A double manned ambulance is a working environment like no other. Just you and your crewmate, on your own, dealing with (the occasional) life or death situation with no-one else to turn to. It’s something I’ll miss as I descend into hospital medicine, surrounded by other doctors, nurses, and machines that go ping.
It means that you build up a pretty special relationship with your crewmate. It gets to the point where you can almost read each others’ mind, the subtle changes in body language and the way they speak indicating when the shit is hitting the fan, and to what degree. Second guessing equipment and techniques needed, acting as a second pair of eyes and ears. Because by working together, almost as one “ambulance” entity, you’re going to help the patients best.
But most importantly, it also turns out you make a kick-ass dirty charades team.
In news that will probably only appeal to, and be got by, twopeople (though Kal and l0ttie seemed to second our opinion on this being a good thing), here’s the latest JRCALC drug guidelines.
[It's coming up to that time of year where I need to hastily compile my CPD portfolio, so I thought I'd write some of it up and publish it here. Feel free to skip: It's a fairly academic review which will probably only appeal to pre-hospital medicine geeks...]
Background
Nick Hough asked a while back about the use of scoop (“orthopedic”) stretchers verses longboards for spinal immobilisation. This was brought about due to differences in training with St John ETA courses – the county where I trained are very big on using a scoop “as is” for immobilising the supine patient (slide it either side, strap them down) whereas the counties where both Nick and GrumpyAmbulanceDriver trained prefer using longboards (formally known as “spine boards”), to the extent where the supine patient is either log-rolled onto the board or even scooped onto the board and then strapped down, both of which it seems to me intuitively lead to far more motion of the patient, a patient who you’re trying to immobilise because they may have a spinal injury!
"Scooping" the supine patient (wiki)
Literature discussion
Ferno, manufacturers of scoops, obviously have something to say on the matter
[The scoop] was found to be as effective as, if not superior to, the standard of care, a rigid long backboard when used for spinal immobilization… The advantage of [the scoop] comes from “the elimination of two logroll maneuvers, used during application and removal from the (long) backboard”. .. [the scoop] demonstrated “6-8 degrees less movement in all planes of motion during application”, or three to five times less movement than using a traditional long backboard. (Ferno press release)
Sounds good? But media bias and all that, so let’s hunt out the original article in the Journal of Prehospital Emergency Care, comparing the Ferno Scoop Stretcher (FSS) to the Long Backboard (LBB). From the abstract…
Comparison of the Ferno Scoop Stretcher with the Long Backboard for Spinal Immobilisation
Adult subjects had electromagnetic sensors secured over their nasion (forehead) and C3 and T12 spinous processer… Sagittal flexion, lateral flexion, and axial rotation were recorded during each of four phases: 1) baseline, 2) application (logroll onto LBB or placement of the FSS around the patient), 3) secured logroll, and 4) lifting.
The idea was to measure how different parts of the spine move relative to each other in three planes – bending in the sagittal plane (along the back), bending in the lateral plane (through the middle), and rotation in the axial (or transverse) plane.
Human anatomy planes (wiki)
Obviously, we want people with possible spinal injuries to keep all bits of the spine in alignment, i.e., no movement with respect to each other in any of these planes. Parts chosen were the forehead, cervical spine (neck) and thoracic spine (under the chest) – the lumbar spine was tried, but the electromagnet kept getting in the way of the immobilisation device!
The volunteers all worked prehospital or in hospital “residency”, so they all knew how to do log-rolls etc and did it on a daily basis. This is an important point to make. The original discussion was how the two methods differed when being used by St John members. If one is significantly worse than the other in this study, with professionals competant at all the techniques used, it is likely to be even worse when used by volunteers who don’t have the training, and more importantly, experience.
The hypothesis to be tested was “that the scoop stretcher would be as effective as the LBB”. In fact, the results show:
There was approximately 6-8 degrees greater movement in the sagittal, lateral, and axial planes during application of the LBB…
No difference was found during a secured logroll…
FSS induced more sagital flexion during the lift…
And so the study concludes:
The FSS caused significantly less movement on application and increased comfort levels. Decreased movement using the FSS may reduce the risk of further spinal cord injury.
