 at Harrow and Wealdstone station, 3 express trains crashed following a train running through a red signal. This left 112 people dead and many more injured. There was an emergency call put out and ambulance's were sent from Middlesex Fire and Ambulance Service, from the London County Council service and the US Army sent ambulances to the scene.
There was confusion of how this was to be dealt with. When people saw the first ambulances arriving outside the station, they simply viewed the ambulance's as a carriage for the injured. Therfore, the first, minorly injured people to walk out from the wreckage were bundled into the ambulances and sent to nearby hospitals. When the Fire brigade began removing the more seriously injured casulaties, the ambulances were gone and so passing vehicles were flagged down to carry the seriously ill patients (A removal van is cited in the documet I have here). When the ambulance's returned, many had died or were being moved hap-hazardly.
It was I believe, almost the first wake up call in the importance of proper ambulance transport for causualtied in the NHS (though remember here we were talking 4 year's into the NHS). As an aside, it was the work of a black US army Nurse (Nurse Sweetwine) who was using a system of casualty evaluation on the platform that day where the triage system was first derived from.
Thank you.
I knew the story, just didn't recognise the name of the incident.
Interestingly, the performance of the US medical teams from the nearby US base was a revelation to UK pre-hopsital providers.
Quick question: if you are shot in the chest/abdomen are you better to
(1) flag down the nearest car/taxi and say 'take me to A&E'.
or
(2) Call 999.
(2) Call 999. I live in a rural area where it can take 45 minute's to get a taxi, and I would be given a £50 clean up charge.
Unless I am very close to an A&E and have a passing taxi. That woud be the quickest thing. Remember here statistics collected in 2005 showed on average only 22% of admissions to A&E were by ambulance.
Dr Rant - your question alludes to the scoop and run vs stay and play dilemma.
I was on duty after HEMS performed a roadside thoracotomy [after a young man had been stabbed in the chest], the patient came to A&E with a paramedics hand tamponading the internal injury, the patient survived.
As you know a bullet inflicts a completely different injury pattern - but HEMS might still be able to treat immediately life threatening thoracic injuries, i.e. tension pnuemothorax, sucking chest wound, cardic tamponade, or massive haemothorax [flail chest would be unlikely].
The most likley [immediate] life threatening problem following gut injury is hypovolaemia/PEA arrest, so x2 large cannulas and fluid resuscitation might buy time.
The research shows that the only thing to make any difference to survival in penetrating trauma (stabs, shootings) is time to arrival at hospital.
So the correct answer is (usually) to pile the person into the nearest police car and GLF* to A&E.
Interestingly, the only large study into survival rates with paramedics vs technician crews that's I've seen from the UK was in the late 1990s (?early '00s) in Scotland showed that mortality went up if you were treated by a paramedic.
Before Tom Reynolds jumps down my throat with stuff I already know about potential problems with such a study, I mention this because our degree-nurse colleagues mention the study showing that non-degree nurses have a lower survival rate than degree nurses. Something that drives non-degree nurses demented with rage as those studies too had design issues.
*Go Like Fuck (GLF) - thankfully the days of clutching onto the roof rail of the ambulance with one hand whilst going CPR on a patient with the other are (almost) gone now, but GLF is still a valid approach. It's knowing when to stay and when to play.
Current US studies show no benefit to ANY intervention in trauma in an urban area. All interventions (IV access +/- fluids, intubation etc) decreased survival rates. The only intervention that increased then was immediate despatch to surgery. There has been resistance to this from both paramedics (and, sadly, some emergency docs) because no one wants to admit that the stuff they've been trained to do doean't help or makes things worse. But the important thing is that we do take this on board and we do change our practice rather than letting egos get in the way.
The initial studies were done in penetrating trauma - what's really interesting is that it looks like the same is true for blunt trauma.
So yes, there is actually little controversy about scoop and run; in the majority of the western world it is EXACTLY what paramedics should be doing.
As for the rest, I have no objection to them refusing to transport people with insect bites and colds. That's what this change in their training was about. It was NOT brought in so they could overrule medical practitioners with vastly more training, insult them in front of the patients and relatives and leave seriously ill people at home.
Recent paramedic refusal to transport on GP instructions (excuse in brackets):
2 heart attacks ('because the ECG was normal')
1 broken hip ('it didn't hurt if she didn't move it')
1 pulmonary embolism - blood clot on lung ('she just had the flu')
What really scares me is that these were people assessed by a GP - how many unassessed patients are being left at home?
Still, let us not get carried away here. I spent some time working with the county ambulance crews in various role's as well as my time on the St John Ambulance vehicles.
I have had a cardiac arrest patient who survived a VF (at least till they were handed over to A&E) so there was a good use of both RRV paramedic and ambulance crew in the resuscitation. The majority of calls I had were either angina related chest pains (never saw an MI on my watch, which I am pleased about!), though overwhelmingly shortness of breath/diffuculty in breathing were what sent us out on the blue light calls.
