"71 year old male, intermittent chest pain, in GP surgery"
I have recently had a few pops at GPs, in fairness with good reason, but in the interest of equality it is only right that I highlight the other side of the coin: How GPs sometimes view the ambulance service.
After my recent blog 'GPs: Take Note' some of my sweeping statements were highlighted. I often make them without much thought and with little investigation! That's the 'hot head' inside of me. I think of something and write it and that is where it stays! Obviously GPs don't all work 9am to 5pm. I was reliably informed that in fact it's near 8:30am to 6:30pm which I promptly corrected! I was also asked how many extra hours on top of their 50 hour weeks they should be expected to do 'out of hours'?! Good point! I didn't really have an answer other than a sarcastic '80+ hours?!' In all honesty, it is easy for everyone to point the finger and say 'do more' and 'work more nights' but I'll be honest, I wouldn't. Despite my stupid hours I still average 37.5 hours a week over the year and anything over and above that I am paid overtime for. I suppose everyone just wants a GP whenever it suits them. Sure, they could all start working from 6:30pm to 8:30am but then we would moan there were no GPs during the day. It's a lose lose situation for everyone. It is how it is, but I'll still have a dig for my own satisfaction as and when the opportunity presents itself!
To that end, I was sent a link to a blog by Dr John Crippen, author of the now archived The Crippen Diary (2008) to look at my GP surgery moans from the other perspective. We are guilty of groaning when we see a 'chest pain' at a GP surgery pop up on our screen, but likewise, this post highlights the groan when a GP has to call an ambulance! It thoroughly amused me and I felt it warranted sharing. To be fair, he makes some excellent points! Enjoy!
"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 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 an 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.
Andrew 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 rap 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."
We do huff and puff! A lot! As a service we are obsessed with ECGs and with good reason. I think we often lose sight of the point of them though. The problem is, like Dr Crippen alluded to, we have protocols. Shit loads of them! On top of that we are judged on our paperwork, and if the words 'chest pain' appear anywhere on our paperwork there has to be an ECG! Why? Because we are told too and as a result some people do them at inappropriate times. It does often seem pointless in some patients and personally I wouldn't have done one on this guy unless it was going to change my plan. In this case it wouldn't have. He was already going to a cardiac unit. Doing an ECG on someone not in pain was not going to change a thing in this instance. If he wasn't booked to the cardiac unit, even if the ECG shows some kind of cardiac event he would still go to an A & E because the criteria for going straight to a cardiac unit is central chest pain for more than 15 minutes with some exceptions, none of which he fits into. We also do an ECG if a patient's blood sugar is above 10mmol/L. Not 9.9, oh no, 10.1 makes all the difference! In reality it is a number. I will do an ECG if I think it's indicated or if a patient will benefit from the investigation, not because of a difference in 0.1! Some people will see a BM of 10.1 and just do an ECG but why?! It's all relevant to history. If a non insulin dependant diabetic who's BM sits between 10 and 14 normally has called for a back injury doing an ECG won't change much! Some of the things we do are over the top and it doesn't surprise me in the slightest the GPs get annoyed with us but they are over top for a reason. History has taught us to be over cautious for a reason. They have years and years of training and we are certainly not placed to second guess a diagnosis or decision, but can ignore and make our own ones! Obviously we can share an opinion about leaving ill patients alone in a waiting room with a letter in their hand, but we certainly shouldn't be questioning whether or not an ECG has been done. If we think one should be done, we'll dam right do on!
It all comes down to the age old problem with the NHS. Services not working together! There is not a big enough understanding between job roles and policies in different areas of the NHS. Yes, a GP should be able to say 'I need an ambulance, don't worry about lights, but as soon as possible would be great' without having to answer pointless questions! Likewise the GPs need to understand why we have to do ECGs and wait around for 11 minutes when it appears we are simply delaying definitive treatment. We don't delay for fun and it isn't simply a box ticking exercise. We do it because we have the knowledge and equipment to be able to form a more comprehensie history and picture of a patients health and in 'staying and playing' can benefit a patient in the short and long term. I doubt it will ever change, everyone has their arses to cover and everyone thinks their job role is more important than others. That's just how it is. We will all continue to love to hate each other and engage in professional banter wherever possible!
Full article: The Crippen Diary - 2008 : January (2) | Trusted.MD Network http://trusted.md/feed/items/system/2008/01/15/the_crippen_diary_2008_january_2#ixzz1uNIWHPXm
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NB: I have made some edits to this post following comments which showed the point I was trying to make had been lost. I am not making editing notes. This is not a scholarly article, a journal or anything other than a personal blog. Just be aware that most of the comments were made before my edit which were merely the re-wording of a couple of sentences. I stand by what I say, like always.