What does this mean? Essentially, while applying the spine board, the necessity to log-roll and to perform the “Z-maneuver” (moving the patient up the board to a position where they can be secured) leads to a large amount of movement of the spine. Although once immobilised, the spine remains almost perfectly in line, getting them on is much worse for any possible spinal injury than getting the patient on the scoop (which also keeps them almost perfectly immobilised, as shown by the secured log-rolls). The following graphs show the movement – applying the spinal board takes one and a half times longer than the scoop, and leads to far more movement, especially during the log-roll (red) and z-maneuver (blue):
Movement of the spine with time on application of a board and a scoop
The results are clear - applying the scoop leads to far less movement of the spine than the longboard, and presumably the same applies getting the patient off on arrival to hospital. Though there is another point to be raised – how the patient feels about the whole thing. Getting boarded is scary – we’ve all had it done to us (if only for poops and giggles), and we’ve all had patients screaming with fear as we do it to them. The “casualties” were all asked therefore to rate how they felt on both, and conclusively the scoop came out higher than the board, both on comfort when laid on it and the floor and in how secure people felt being attached, rolled and lifted.
Problems
This study does have a few flaws. Firstly, it looks at the newest, most rigid Ferno scoop. Unfortunately, we don’t see any kit like this, making do with older alumnium scoops. The issue here is that they flex far more in the middle, and the taller you are, the worse it gets. As the study highlighted, the biggest problem with the scoop is flexion in the sagittal plane, which we’re going to induce yet more of due to arguably substandard eqipment. However, sagittal movement is still significantly better for a spinal injury than axial rotation, which is what we’d be doing putting them on the board, especially because, as discussed above, we’ll probably do far worse a job of the log-roll as a VAS.
Secondly, the research doesn’t cover comfort and security in transit. Now common sense would say that the same results would apply in terms of security (i.e. the scoop is comfier and feels safer – personal experience will vouch for that), but what about preventing movement? We know common sense can’t necessarily be trusted (hence the point of this study), but grossly, I feel that the point isn’t important as a) They were shown to be equally as good (other than the sagittal flexion) during a lift and just as good as each other during a secured log role, both of which are likely to induce more movement to the spine than being in a moving van, and b) The majority of movement is getting them on and off, for which the scoop is (as shown) significantly better due to not needing a log role or Z-maneuver.
Finally, the study was funded by Ferno. Now this is declared in the journal article, and points to avoid this bias were made including
we agreed, prior to initiation of the study, that the results would be submitted for publication, regardless of the findings.
I guess the bias to one of the other mode of immobilsation isn’t really there anyway, as Ferno make both boards and scoops, so they win either way…
Conclusions
The evidence is pretty conclusive – in the supine patient, the scoop is significantly better, especially when used by a voluntary aid service. We’re never going to acheive perfect immobilisation, even if the equipment was perfect we just don’t have enough experience to do it properly every time. However, we can do our best, and the scoop allows us to do just that.
Should we drop the longboard entirely? Hell no! It still has its uses – extrication from vehicles, standing takedowns, and patients in awkward positions who need to be rolled and moved anyway. But the majority of spinal injuries we come across are laid approximately supine, and so here the scoop can be utilised far more than it already is. Anything that needs scooping onto a board we should be thinking “why don’t we just leave them here?” – not only is it more comfortable and makes the patient feel more secure, it also minimises the amount of manual handling (danger to ourselves) and movement of the patient (danger to them) while maintaining just as much inline immobilisation as the “gold standard” longboard.
As soon as we were passed the job, I knew it was going to be a waste of time. “Back pain, unable to move, requires a chair”. Sometimes, just sometimes these do actually require some medical assistance – more often than not, it’s only sheer laziness that needs treating.
Driving through the very exclusive looking village, we spot the house name (never a number) at the foot of a wooded driveway, leading to a rather grandiose house. In front were parked two Chelsea tractors that we manoeuvred around to park up as near to the front door as possible.
We were met at the door by a perfectly manicured woman. “He’s upstairs,” she told us abruptly, followed by the classic, “we’re not ready, the doctor said you’d be four hours.” No dear, up to four hours. If you wanted precise timings, you can always book a taxi.
“Of course,” she continued, “he only needs you to take him to hospital. There’s nothing wrong with him, and even then, I’m ILS trained and so better qualified than you.”
Are you indeed? Obviously I have no idea how to use the defib and resus gear in the emergency ambulance parked outside your house. Damn my lack of training! Good job you’re here isn’t it?
