Image courtesy of 'ECG Made Piss Easy'*
This time it's an 'electrocardiogram' machine.
This clever gizmo can now be used by GPs. So long as they have a phone-a-friend nurse to show the pretty pictures it makes to because, you know, GPs are way too fucking stupid to read an 'electrocardiogram' themselves. Even if modern ones actually print out the diagnosis in ENGLISH at the top.
This is saving lots of money because:
The only way to get a proper diagnosis is with an Electrocardiograph (ECG) - a machine which monitors the patients heart rhythms, which means a time-consuming trip to hospital.
The only problem is that THIS ENTIRE STORY IS A TOTAL CROCK OF SHITE.
For a start, the 'newfangle electocardiogram was invented in 1862. GPs have been using them in their surgeries for decades, and - get this - A NORMAL ECG DOES NOT EXCLUDE A HEART ATTACK.
In fact, as any fresh-out of medical school doctor could tell you, relying on a normal ECG to rule out a heart attack is really good way to kill your patients.
But, then, this government is not interested in saving patients. It's interested in saving money.
* Not only is this not our own image, but we nicked that joke as well - Unapologetic Ed.
Dr Rant
Dr Cardigan
Dr Blue
Dr Brown
Rev Dr Green
Dr Mustard
Mr Orange
Dr Pink
Dr Purple
Mr Salmon
Dr White
Mr Beige
Ms Scarlet
Dr Informed
24 comments:
Propaganda bullshit.
I'm a Paramedic & must say, the majority of GP practices do 12 lead's as a matter of routine.
As you rightly state, a normal trace does not rule out MI/ACS, somthing which some of my colleagues would do well to remember.
Be nice if the local A/E would remember that too, instead of "why's he/she here if the trace is norml?"
We have been doing 12 lead ECGs in our surgery for years. I am unaware of any practice in town that does not do these routinely, interprets them and only uses the hospital if there is a weird tracing. To promote this as a huge advancement is very strange, especially as clinical acumen is so much more important than a single result. How much did this cost and can I get some please?
Urbain le Grandier
The ECG was ctually invented by a GP- James McKenzie in Burnley!
I think that BBC article has made me more angry than any other single article I have read since I started blogging. I was shaking with anger. It really is not good for me.
I have had a serious go at it as well.
How dare the BBC foist crap like this on the public; how dare the government try to save money in this way; how on earth did they get a GP to go on record support this?
I despair
John
Sit back - I agree. Total bollocks. As a nurse I know the risks are far too high and even in hospital setting I refer for med review if there are at least 2 clinical indicators (one being 'ooh me chest hurts'). ECG is completed as standard and never used as a diagnostic (cos I have no idea what I'm looking for outside of a normal sinus rhythm).
However, I am sure there are many competent nurses who can read ECG and understand them. If I was working cardiology I'd make it a priority to know this. So I'm a little racked with Crippens comments on the 'nursing fuckwit' jibe again - if the journalism is spouting shite about ECG's why readily accept that nurses are making these diagnoses? They're probably receiving the reading - handing it to med reg or above and feeding back the clinical opinion. Never hurts to have a second opinion in making a differential.
Lets face a few simple logistical facts;
A&E attendences are up by 33% in the last 3-4yrs.
Emergency admissions have increased by an even higher percentage over the same period.
Hospital beds/wards are being shut down if this is at all possible (and are still being shut down when it is apparent that it will be an unmitigated disaster).
The NHS has a meagre 140,000 or so beds serving an ageing and growing population.
Is it any suprise that the increased use of ECGs as a screening tool (+ clinical condition of patient, of course) has been advocated ?
Surely, if we continue to pursue a vision of increased health services delivered in the community (management of chronic disease, etc) then greater emphasis is going to be placed on diagnostics by GPs - how often do GPs send a patient to A&E stating in their covering letter that it is 'probably indigestion' but need to rule out a cardiac event, etc.
When are people finally going to realise that hospitals are on their knees trying to deal with patient/bed ratios - HAIs are but one facet of this insane policy (although too many doctors are very keen to blame poor nursing care, conveniently overlooking decades of ABx misuse, and lack of appropriate infection control measures).
I wish all I had to do was worry about BBC articles.
