Diagnosis R.I.P

Senior management’s attitude to patients and staff

If you came here looking for the DiagnosisN.F.I. blog then I’m afraid you’re too late. I’ve deleted all the posts and this is all that’s left.

Too be honest I can’t be arsed any more. The NHS Ambulance Service is fucking shambles. It used to be about caring for patients and taking them to hospital for definitive treatment. Now its all about Nu-Labour’s top-down control obsession, a.k.a. response times.

In the Nu-Labour ambulance world You, the patient, don’t matter. Management don’t give a toss about you; whether you live or die, suffer or get treated is immaterial. To them a 999 call is a pain in the arse; just another target to hit. And they certainly don’t give a shit about the staff: training’s non existent; development’s out the window; most of the vehicles are off the road with faults; equipment doesn’t work; we can’t get hold of the drugs we need; shifts go uncovered coz staff have just had enough – but still the relentless drive to meet those 8 minute response times goes on and on (even though there’s not a shred of evidence that it makes any difference).

I care about patients. I’m good with them and I treat them the way I’d want to be treated. In 12 years I’ve never had a complaint about my patient care and I’ve never had anyone question my treatment. That’s the way I think it should be. If I can treat them at home, then great. If they have to go to hospital, well that’s what we’re there for. After all the word ambulance is derived from the Latin ambulo (to travel, to take a walk).

I’ve lost heart in the current climate. I was informed the other day that I must now spend all my shift stuck in the response car out on cover “so we can hit our A cat response targets.” I told them to fuck off. I’ll be damned if I’m going to spend hours stuck on a street corner or driving aimlessly about. Ambulance crews can return to station but not response cars: another desperate move that shows how obsessed the management have become. They haven’t got a clue what’s really happening on the front-line. An operations manager recently expressed his surprise when he had to wait 20 minutes for a back-up ambulance with the patient only 5 minutes travel time away from the hospital. “Hey arsehole! wake up and welcome to the real world of solo response. A 45-90 minutes wait is now the norm“.

So…

If your a senior ambulance manager or a control manager – then fuck off!! You’ve wrecked a once excellent service.

If your a Nu-Labour politico then I say to you – I hope you never have occasion to call an ambulance coz you’re in for one hell of a shock.

To all my patients – I’m sorry. I’m doing my best but in the current climate you don’t matter any more.

Happy Crampers

The out-of-hours team – at your service Sir

There’s been a lot of criticism recently about the current state of the out-of-hours doctor service now that most GPs have chosen to opt out. (Telegraph report) Down in my neck of the woods though we’re providing an OOH service that’s second to none.

Sometime early last evening Bill managed to get an OOH doc to call because his legs were “playing up“. To be fair, his legs are a bit of a state; oedematous, ulcerated and in no condition to go marathon running or morris dancing. Bill reckons he’s got cramps but whatever the actual symptoms were the doc decided a prescription for some diazepam tablets should do the trick. GPs usually prescribe quinine sulphate for cramps in my experience. Alternatively why not try some tonic water, its got quinine in it and goes rather nicely in a tall glass with a liberal splash of gin, some ice and a slice. Now Bill lives in Tumbleweed Village and the local pharmacist was closed so he was going to have to wait until morning to get his tablets.

Moving forward a few hours and Bill decides that he’s really not going to make it until morning, so what to do? No point calling the OOH service again; he’s already got the prescription. NHS re-Direct can’t help, other than to suggest he gets the prescription filled “Hey, the chemist’s closed what other bright ideas have you got?” So, following a time honoured tradition he naturally dials 999. Good old AMPDS managed to come up with a ‘B’ cat ‘patient unwell’ code and Control sent a 5 tonne front-line ambulance round on blue lights.

Needless to say the crew weren’t too impressed. One of them had a bit of a ‘light-bulb’ moment and rang me up on the bat phone. “Hello Magwitch, you carry diazepam tablets on the car don’t you? Fancy coming round and helping Bill out?” Not much was happening so I squared things with Control and tootled off for a pleasant drive in the country out to Tumbleweed Village with Chet Baker happily playing on the jukebox.

Now it was a bit of an oversight on my part but I didn’t think to ask exactly what the OOH doc had prescribed. I’ve got 5mg diazepam tablets on the car but the prescription was for 2mg ones: oops. I put in a call to the doctor who sits up in the Control centre covering the telephone triage for what’s left of our service’s OOH contracts. The doc wasn’t too impressed either and, as I expected, he wasn’t happy for me to leave my tablets to fill Bill’s prescription. So on to plan B then; or is this plan C? The OOH co-ordinator on the desk did a bit of tap, tap, tapping on her computer and advised that there was a late night chemist still open back in Scroatsville. Looking a bit sharpish I grabbed Bill’s prescription and headed back towards base to get the pills.