We went upstairs, to find the patient sat on the edge of his bed. “How’s that pain?” I asked, to which he replied it wasn’t too bad. As in, he could stand up and walk downstairs on it. Walk out to the ambulance in fact, then sit down into the distinctly uncomfortable and cramped seat in the back of the van, without even a grimace on his face. His pain score was negligable – I didn’t even bother offering pain relief.
“I’d rather follow him in the car, then we can get back,” said the wife when I asked if she’s be travelling with us.
As soon as I walked into your room, I knew this wasn’t going to be pretty. Your wife was laid in bed, frail looking, pale and sweaty; you were sat by her side, holding her hand, a mixed look of fear and devotion on your face.
I moved round to your side of the bed, and tried to rouse her – she responded only with incomprehensible noises as pinched at her earlobe. I tried to get a history from you, and the tears welled in your eyes as you told me you weren’t sure what had happened. She’s normally so well, you said, but this morning you woke and she was just awful – lethargic, breathing shallow, eyes scrunched shut, complaining of a severe headache. And she’s just got worse since. Anything I asked you more specific got the same response, that you’re not sure.
I politely asked if you could move so I could assess your wife, and you hurried back out of the way, prepared to do anything you could to help your other half. You look horrified as my partner sets up an oxygen mask; as your wife screams and curls up when I shine a torch in her eyes; as every movement of every joint leads to her yelping in pain. Your face dropped further and tears began to flow freely as my partner reappeared with a chair and the two of us manhandle her on to it while I ask you about the rash on the side of her head. You don’t know, you repeated, shaking your head, you just don’t know.
As my partner rapidly moved your wife outside with the help of the carers, I stopped next to your chair. I watched you, slumped dejectedly in the chair staring through watery eyes at the detritis of wrappers and equipment littering your room, the envelope in your hand which until recently contained a letter from an out-of-hours doctor diagnosing your wife with a mild chest infection. I crouched down, and took your hand, and told you not to worry, that she just had a little infection that needed to be treated at hospital. You asked if you’d ever see her again, and I told you what the carers had told me, that your son was coming to pick you up and take you to hospital this evening. You took my hand, and asked the same question again, this time with more urgency and a definite aim behind it. I told you that we were doing everything we could.
I know she’ll be dead by now. Looking at her, she had no more than a few hours left. That rash, spreading over her body as we watched; the most severe photophobia I’ve ever seen; the screaming when I moved her neck or knees; all that combined with her overall frailty suggests to me that she won’t have lived through the night. I should have told you this, but I didn’t. I gave you false hope. And I felt fucking awful for it, as you shook my hand and thanked me. But there’s a part of me suspicious that you’d worked out the likely outcome way before we even got there.
Should have gone to Specsavers? King Magic points us in the direction of this story….
A critically ill patient died after a neighbour deliberately blocked an ambulance taking him to hospital… Gillian Birdsall, 50, was yesterday convicted of deliberately obstructing the emergency vehicle, preventing paramedics from getting the father of two to hospital where he died hours late (Daily Mail)
I’m always amazed at how selfish and unthoughtful the public can be towards ambulances. The majority of people are fantastic, but there’s more and more who seem to think that all we’re doing is getting in their way deliberately and abusing our power. The most common is being told to move our vehicle – I remember being told that “there’s too fucking many of you, one of you might as well go” when at a patient’s house with two ambulances and a car by a white van driver. Then there’s the people who just get in the way, sometimes seemingly deliberately, of the ambulance when on blue lights and sirens, as if we’re somehow taking the piss and just using the excemptions to get home early rather than because there’s someone very ill and/or in pain in the back.
I could go on. But there’s something in this story that amused the hell out of me. And worried the hell out of me too, for that matter…
Married mother-of-two Birdsall, who works at two part-time jobs, later told police that she was in a rush and did not realise it was an emergency vehicle… She told police: ’I thought it was one of those ambulances they use to pick people up but did not think it was a real ambulance. (Daily Mail)
For one, the patient transport ambulances are still “real ambulances”, with trained staff and ill people on board, so that’s no excuse. But didn’t realise?! It’s a big yellow and green van with flashing blue lights and “EMERGENCY AMBULANCE” plastered all over it. How the hell can you not realise what it is?! (yeah, I’m playing with html tags, so sue me). Surely, if you can’t spot that one, then you shouldn’t be driving?
[Because I haven't written about work for a while... And no, this isn't about my crewmate's favourite use of the word "smurf"]
Yesterday evening we were sat in the pub regaling* a first year pre-clinical med student (a metastudent doctor?) who was suffering a bad case of I’madoctoritis with stories of how bad some of the GPs we come across are. Today, our view sunk to a new low.