The a&e charge nurse makes valid points to make but fails to understand one of the major points made by crippen and dr rant.
Is it any suprise that the increased use of ECGs as a screening tool (+ clinical condition of patient, of course) has been advocated ?
No, no and again no. If a patient has angina or having a "heart attack" and the ECG shows changes that is useful. If the ECG is normal this is not helpful and cannot be used to say no heart problem. The patient needs a troponin blood test and serial ECGs over time - neither of which can be done in primary care.
how often do GPs send a patient to A&E stating in their covering letter that it is 'probably indigestion' but need to rule out a cardiac event, etc.
I don't know how often but not an unreasonable request as the GP cannot rule out a cardiac event without the above mentioned tests that are unavailable in primary care.
It's like the a&e docs and nurses who moan about GPs sending patients with ?PE or ?fractures to A&E when "it clearly isn't" AFTER the x-rays, ECGs, blood gases, whatever are back...
Accepted Luke - I have tremendous respect for GPs and it is abvious they have a huge responsibilty.
It is also worth reiterating that they do not (routinely) have immediate access to diagnostic tests available to their hospital colleagues.
The first bit of advice given on any ALS course is to treat the patient, not the ECG (cue PEA scenario).
Honestly, I'm not knocking GPs (although I could do without the undercurrent of nurse bashing on some of the recent threads).
There are clearly numerous variables influencing referral decisions - as I say the ECG may be helpful but as a facet, rather than the centre piece, of their clinical assessment.
As to the significance of the trace, well I'm sure most GPs have got a copy of Hampton gathering dust somewhere on the shelf ?
"how often do GPs send a patient to A&E stating in their covering letter that it is 'probably indigestion' but need to rule out a cardiac event, etc."
Not often enough.
I've seen several such patients die in A&E and as a GP.
What are you trying to say A&ECN?
If you are trying to say 'We need more staff and beds on the front line to do the job right', then I agree 100%.
If you are saying 'GPs send in crap', then I think you are suffering from trench fever and need to get some R&R before you become part of the problem.
Trench fever, oh, that's just the A&E consultants, Dr Pink, the rest of us are far worse ;o)
There is undoubtably variability in the quality of GP referrals (just as there is in everything else), an aspect of the service that will increasingly be put under the mircroscope IMHO (especialy since there are no beds left).
http://jpubhealth.oxfordjournals.org/cgi/content/abstract/11/1/65
Maybe a minority of patients are sent to hospital because there is unsfficient back-up in the community ?
We had a woman with lower limb cellulits (recurrant problem after suffering extensive burns a while back) - she had a 4 month old baby but it proved impossible for anybody outside of hospital to sort out IV ceftriaxone on a domicillary basis.
Incidentally, if GPs are saying there is NO ROLE for ECGs (for anginal chest pain) and tachy or bradyarrythmias can be inferred from pulse + history, why did GPs ever bother getting an ECG machine in first place ?
A&ECN, I'm surprised at you.
There is ASBOLUTELY NO role for a single-ECG in the EXCLUSION of MI. Period. Anywhere.
That does not mean the ECG is useless, because of course a postive ECG is diagnostic, which speeds up call to needle times.
That's an absolutely vital difference to understand if you are going to safely diagnose illness.
Absolutely Dr Rant - no role in the exclusion of MI, any GP suspecting this diagnosis should pack the patient off to hospital, by ambulance, having administered aspirin first.
But.......it still begs the question does this investigation (ECG) have ANY role in risk stratification in the community - I think it's an interesting question given the aspiration towards managing chronic diseases at home (whenever possible).
You know as well as I do that we are approaching almost 1/4 million heart attacks each, so god knows how many episodes of angina occur.
Surely, some GPs will decide (sometimes) that a patient is stable enough, after experiencing a transient episode of exertional angina, say to be managed with aspirin/GTN/rest ?
If an ECG (30mins post symptoms) reveals no acute changes, isn't this useful information ?
In fact couldn't some patients be sent home with advice after medical examination, assuming everything was settling ?
Or is the alternative mandatory anticoagulation, serial ECGs and troponin +/- angiography after every episode of anginal chest pain ?
But.......it still begs the question does this investigation (ECG) have ANY role in risk stratification in the community - I think it's an interesting question given the aspiration towards managing chronic diseases at home (whenever possible).