The pharmacist was wonderful. Prescription filled, FP10 form signed and I was winging my way back to Bill in double-quick time. Problem solved. Another happy punter for the ambulance service.

So what did it take to get the cramp in Bill’s legs sorted out?

Meet the A-Team: an OOH GP, A front-line ambulance with a paramedic and EMT crew, an ECP on an FRV, another OOH GP, an OOH co-ordinator and a pharmacist.

God we’re good! Don’t you just love it when a plan comes together!
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Photo from The A-Team Shrine

Booze Brigade

They’ll be running the country in a few years.

Following the tragic and senseless murder of Gary Newlove, Peter Fahy, Chief Constable of Cheshire Police, has quite rightly in my view, reopened the debate on under age drinking and anti-social behaviour.

“Alcohol is too cheap and too readily available and is too strong. Young people cannot handle it.” [plus], “a hardcore” of parents “abdicated” their responsibility.”

My thoughts exactly. 3.30 this morning and I was called to a house where someone had fallen down the stairs. Turned out its a 14 year old lad and he’d been drinking. When I arrived he was in a crumpled heap on a small landing half way down a flight of stairs. Claret (blood for the uninitiated) all over the walls and down his head; vomit all over his shirt and covering the stairs; and he’s totally ‘out of it’ – GCS of 7. These kinds of jobs are a nightmare for a solo: what to do? You have to consider a cervical spine injury given the circumstances; you need to maintain his airway what with all the blood and vomit; you can’t drag him down the stairs but he’s thrashing about all over the place (probably from cerebral irritation) so its a case of trying prevent him from toppling the rest of the way down. Things are not helped by Control telling me that “we don’t know where your back-up’s coming from as we haven’t got any vehicles available.” – nothing new there then (remember this one?)

In the end I was with the lad for over 40 minutes before a vehicle turned up. During that time at least 10 other people ‘appeared’ in the house and not a single one of them looked to be of a legal drinking age. All of them seemed a little “worse for wear” and some of them gave me the usual abuse of “where’s the f**king ambulance mate? What you doin ’bout it then, eh?” Plus more antagonising comments of a general nature nicely punctuated with swearing.

This wasn’t the lad’s home either. Did his mother know where he was? Apparently not it seems when the hospital got around to calling her. And where were the ‘responsible adults’ who owned this house? Certainly not on the premises that’s for sure.

I checked back at A&E before I came home to see how he was getting on. They’d intubated him. He’d had a scan and a ‘C’ spine X-ray. All clear. No other injuries so that was a relief. “He’s just pissed” the anaesthetist who was with him told me. “I can’t believe all the time, effort and money the NHS has had to spend on this guy and all because someone let him get drunk at 14!“

I went back to station after the job to clean off the vomit that was stuck all over my boots. Someone said I even had blood in my hair, that must be from where he’d flailed out and caught me round the head as we carried him down the stairs. I had to spend the rest of the shift with vomit stained trousers as our service is too tight/incompetent/irresponsible to provide me with enough uniform to leave a spare shirt and trousers in my locker. I’ve only got two pairs of uniform trousers and I’ve been waiting nearly 10 months now for that ‘interim uniform issue’ to reach me.

Ha! was that another pig I just saw go flying past the window?

Walking into Walls

Walk this way sir.

I was passed an ECP call the other day to visit a 50 year old gentleman with pain behind his eyes and dizziness when standing. What on earth did they think I was going to do? I don’t carry any magic pills for that sort of thing. Besides, it was a weekday and just before lunch, so the GP surgery would be open and there was still time to book a home visit for that day. Bear in mind as well that this was originally a 999 call so we’d already gone through the useless ultra cautious triage provided by AMPDS which had churned out the result that this was neither a life-threatening call (the usual response) nor even an urgent one. In fact AMPDS had given this a ‘C’ rating and the call had been passed to the ‘C’ category desk – a relatively new set-up along the lines of NHS re-Direct – where all the crap inappropriate 999 calls we receive are sent. The paramedic on the desk had phoned the caller back and had had a good old question and answer session to try and determine what was wrong. This normally results in offering self-care advice or telling the patient to contact their GP. Today, however, they’d decided that I needed to go round. WTF?