A quick primer: Oxygen saturation. This is a measure of how much of the available haemoglobin in the blood is carrying oxygen – as a general rule, high is good, low is not. For a healthy person, “sats” want to stay between 95-100%; for someone suffering with COPD who’s body is used to living in a low oxygen state it can slip to 90-92%. Measuring oxgyen saturation is easy – you clip a pulse oximeter on their finger, wait a while while it settles down, and write down the answer. But with a lot of people you can tell before you put it on whether their sats are ok or not – if they’re good, the patient is pink; if low, the patient is blue.
Asked to go to an urgent in the middle of nowhere for shortness of breath (for a change). We set off, and in an hour and a half we reach a little town in the middle of the dales. No sign of the patient, so I contact control who give the patient a ring back, see if anyone can come out to meet us. In the mean time my crewmate has gone off to see if there’s anyone around who can get us to the patient – turns out that we can go through a cafe and out the back of their kitchen to get to his little flat. Grabbing the back, in the off chance the patient really is SOB and needs some oxygen, we walk through the cafe to the suprise of the customers, and round the corner to the patients house to find him just leaving.
Both our jaws drop. Not only is the patient pushing 7 foot and built like a brick shithouse, he is also properly blue. Not “slightly cyanosed“. I mean blue, like Papa Smurf if he’d wandered onto the set of Honey I Blew Up The Kids, then hit the gym to make up for his lonely existence as the only giant smurf. Worse, he absolutely insisted on walking out to the ambulance – how he was still walking in that state I’ve no idea!
The resemblance is striking
In the van, we take his sats – 59%. What. The. Fuck. I find it hard to believe that the man is still walking and talking if his sats are that low, but the machine is flashing green meaning that it’s pretty certain of that reading, and palpating the radial pulse confirms it’s picking up the right signal. He has no history of breathing problems that could possibly cause this and it sure as hell isn’t normal for him, so we pop some oxygen on. Within a few minutes he’s pink again, and we trundle into hospital normal road conditions.
Ah, but dear reader, you want to know why I dislike a GP over this one. I’m getting there, patience! I have a look at the GP’s letter regarding the patient. The man is being admitted due to his low sats – apparently they were 77% when the man visited his GP surgery complaining of shortness of breath. The doctor then sent him home to wait a four hour urgent ambulance. You tell me why that was right? Surely the basics of “oxygen is good for you, no oxygen isn’t” are taught at medical school? Ok, so I’ll forgive family doctors some things, for the majority pre-hospital isn’t their forte. But that? I tell the nurses in my handover at A&E – their response? “Surely there’s someone you can put a complaint in with? We’ll do one from our end…”
Later, we visited the Smurfette. An elderly lady with “infective exacerbation of COPD”, a chest infection making her already ropey breathing worse. Doctor had been out to see her this time (wow!) and taken her sats at 65%. He explained to her that they’d be low with her condition… But surely, surely not that low? Again she was blue, but could barely move let alone walk. A bit of oxygen and again we were on the mend, and minutes later I was handing over to that same nurse who was once again mortified.
The moral of the story? I don’t know, that some GP’s are crap? But then, anyone who’s been to visit one would know this! It’s a shame, because the majority of GPs are very good at what they do. But there’s a few who just let the side down time and time again, and that’s the overiding image of GPs that sticks in your head. I remember on our first week off the job, an IC bleed that the doctor had diagnosed as the flu. The RRV paramedic that came to meet us saying, “let’s see what the quack has said”, glancing over the doctor’s letter – I thought this was quite rude! Now I say it…
* Ok, so it was more a bait as we were spoiling for a fight with him. But you wouldn’t blame me if you’d heard the stuff he was going on about!
The job came in as a GP urgent for a gent going for palliative care. This is obviously nothing that’s going to change in a hurry, so we grabbed a quick drink from the vending machines in A&E and headed off on normal road conditions – hell, the family will probably complain we were there too quickly (“The doctor said you’d be four hours, we haven’t even got his bag packed”).
After over half an hour drive, we parked up outside the house. Grabbing some gloves – these have a chance of being messy – we wandered over to the door, where we were met by a relative.
“You’re going to have a bit of a job,” he said. I thought this just meant it would be a mission to remove him from the house, so I walked upstairs. Then heard the patient.