You know as well as I do that we are approaching almost 1/4 million heart attacks each, so god knows how many episodes of angina occur.
Surely, some GPs will decide (sometimes) that a patient is stable enough, after experiencing a transient episode of exertional angina, say to be managed with aspirin/GTN/rest ?
++++++
A/e Charge nurse - you are a nice guy, and I am sure you mean well but I lapse once again into despair when I read this; you really do not get it, do you.
First GPs have been looking after chronic disease in the community since the dawn of creation. But you don't mean that, do you? We do not have any aspirations to "manage chronic disease in the community" because by that you mean refusing to let people with serious illness into hospital, or turfing them out too early to allow non medically trained nurse specialists "care" for them. Seeing a nurse quacktitioner in the community is not subsitute for seeing a doctor at home.
You know as well as I do that we are approaching almost 1/4 million heart attacks each, so god knows how many episodes of angina occur.
Surely, some GPs will decide (sometimes) that a patient is stable enough, after experiencing a transient episode of exertional angina, say to be managed with aspirin/GTN/rest ?
There is not the time to give you detailed tutorial on the difference between angina and heart attacks. A transient episode of stable angina (is that what you mean) in a patient KNOWN to have ischaemic heart disease is one thing; a patient presenting, as they do, with a new and clear cut history of stable angina which has been going on for six months is another; he probably can and should have initial investigation and treatment in general practice, but will need referral for an exercise test etc.
THIS IS NOTHING TO DO WITH PATIENTS PRESENTING WITH ACUTE ONSET NEW CHEST PAIN. I don't know how best to teach you about this, how to get through to you the dangers of a one off ECG in that acute situation.
As to your New Labour suggestion that as so many people get ischaemic heart disease it is cheaper and best to fob some of them off with inappropriate and non-diagnostic investigations...well, you need to get real. You will say you did not mean that but it is implicit in what you say.
Finally, note the American medical bloggers have picked up the story now. They class ECK telephone triage as "stupidly asinine". I would be intereseted to see how you manage if you take the argument to them.
John
Thank you Dr Crippen - cardiac chest pain is common place and not all patients need hospital, as you have already pointed out GPs have long been the arbiters of determining the threshold between referral or advice/self care.
I was interested in the thoughts of bloggers about the potential useful (or otherwise) of the ECG as a tool to aid diagnosis in the community, maybe I have not made this clear, since you seem to be suggesting that we monkeys automatically assume that a normal ECG excludes a significant cardiac event - I can tell you on this one accusation alone that you are way out of touch with how much experience some nurses have in these type of cases.
The American doc you highlight mentions LITIGATION in the second sentence, I think, and there is minimal comment on any of the actual clinical pros/cons - as I mention ealier I do not fully the understand the rational for any GP aquiring a tool that (if we accept your argument)has no practical value outside of hospital, apart from the placebo affect mentioned on your own site.
Just a couple of final points - I am not the architect behind the drive toward community based health services (in fact the inverse relationship between dwindling hospital beds and patient acuity is a major pain in the fucking arse for us A&E bods) - like you I do my best with the cards I have been dealt, if I'm asked to do an ECG on a well looking 25yr old man because he had a slight twinge in his chest 2 days ago, then I will slap on the stickies and get on with it, hell I'll even send a pointless biochemistry tube if this keeps the FY2s happy.
By the way, I do not have the power to turf anybody, anywhere,(if they present with a heart problem) in fact I have had a few squabbles with doctors about discharges, including a recent spat with an ortho SpR who wanted to discharge a mildly demented old man who lived alone because his fractured humerus (dominant hand/arm) was not a 'surgical' problem.
Isn't an ECG one of those "machines that goes bleep" so vital to modern medicine that the Monty Python team described?
These days the machine must go bleep, and then transmit to a far off expert.
The worry in all this story about the ECG is that there seems no mention of interpreting it in context of the patient's history.
Emma Wilkinson
I have been working as a freelancer for almost a year after a nerve-wracking decision to leave my senior reporter job at Pulse. I’m glad I did take that leap though, as I’m enjoying every minute. It’s great to be able to cover such a wide range of topics. I’ve written about everything from NHS IT for The Lancet, hospital-acquired infections for Hospital Doctor, cardiovascular disease in Bosnia for Circulation, and the risks of dealing with mystery illness for Nursing Times. I also work two days a week for BBC News Online, which has taught me a lot about writing for a general audience.