When we used to have OOH calls as well as all the 999 stuff these ‘odd’ visits were quite common but at least the triaging doctor in the control room was usually good enough to speak to us lowly plebs and explain his or her reasoning. Invariably it was along the lines of “haven’t the foggiest what’s wrong with this patient but its the middle of the night so would you mind popping round, doing a quick assessment and then phoning back so we can sort it out together.” Teamwork, that’s what it was all about. I was the doctor’s eyes and ears on the ground and in return I would probably pick up a tip or two to file away for future calls. With the ‘C’ cat desk there’s none of that. They haven’t got a clue either and seem to be under some kind of misapprehension that ECPs are miracle workers.

Anyway, I eventually pitched up at the address about 2 1/2 hours after the patient first dialled 999. Oh, and why did they dial 999 in the first place? Because they’d already spoken to the GP, explained the symptoms and the GP had advised an ambulance response and a trip up to the hospital – of course Control and AMPDS know better!

“How can I help?”
“I’m having trouble walking.”
“In what way?”
“Well every time I try and go through a door I end up crashing into the wall.”
“Is it like your body/eye co-ordination has gone?”
“Yeah, that’s it.”
“And does it always affect the same side?”
“Yes, the right. I always seem to end up veering to the right.”
“Is there anything unusual about the right side of your body?”
“Its all numb. I can’t really feel it properly.”
“When did all this come on?
“Only since I woke up this morning. I was fine yesterday.”
“And have you got a headache?”
“Oh yes, right behind my eyes.”

Ok, now you don’t need to be Sherlock Holmes to surmise from this little exchange that something neurological is going on; possibly a CVA (stroke) or a TIA (mini stroke). Either way this guy needs to be seen at the hospital. I’m guessing that’s what the GP thought too. Yet the pile-of-shit wonderful piece of software that is AMPDS didn’t think so. Nor did the paramedic doing the telephone triage on the ‘C’ cat desk.

I figured we’d already let this patient down enough so I rang up to see if we had an ambulance available. Silly me, what was I thinking. Of course not. Nearest vehicle was about 30 miles away whilst the DGH is only over the road from the ambulance station and I was due to head back for my break after this. So, with the aid of the patient’s two sons, I guided him through the doors of the house and got him into my response car. I had him up to A&E in about 15 minutes.

I stopped by the department again towards the end of the shift to see how he was getting on.

He was up on the stroke unit.

Another AMPDS success!

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Picture by Banksy

Sad and Lonely – Part 3

All Alone

I met Terry the other day – a former boxer and now struggling alone at home having been discharged from hospital after his second stroke.

Terry has fallen through the cracks in ‘the system‘.

The call was given as an elderly male suffering a CVA. When I arrived Terry was on the phone to his doctor; nearly in tears and at his wits end. Terry’s one of the ‘old school‘; an independent and ‘pull your socks up and get on with it‘ sort. He’s used to being able-bodied and now his second stroke has literally taken his legs out from under him. Sure he can still get around; but only just; and he needs a frame to do it. Terry’s not a man for frames though, he still wants to dance around the ring like the old days but he’s all at sea. His legs won’t do what he wants and he has to flail his arms around trying to keep his balance. Luckily he still has amazing upper body strength and a physique that Arnie would be proud of. For now that strength is all that’s getting Terry up and down the stairs to the bedroom and the bathroom; he hasn’t yet contemplated a life where the stairs are an unassailable mountain.

Terry got discharged from the local DGH about a week after his second stroke. “I can manage”, was his attitude so the staff packed his bags and sent him home – no social care package; no follow up appointments; nothing. Terry’s out the system and been forgotten. A fortnight on and he’s struggling. He doesn’t know what to do or who to turn to. He thought he could live a normal life but he was wrong. He needs two hands on that frame to get around so how’s he going to carry his cup of tea from the kitchen to the lounge? Get his dinner from the microwave to the kitchen table? Carry the kettle to the sink? Put the dishes away? Sweep the floor? Tidy up? Have a bath? The list is endless. And to top it all there are two huge steps outside his front door and no way for him to manage them – he’s effectively a prisoner in his own home.

Before you ask, he has a sister who comes once a week to do his shopping but she wants to ‘mother‘ him and he’s having none of it. He tells me their relationship is getting a little strained whilst they work out this new brother/sister arrangement.

In desperation he called 999 – he didn’t know where else to turn. Then he tried his GP and luckily she was both available and sympathetic. I spoke to her after Terry had finished. She’d be round tomorrow for a full assessment we just needed to get him through the evening and the night.