The breathing. Gurgling, or more technically, aspirating. Very rapid. Very shallow. Not normal at all.
I take a peak in the room. “Can I get the bag, please?” I ask my crewmate, as I look at the man, completely unresponsive, flushed and supine on the bed. I try and wake him – no response to my voice, peripheral or central painful stimuli. The eyes don’t open, no noises are made, the only thing we get is a slight movement of the arms on inflicting pain on the fingernails.
My crewmate reappears, and puts an oxygen mask on the patient. She tries to take a pulse, sats and blood pressure while I get a history from the family – he was found completely out of it this morning, and hasn’t improved since. The family called the patient’s GP, who referred them onto the out of hours doctor, who referred them onto the local (none-A&E) hospital, who asked if we’d take him in. No-one saw the patient before we got there.
The gurgling is worsening, so I grab the suction and start clearing his airway. I’m informed that the patient has oral thrush, which will explain the white gunk coming down the suction catheter. With the risk of aspiration abated, I take a peek at the man’s pupils, peeling back the eyelids with my fingers. I shine a pen torch into each eye – his pupils don’t dilate in response to the light, and his eyes immediately shy away from the light. My crewmate informs me that she can’t get a blood pressure and can barely find a radial pulse, and asks if I’ll have a go. I try for a radial pulse – it’s weak and comes in and out, implying a very low blood pressure. I notice his hands are pale. and worse, have a non-blanching pruritic rash on them. I look at his stomach – the rash is widespread across the chest and abdomen. I call for backup.
A non-blanching, pruritic rash
The RV arrives, takes one look at the patient, and calls for further backup. This patient needs IV penicillin, the front line treatment for septicemia (aka “blood poisoning“), often a terminal sign of meningitis. The responder was an EMT, and so like us couldn’t give the drug – the only thing the three of us could do in this scenario was “GLF”, and with a twenty to thirty minute hospital time getting a paramedic there would be more beneficial to the patient.
It takes fifteen minute or so to get us a paramedic crewed ambulance – in the mean time we continue monitoring, suctioning and the oxygen flowing. The technician’s defib gets a blood pressure of 70/50 – this man is going into septic shock, and needs to go to hospital now. We get the man packaged on the carry chair and between us get him downstairs to await the ambulance. The whole while his respirations get faster and shallower, his pulse shoots up, and the rash spreads across his body before our eyes.
Blue lights and sirens in the street herald the arrival of the ambulance, to the very visible relief of all three of us. We wheel the patient over to the vehicle, and hand him over to the two paramedics on board who immediately get the drug started. They blue-light the patient into hospital – we hear a pre-alert over the radio that his condition has deteriorated further. Chance are he’s dead by now.
*****
My reason for this story is to answer a question that’s bugging me – is this negligence on the part of the doctor? The family told the GP that the patient was unresponsive – to us, this is a “red flag” condition and warrants a paramedic (for advanced airway management) and rapid evacuation to hospital. Yet the GP didn’t bother to come and see the patient, instead referring the patient to a completely inappropriate service, which lead to our visit.
Inappropriate behaviour, surely. But it is actually negligence on their part? There’s several parts to this:
Did the doctor have a duty of care towards the patient? If it was the patient’s regular GP then I’d argue so. But what if it was a GP the patient had never or rarely seen, who wasn’t aware of the patient’s pre-existing neurological condition. Though even if it was, surely a GP has a duty of care towards any patient that is referred to them?
Did the doctor breach said duty of care? Did the doctor’s conduct not match that expected of them? The family certainly thought so – they were disgusted that the original GP hadn’t come out to see the patient, and I’m inclined to agree with them. If nothing else, the doctor should have questioned the family and called this in as a “GP red”, i.e. an 8 minute, paramedic crew response time.
Did the doctor’s breach of duty cause the patient’s serious illness? In other words, is it the doctor’s fault that this patient nearly, or probably did, die? Had the doctor visited and worked out what was wrong with the patient, would the story be different? This is the toughest one – perhaps, regardless of what the doctor did, the outcome would have been the same. Maybe the illness was so far advanced by the time the family called that there was no hope for him.
Finally, did the doctor’s breach of duty lead to damage to the patient? Did the patient suffer a loss, or even did the family suffer a (permanent) loss? I may well find out tomorrow.
What’s your thoughts on the matter? Though another question is if the GP had visited, would they have picked up on the signs and symptoms and made the same diagnosis (or rather, “impression”) we did? Would the patient have had any more chance of survival than with our skill set?
