As part of my upcoming ‘induction week’, I spend a day meeting “my” General Practioner. And I’m really looking forward to it.
Who am I, and what have I done with Nick? Yes, so I may not come across as the biggest fan of the GP on this blog. But it’s not just me, no-one involved in prehospital work is a massive supporter of primary care. Tom Reynolds is probably the most eloquent on the subject, but we all have our horror stories. One of the first things I was taught on the job was the GP actually stands for “Get paramedic”, with the phrase, “Let’s see what the quack has written,” uttered when I asked for backup on a SAH that had been diagnosed as “?flu”.
But, shock horror, there are good GPs out there. Once in a while, we get an appropriate GP Urgent or GP Red. The doctor has been out, properly assessed the patient, worked out they do needto be in hospital within a given timeframe, given us a thorough written handover, let the hospital know, and explained what’s happening to the patient. But this happens rarely. The reason why? In the majority of cases this same GP goes out, properly assesses the patient, works out they don’t need to be in hospital (or if they do, don’t need an emergency vehicle to take them in), and treats appropriately themselves. So we don’t see them. What we do see is the lazy, bad GP, for whom every single patient has “HR 70 reg BP 120/70 RR 12″ with “chest clear, basal creps”. Every single one (I’m not joking). We see the GPs who miss the blindingly obvious MIs and strokes, and we see the GPs who call ambulances for “eye pain” and other shit that means the patient doesn’t need to be stuck in a ward full of infections, let alone a blue-light vehicle to take them there.
So because of this, pre-hospital has a deep mistrust about general practice. And the same is reciprocated, where the good GPs see the ambulance staff completely ignoring them and disregarding what they do. And it leads to all manner of incident like this Doctor Crippen rants about. Patients diebecause of ambulance staff not trusting GPs. But the crews have to gothrough the rigmarole, because they need to properly assess every patient themselves, as in the majority of cases the doctor hasn’t. The two professions, who should be working together for the benefit of patients, are in fact at each others’ throats, and it doesn’t help anyone.
Where am I going with this? Well, it’s the reason I’m really looking forward to getting involved with a GP surgery. I have a very biased view of general practice so far – a whole lot of shite from running urgents, and the bipolar opposites of some amazing GP for my personal medical issues through to those who just don’t seem to care and the continual argument of how some primary care physicians can fuck up pain management just so much. So I want to see things from the other side, the view from the overworked GP without enough time to properly do their job, having to be not only jack of all trades but also master of all trades. I want to see how the whole thing works, from start to finish, and where my pre-hospital role and (hopefully) future in-hospital job come in to the holistic, life-long care of the patients.
Don’t worry, I’m not going soft. I’m not interested in general practice as a career - even if I did have the compassion or sensitivity to deal with people, the reason I ran away from geology was the nine-to-five, stuck behind a desk life. But hopefully, working in general practice will help me see why things work the way they do. And I’ll appreciate the good GPs, forgive the GPs who occasionally slip up (and realise that I will one day be making those fuck ups), and maybe get an inkling into where those bad, lazy doctors come from, and how to avoid becoming one.
I’m almost bored of ranting about the lack of adequate pain management in primary care. I say almost, but the slightest provocation in real life will probably set me off (as it did today… and regarding euthanasia, abortion, etc….), however I’m really quite fed up writing about it.
But that’s ok, because (another) Nick has taken up the torch. So go over there, and get your daily dose of rant. Insulting primary care doctors due to their mismanagement of chronic pain? Just my cup of tea…
The BBC News, as with every media channel, are running with the story that Michael Jackson’s personal doctor may be responsible for his death. Not only are they questioning the drugs he prescribed and his standard of care, they’re even going so far as to question how he behaved after he found the plastic figurine in arrest:
Paramedics were called to Jackson’s Los Angeles mansion while Dr Murray was performing CPR, according to a recording of the 911 call. Because Jackson was so frail, Murray “administered with his hand behind his back to provide the necessary support,” Chernoff said. He denied claims that the doctor may have botched the resuscitation attempt: “He’s a trained doctor,” Chernoff said, “He knows how to administer CPR.” (BBC News)
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.
[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?
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 