Now I don’t have any psychological training. There’s no referral to the community mental health team. No back-up. No support. Just me with a few years of doing this job under my belt and Terry with his ‘I can do it‘ attitude. I tried the softly, softly, understanding approach – it was getting nowhere so I figured I’d nothing to lose by trying a bit of trainer/boxer tough talking. We spoke matter-of-factly. I had him up and about and using that frame whether he wanted to or not. I moved a few things about – I put the microwave on the kitchen table so he didn’t have to carry his meals. I moved the kettle, re-arranged some of the furniture. After an hour things seemed a bit brighter. Help was on its way. The GP was coming round tomorrow. Things will get sorted. He will get out of his house again – and down to the cafe for a cup of tea and a spot of lunch. Life will be different – sure, but it will go on and Terry will survive. He’s a fighter after all but even the toughest of tough guys need help occasionally.

Crying Wolf

Crying “wolf” once too often

Regular readers will know that I am not a big fan of the AMPDS system our Control now uses to ‘aid’ dispatchers. I’ve blogged before how so many calls seem to be categorised as ‘life-threatening’ only for us to find that the unconscious patient is the one who opens the door (see earlier blogs; here, here and here). In fact AMPDS appears so over cautious in its triaging protocols that the merest hint of a cold, a cough, or cut to the head will get you an 8 minute ‘A’ cat response.

Welsh Ambulance Service chief executive Alan Murray made the point in his Ambulance Today interview that…

“If we expect EMS crews to respond immediately to 999 calls they have a right to know we won’t abuse that responsiveness.” (see here)

I think many of my colleagues would agree that our responsiveness is being abused. In fact so may calls now come over as Cat ‘A’ – life threatening that staff just roll their eyes and go “yeah, whatever”. Complacency has set in. Control have cried ‘wolf’ once too often.

Now I’ve not been up to Control for a while mainly because the control manager and I loathe each other (see here). Anecdotal reports suggest that part of the problem might be that caller takers ask leading questions.

Consider; you have a cold with a bunged up nose and a cough.
Can you breath? – of course!
What’s you chief complaint? – I’ve got a cold.
Are you having difficulty breathing? – yeah my nose is bunged up!
Does your chest hurt? – Well it does when I cough.
Ah! so you’ve got chest pain with difficulty breathing! According to AMPDS, you’re an ‘A’ cat – life threatening call. An RRV and fully crewed 5 tonne ambulance are, even as we speak, hurtling their way through the rush-hour traffic on blue-lights and sirens to get to you.

What a load of bollox!

Two’s Company

Another set of hands is always welcome.

When you’ve spent your whole (ambulance) career working for the same Trust you rather take it as ‘given’ that how ‘we’ do things is how they’re done elsewhere; of course that’s rubbish.

John Robertson @ I Like Curry, works as an EMT in the West Midlands. His recent post The Long Drive In opens with..

When a call comes in for a cardiac arrest, control do their best to send two ambulances, or at least one ambulance and a responder if we’re a bit stretched. Extra pairs of hands are very useful!

Damn right they’re useful. The more the merrier. Then I remembered that Tom Reynolds had mentioned much the same about London. In his post Thanks to a Bystander he writes…

It was about then that another ambulance and an Emergency Care Practitioner arrived.

Excellent, another three pairs of hands. And Nee Naw confirms the LAS practice in A Sad Suspended…

This flagged the call as a Red 1, and already two ambulances and an FRU were on their way.

Now in my service you get one, repeat one, ambulance for a cardiac arrest, suspended, call it what you will. If you’re (very) lucky, they might actually send an RRV as well, but only if the ambulance won’t make it within the 8 minutes. And on occasion its not unknown to just send the RRV on its own. Believe me, trying to handle a cardiac arrest on your own, with attendant hysterical relatives, plus trying to get someone in Control to answer the f**king radio so that you can ‘scream‘ for back-up is a barrel-of-laughs.

The only time two vehicles will ever turn up is if the first is a double EMT crew and they specifically request paramedic back-up. Routinely sending two vehicles is NEVER an option.

I have no idea how my Trust’s survival-from-cardiac-arrest figures compare to other services, that kind of thing is a closely guarded secret from us plebs on the front-line. I’m sure they’re shite. I’ve only ever got two patients ‘back’ and neither of them made it out of hospital.

Oh, and by the way, I’ve only ever had to attend two (working) paediatric cardiac arrests. They’re extremely distressing and its impossible to do any advanced life support on a kiddie in the back of a moving motor without assistance; and on both occasions I was refused a second vehicle!

Thanks Control, I just hope its not your kid next time!

Bravo Murray

Alan Murray: at last, an ambulance chief with balls.