We pull up alongside the doctors’ surgery, and my crewmate hits the “Arrive Scene” button as we’re blocking the entire street, bathing the narrow road in strobing blue light. I check the job description – a GP urgent for shortness of breath.
Walking into the main entrance of the still packed surgery, the receptionist informs us that the patient has been moved to “the treatment room”, and directs us round the corner. We’re greeted by the practice nurse, who introduces us to Jenny, the patient. An elderly lady is sat on a chair in the centre of the room. In addition to obvious difficulty in breathing (not the same thing as SOB), she’s clammy – visibly sweating – and anxious. On a quick examination, she informs us of a quite painful aching sensation across her shoulders that radiates up her neck and down her left arm, and that she’s feeling very nauseous.
I switch to “OPQRSTA” history taking mode. It started when she got off the bus (she was coming to visit the doctor on something unrelated), and got worse with exertion. It didn’t get better with rest or positioning. It rates somewhere between five and seven out of ten, and she’s had the same sensations before.
GTN spray
I asked Jenny to elaborate on this a bit more. Apparently she has difficulty breathing and shortness of breath semi-regularly, and has a GTN spray to control this. Sometimes the pain accompanies it, more often than not on exertion, but it usually goes away when she rests. But then there were two occasions when it didn’t go away, just got worse, and then she was told that she’s had heart attacks. I ask about the spray, but Jenny forgot it today. I ask the nurse if she has some (we don’t carry it as an SJA crew), which she thinks she does. But it turns it’s missing from her cupboard.
The nurse finds the patient’s notes on the computer, and passes me a print out. She has a long and complicated cardiac history, including current angina (hence the GTN) and as stated, two MIs, treated by thrombolysis and pPCI. I ask the patient about this, and she tells me that this feels just like the last time. She was told later that it was a heart attack – she never has chest pain, the traditional heart attack symptom, so it didn’t occur to her that her heart was dying.
“Have you done an ECG?” I ask the nurse. She replies not, because the GP told her not to. You what? I ask if she’ll do one, and she’s more than happy to, and goes off to find the surgery 12-lead. By this point the patient is already on high flow oxygen, and we’re digging out some aspirin for the them to chew. The nurse returns with the machine, but also an unwanted visitor – the doctor who originally called this patient in as a low priority emergency (we are expected to respond to GPUs within 4 hours unless otherwise specified).
“What’s going on?” he asks. I inform him that we’re querying ACS, to which he informs me that it’s impossible for Jenny to have a heart attack as she’s already been treated for two. Excuse me, what? He asks what we’ve done for her, and the nurse mentions that her GTN is missing, but he has an answer for this too – it’s in his car. I dispatch him to (reluctantly) fetch it.
In the mean time, the nurse has been trying to take the poor lady’s ECG. This hasn’t worked, for the simple reason that she’s sweating so much the dots keep slipping off. Doesn’t matter anyway, as I’m not allowed to make decisions based on interpreting it, and the doctor seemed to be as much use as chocolate teapot. I phone for an RV paramedic to back us up – as ETAs, there isn’t much more that we can do than we already have.
A "barn door" MI. Even I can tell it's not supposed to look like this.
As we wait for the paramedic to arrive, the lady tells us that the symptoms are lifting. The interventions we’ve made so far seem to be working – not only is she feeling better, she’s less clammy, and her blood pressure and heart rate are returning to more normal values. By the time he turns up, she’s breathing much easier, and claims the pain is lessening, retreating back up her arm and down her neck.
I hand over, and he connects her up to his Zoll monitor, which comes with much stickier pre-hospital ECG dots. He hits record, and examines the print out carefully. Very carefully. My neck cranes over his shoulder to take a look as he studies it intently.
Finally he announces, “there’s nothing wrong”.
What? Aside from some inverted T waves due to her past heart attacks, there’s nothing to suggest anything going wrong that would cause her symptoms. And that seems to worry all three of us more. We get her on the carry chair and quickly take her out to the ambulance. The paramedic grabs his big red bag of kit and jumps aboard. As her symptoms still haven’t completely disappeared (the pain remaining around three out of ten) he pops a cannula in as a precaution in case things go wrong in a hurry, and we set off to hospital.