Emma - I was practically salivating at the thought of 2,000 patients being siphoned away from A&E (thanks to the wonders of modern technology) - did they all live, surely there must have been one or two teeny weeny adverse outcomes ?
http://news.bbc.co.uk/1/health/7270586.stm
A&E is showing all the syptoms of 'ignoramus!' They usually present with severe 'passionate intensity!', or 'NEVER' give up
I wouldn't teach them docs, you're helping them become more dangerous, lethal!
;-)
A A&ECN
If they're such rubbish referrals, how come they nearly ALL get admitted overnight, rather than being sent straight back home?
Or perhaps that lingering diagnostic doubt, and the need for lab tests etc, means that in fact they really DO need admission for obs and tests, even if just overnight.
Anon 1
'symptoms of ignoramus'
'passionate intensity'
'dangerous/lethal'.
Rabies must be slightly more common than I thought.
Stop frothing at the mouth anonymous and make your point (about the original post) - if indeed you have one.
Anon 2
Can you just remind me when I claimed that referrals are 'rubbish', or that ACS should not be admitted ?
By all means slag of my comments but please try to stick to the actual points made rather than those imagined inside your head(s).
A&E,
Doctors are taught to know their limits and when to ask for help. They have been trying to 'ploitely' tell you that for a long time, either on this blog or indeed others! However, you seem adamant that you know it all! Even better than all the docs combined! My point therefore is:
You are making a fool out of yourself
OK, rabies is curable, now we are getting somewhere.
Admit it, you have no interest in the original post but instead have been upset by the ramblings of a blogger ?
May I offer you some simple advice ?
Please feel free to ignore any further items that begin with 'the a&e charge nurse said'.
Personally, I don't subscribe to chaos theory. i.e. a nurse flaps his wings in the sluice room and the establishment appoints a surgeon to fuck up primary care: comments made by bloggers are transient ephemera (most of the time), a bit of harmless fun - the blogsphere is a broad church my sensitive friend, and there is plenty of space even for opinionated nurses.
A&E 'Admit it, you have no interest in the original post but instead have been upset by the ramblings of a blogger ?'
We are all worried about the direction health care is taking nowadays, that is why we are all here, docs, HCP, patients .. etc
And, I read the post but as others, including the docs, have commented already and explained, in their 'professional' opinion, complimented by years of experience,why they do not trust ECGs being interpreted by anyone other than qualified doctors and gave reasons, I have now formed my own opinion based on the argument and the reasons presented and am now convinced that, should the need arise, I would not trust a nurse to dismiss my ECG because she followed a tick box protocol and decided I was fine when I may not be.
I think the problem is, you think docs just do not want nurses to 'it' for the same reason some nurses like to play doctors! :-)
And BTW, one would have also thought that because you are an 'opinionated' nurse,ie, one who presumably 'thinks' before forming an opinion, that you too would have weighed the argument and came to the same conclusion. If only for 'your' interest as well as your patients and their safety.
A&E: 'comments made by bloggers are transient ephemera (most of the time), a bit of harmless fun'
Surely, an 'opinionated' person can not be that naive?! ... If you are, then this is a good reason why others should not ignore your comments, just in case the fun 'you' are having goes a bit OTT as happened in this case here..
Of course, the doctors are blogging because of the impact of current policy on people's LIVES!' I never thought anyone can find this 'funny!'
you cannot teach common sense - what is it with attributing claims to me that I have not made ?
For example, where do I suggest that nurses, rather than doctors should interpret ECGs ?
I thought I had made it clear (because the point is reiterated) that ECGs may or may not have a role to play in GP referrals - is that really such a controversial question to ask ?
Re-read my posts (if you can be bothered) and tell me specifically what I have said that is so outrageous.
By the way, we ALL blog for a variety of reasons - not even Sigmund Freud (if he where still with us) could figure out why some of us prefer this brand of therapy.
On the shop floor we have to be on our best behaviour, but here, well, we can run something up the flag pole to see who salutes it.
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