June’s edition of Ambulance Today has a 2 page interview with Alan Murray, the man charged with dragging Welsh Ambulance Service out of the mire. Amongst all the usual back-slapping over how wonderful the staff are and what a difficult challenge they all face there was one poignant question and, for once, an answer that didn’t reiterate all the usual shit, propaganda from the commissariat.

Q: “Should the Ambulance Service’s performance be evaluated solely on response times or are there other indicators which give a clearer picture of overall service-delivery?“

A: “Response times are just a proxy for clinical effectiveness. We categorise too many of our 999 calls as potentially life-threatening and we need to focus much more attention on this area. I have an ethical objection to sending a five-ton vehicle at high speed through heavy traffic when we know the patient doesn’t need it. A clinically effective response to life-threatening emergencies is still a priority but we must find new and better ways of serving the rest of the 999 population. I would expect new measures to be more focused on good clinical outcomes and appropriate delivery of care and advice to people who don’t need an emergency ambulance. This is important to the patient but its also part of the Trust’s duty to its staff. If we expect EMS crews to respond immediately to 999 calls they have a right to know we won’t abuse that responsiveness.“

Bravo Mr Murray! How refreshing to hear a Chief Ambulance officer speaking out and stating what road crews have been banging on about for ages. Pity that none of his peers have got the balls to put their heads above the parapet.

How Long is Too Long?

Where’s that bloody ambulance got to?

Many readers will, I’m sure, have read the recent article in the Daily Mail about Tom Reynolds in his war zone of East London. At the end of the article Tom says

“There is a plan to cut the number of ambulances and instead send us out individually in cars so we can assess whether an ambulance is really necessary.”

I’ve blogged previously how Nu-Labor’s target driven culture is leading to ambulance services being re-configured to meet the change in ‘A’ category response times due next April. Leaving the vulnerability issue aside, one of the primary results of this change in ambulance fleet composition is that solo responders will be left at scene with potentially very sick or injured people whilst waiting for Control to send them a back-up ambulance to convey the patient to hospital. From a management/Control point of view a patient with a solo on scene is no longer a priority no matter how sick or injured they may be. The response-time target will have been met (hopefully) and all the boxes ticked with the arrival of the solo. Diverting an ambulance only results in one less ‘resource’ available for the next target job. The are no points, prizes or cash available for using an ambulance to take a patient to hospital – clinical outcomes are not a priority.

We’re currently running a ‘scorecard’ on station for how long solos have had to wait before the cavalry arrived. The record at the moment is held by a trainee para (under-12 EMT) who was with a deteriorating patient for nearly an hour and a quarter. For myself, over just this last weekend, I can cite an 80 minutes wait with a patient having a suspected pelvic fracture and 55 minutes with a patient who’d collapsed in the middle of a car park, suffering a head injury, who subsequently fitted and who additionally had a confirmed tib + fib fracture. Luckily it wasn’t raining.

I admit to being a bit of a pessimist and reckon its only a matter of time before the Daily Mail (and other tabloids) start writing articles about how a patient died in front of a solo responder because the nearest ambulance was diverted away (probably to a patient with a cold that AMPDS had ‘triaged’ as a life threatening call – but more on that another time).

Re-Educating the Workers

Welsh comrades who refused to toe the Party line

In 1976, the Khmer Rouge, under the leadership of Pol Pot and the mysterious “Angkar” (the secret revolutionary leadership), took control of Cambodia. As with so many other despot regimes the intellectuals and the bourgeoisie where either exterminated or ‘re-educated’. Independent thought was anathema; wealth and status were irrelevant; families where broken up and displaced to farms or building projects; all in pursuit of the utopian society. It is estimated that between one and two million Cambodians (20% of the population) and some foreigners were tortured and executed throughout the 3 years, 8 months and 20 days of Khmer Rouge rule.

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The June edition of Ambulance UK appeared on station recently. This is the “see how wonderful we are” magazine for the Ambulance Services Association. On page 154 there’s an article about Alan Murray’s crackdown leadership of Welsh Ambulance Service. I’ve blogged previously about the mess WAS has got into (see here, here and here). Apparently he’s decided that tactics that were good enough for Stalin, Mao and Pol Pot are good enough for him…

“[Alan Murray] is on record as saying the service will meet the 60% response time target during 2007/08 – staff are being “educated” that the targets are clinically meaningful and and not just another governmental hoop through which they must jump.” (the emphasis is mine but the quotes around educated are as printed in the magazine)

Those who refuse to believe will be shot – or worse, made to work for NHS Re-Direct.