Sat in “the airway seat” as he talks to the patient from the side, I spot something going on with the ECG behind him. She appears to have a ventricular ectopic creeping in every three beats – that is, a beat of the heart that is triggered by a pacemaker within the ventricles and flows up the heart, as opposed to a normal beat triggered by the sinoatrial node (SAN) in the right atrium that flows downwards. Now, lots of people have these and normally they don’t cause any problems. But they are a problem in people with a cardiac history, as they can lead to a horrible heart rhythm known as ventricular fibrillation if they overlap with the normal heart beat, stopping the heart from depolarizing properly and leading to the ventricles essentially just wobbling about. This is a bad thing, as the heart cannot shift blood when doing this, and so violates one of the essential tenets of being alive (those being “air goes in and out, blood goes round and round”) and very rapidly leads to not being alive. Incidentally, this is where the term de-fibrillation comes from – stopping the wobbling heart with an electric shock in the hope that the SAN will take over and the heart will start beating normally again.
Normal beat, normal beat, CRAZY beat, normal beat....
Now, ECG changes are generally considered to be a bad thing. Especially when accompanied by heart attack-esque symptoms. I chat with the paramedic about where and why these beats are arising, and why they’re so regular as we trundle on a little further, stuck in road works enhanced rush hour traffic.
Then another change. The ectopics are arising every two beats, and the interval from the end of the regular beat to the beginning of the ectopic is shortening. On go the lights and sirens, and within minutes we’re in hospital with a cardiac team surrounding her. The ectopics are composing every other beat, the pain is worsening, and her blood pressure is shooting back up.
*****
At this point, the story ends as we had to give the paramedic a ride back to his car before our shift ended. I haven’t seen or heard about the patient yet, I keep meaning to follow it up but getting sidetracked. Entertaining yarn perhaps? But the point that I want to rise is: This GP almost let his patient die.
Something was going wrong with her heart. Ok, so things had been going wrong with her heart for a long time, but this was something new, something acute. And things going acutely wrong with hearts generally don’t go wrong for long, as you normally end up dead quite soon.
This woman was also ticking just about all the boxes for someone suffering with something wrong with her heart, namely acute coronary syndrome or ACS (or in simple terms, either a heart attack or angina that isn’t going away). We could tell just from seeing her. The nurse sure as hell knew. The patient even knew. But for some reason, the doctor brushed it all aside. The patient came to see him for help, and all he did was call her an ambulance to arrive some time in the next four hours and sit her in the waiting room without even the drugs he prescribed her to deal with such attacks.
The nurse recognised there was something going on, and moved her into the treatment room. The doctor told her not to worry, and not to do an ECG. We recognised there was something going on, and got told patronisingly, “well, it’s a good job you ambulance boys turned up so quickly then,” without being offered any help from his supposedly superior medical knowledge and skills.
That patient should not have been left on her own in the waiting room. What would have happened had the nurse not been so on the ball? What would have happened if we had not just come clear up the road? Why didn’t he provide Jenny with the care she needed?
We come across a lot of bad GPs in this job. Those who call ambulances for no reason (the painful eyes that didn’t hurt, the fractured ankle that the GP diagnosed in two minutes over the phones). Those who miss the obvious (meningitis, strokes, intracranial bleeds). But this takes the biscuit. A patient who presents to the doctor themselves (they don’t even have to go anywhere!) with symptoms equivalent to wearing a t-shirt with MY HEART HURTS! in huge letterswritten on it, and he does almost nothing. He can’t even be bothered to leave us a note with what he’s done and why he thinks she needs to go to hospital.
No matter how many GPs I meet who are good at their job, this one guy tars the entire profession with the same brush. And I don’t know what to do about it, because I fear for the patients. This GP dropped the ball in a big way, behaving completely unprofessionally and against his duty of care, and I seriously worry that this isn’t just a one off and that someone will die because of this behaviour.
Thestoriesarealltrue, so I’m off to work to save the lives of those with the sniffles or “painful eyes”. Sucks. I was goinfg to have a rant about GPs, too lazy to go and see the patient who calls them out so they just order an ambulance for them, putting countless lives at risk in the process, but I won’t. Or did I just inadvertently do so?
You are currently browsing the archives for the Ambulance category.
Dysphoric Mania
Rants and raves from a geologist come ambulance man come medical student. Throw in a bit of internet geekery and mentalist pride and this blog is the result. Mostly coherent, sometimes relevant, occasionally sensible, never worth reading.
Posted by nickopotamus 
Posted by nickopotamus 
Posted by nickopotamus 