Now, if I read into your post, one of you in the Dr Rant team are a bit pissed off over some twat in a green suit who was trying to question your wisdom. It seems very odd that you have met such a person. Most of the time, ambulance crews that I know(and me when I was on them) were happy to take doctor's calls in, and knew while we had that on board there was not going to be some drunken idiot trying to beat us up.
I respect that as in the past 40 years in the area where I live there have only been 4 shootings- 3 of which were farmers comitting suacide with shotguns, and one actual shooting, so the gun ananagy is somewhat lost on me.
It's just that the way I read it, it's almost as if your trying to make a case for folks to NOT use an ambulance for help. I apoligise here if I am missing the mark, but allow me to express this another way (as your team have GP's, I will try to make an analagy).
Say person X begnins to feel weak, lethargic and develops a small swelling of the neck over a period of weeks. Now, would you advocate them to go to a health food shop to buy some engrgy pills under the misguided belife that a GP would fob said person off, or urge them to make an appointment with a GP who can arrange a blood test for TFT and tell them they have an under active thyroid and need thyroxine? (NB I know thats a bit far fethed but I wanted to stick to something that I would not end up going off on a tangent with).
A&E nurse - that 15% which is always being thrown in doctors faces includes things like mistaking eczema for a fungal infection, or cluster headaches for migraine. Most of it is non-life threatening and happens because there is significant symptom overlap. But with regard to the paramedics that's not what we're talking about. We're talking about symptoms that could indicate an urgent, life- or limb- threatening problem, where a paramedic is overruling an experienced doctor.
As I have a dual career in GP and A&E, and am about to return to A&E to take up a consultant post, I have all too often seen paramedics turn up in the dept, mouthing of about how stupid the GP was and hoe _they_ have made the obvious diagnosis. Usually by the time I have examined the patienbt and concluded that the GP was right, the paramedics are long gone, trumpeting the uselessness of GPs to their colleagues. On one memorable occasion they brought in a woman with 'flu - because that w**ker of a GP insisted it was septicaemia'. Sadly they hadn't actually notice that she had had a respiratory arrest as they got her out of the ambulance, and I heard them later still bad-mouthing the GP to colleagues and patting themselves on the back fr a 'good call'!
With attitudes like this among a significant number of paramedics, I'm glad my career change is taking me overseas. I love emergency medicine, I really do, but there is no future in it or general practice in this country.
doc1 - HEMS do love their needle chest decompressions and thoracostomies, not to mention intubating patients once their GCS drops to 14 and-a-half.
They have also been known to give the odd shot of morphine and stabilise suspected c-spine injuries.
But research suggests that none of these interventions make any difference, eh ?
I must admit I have seen several patients go off in the "doughnut of death" [aka the C/T scanner] since some doctors seem to have an aversion to rapid definitive surgery [at least until an extensive work up is complete].
I remember a disasterous resus room thoracotomy after an aortic injury had tamponaded.
The patient, who had been stabbed in the chest, was stranded in A&E [waiting for transfer to a cardiothoracic centre] when the clot ruptured, possibly because of fluid resuscitation - the patient exanguinated.
I hope your job overeas works out but I suspect it might be a matter of adjusting to different flavoured shit ?
"some twat in a green suit who was trying to question your wisdom. It seems very odd that you have met such a person. Most of the time, ambulance crews that I know... "
Nursing Student,
Most of the time?
You're surprised?
Considering how many emergency patients GPs send in, then it won't take long for a GP to meet the situation described if the paramedics are only happy to take in GP patients 'most of the time'.
Most of the time is not good enough.
99% of the time is not good enough.
99.9% of the time is not good enough.
99.99% is not good enough.
I've treated around 100,000 patients in my career so far. To my knowledge, two have died who might not have if I had diagnosed them differently. That's 0.00002%.
Am I happy with my patients not dying from my misjudgment 99.998% of the time? No.
Paramedics suffer from poor follow up of patients. They rarely find out if their actions were right or wrong because they don't get to follow through the care.
I am a Paramedic and have been for 7 years. I work on the land ambulance and on HEMS. I work bloody hard keeping my skills and knowledge fresh and hate people slagging us off. There are good and bad in every profession, but lets not tar everyone with the same brush, as that is just crap. If a relative of mine had a heart attack, I sure as hell would want a Paramedic who is able to carry out advanced life support to turn up, and not a GP who hasn't seen the light of day for years and couldn't possibly do a home visit. Paramedics have had to do a minimum of 2 years training before becoming a Paramedic, not 1 year, and the majority of that training is done 'on the road', enabling us to get hands on experience. Everyone in the health service has a hard job, dealing with the idiots that are the public, who think that a broken finger nail requires an emergency ambulance, so can we not fight amongst ourselves. I have never questioned a doctors decision, I do however ask them how they got to their diagnosis, in order that I can learn and pick up assessment skills...it is however amazing how many doctors feel threatened by this...why is that???
looks like some "blue light " envy here. in 31 years in the NHs i've met Doctors, Nurses and Paramedics who shouldn't treat cats. GPs who should not be let out in public with a safety pin. basicaly for every tale of Ambulance woe I have one for Dotors and nurses. Take that collar off now oh why has the patient stoped moving???
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