Sunday, 28 June 2009

I'm Angry!

Ok, so I've just got back from a job, and I am so angry with what has just occurred:

He is 43. He has been out for a drink in a pub. Not something to get hit over the head for. He did ask another drinker to apologise for knocking his drink over. Not something that should lead to him lying on the ground with a gaping wound in the back of his head. But it did.

And so, here is James, a rather pleasant chap, according to his mates. He's not being very nice now. He is swearing and snapping at all of us. And when I say snapping, I mean he is trying to use his teeth on us. He can't, but only because there are 4 very strong police officers, holding him down. He needs cuffing, for our safety as well as his. He doesn't like this, and is pulling so hard at his cuffs that his wrists are red raw. Language I am hearing tonight is bluer than on Saturday Night Live. OK, you know the drill by now: the Primary Survey:-

Airway: perfectly maintained, as evidenced by the expletives that emanate from his mouth
Breathing: there's no point trying to listen to his breathing, but he has not received a blow to his chest, so I am happy
Circulation: we can't get a blood pressure, because he won't keep still, but his pulse is regular and strong
Disability: he scores 3 out of 4 for his eyes, as they open if I shout at him. I'll give him 4 out of 5 for voice - I wouldn't say he is orientated, but he certainly knows what he is saying! And he can have 5 out of 6 for motor, because, while he won't obey commands, he is trying his best to do a Houdini with the cuffs.

I do my usual at this stage. I get down close to him and reason with him: "Keep still and we'll take the cuffs off," I tell him, much to the consternation of the rather battered officers. He does quieten, but I don't think getting him out of the cuffs is going to be a winning decision with anyone else.

I know that we are only 3-4 minutes away from NeuroHospital, and, I reason, it's far safer to just go, as opposed to giving him a Rapid Sequence Induction (drugs to put him to sleep so that I can pass a tube into his windpipe and breathe for him.) So, as we are already in the back of the ambulance, I let the team know my plans, and we set off. As we start, one of the team passes the information to NeuroHospital, so that they are ready for us when we arrive: Male, 43, severe open head wound, GCS 12/15, combatative, DA (that's me!) on board.

We arrive, and wheel him in to Resus. We are met by... A nurse and an FY2! A junior doctor, 1 1/2 years post qualification!! At least we have an experienced nurse, but still!! I look around pointedly, and ask, "Where's the Trauma Team? Did you not get our call?" He replied, "Yes, but we didn't think it warranted a Trauma Call." What?? I only didn't tube this chap because I knew we were on the doorstep, and now there's just no-one here to look after my patient. I ask the nurse to put out a call; she just shrugs and goes out the door. Great!! Now we haven't even got a nurse in here!!!

A minute or so later, she returns and tells me the Consultant is in the Department, and will be coming in. Phew!! But no. He wanders in, looks down at me, and talks over me while I am trying to explain what has been occuring. Not interested in the pre-hospital situation, he goes over to the 'phone and tells the radiologist that the scan can be performed with the patient awake. I storm out, muttering under my breath.

The point here is that, despite the fact that the patient is now much calmer, he has had a very significant injury, with very significant pre-hospital features, and the hospital staff are ignoring all we are saying. This has made me angry. My ambulance colleagues are angry. We sit by the vehicle, drinking NHS tea, and bemoaning the difficulties associated with the interface between pre-hospital and in-hospital. As a Consultant, they expect that at least I will be taken seriously, even if they aren't. It's an eye opener for them too.

I have just rung NeuroHospital - he has cerebral contusions and is being intubated as we speak. I'm not a happy RRD.


  1. I find this very interesting. I would like to be in your shoes one day and make a point (as one of the FY2s you mention) to speak to and get a full history from those who were treating the patient in the pre-hospital phase.
    I am continually baffled by my colleagues (including one of our A&E consultants) who ignore what has happened pre-hospitally.
    You are a professional (with significantly more experience than I), and if you priority-call something, there is a reason for it. To behave as your local neurocentre has done in this case is, quite frankly, disappointing and stupid.

  2. A usually very laid-back friend of mine had quite a bad head injury many years ago. He had gone ballistic when they tried to x-ray him and it had taken several people to hold him down. He told me after that he had a very clear memory of being on one of those big steam presses (like the ones you see on old prison films where they slam the lid down) and was terrified he was going to be "ironed". He saw the radiographer reach up and thought she was reaching for the handle of the lid and panicked!

  3. Doc, I hate to say it, but I'm almost glad that you had that experience, if only to be able to rant about it. I've also ranted about a similar issue on my own blog. I don't know if it will solve all our problems, but I still strongly believe in A&E staff, including senior staff, spending time "on the front line". Two days a year, or something such like. I'm sick and tired of being told that it's impossible for a patient of mine to be in the condition he is now, considering what I describe as his condition on scene. The anaphylaxis that I can treat, the CPR that is successful, the obstructed airway that's now clear... I could go on for days. All of these dismissed by staff in A&E as an error in my initial assessment. I'm a health care professional too, no longer just a stretcher bearer, and to that end, I try to treat my patients so that they get to hospital in as stable a condition as possible. And if that means stepping on the toes of haughty A&E staff, then so be it.
    But really, I'd much rather be on the same side and part of the same team...

  4. Ohhh, been there soooooo many times just like Ben. Even just yesterday, pre-alerted A&E for a 63 yr old female sudden onset of ischaemic left leg. Classical signs and symptoms - cold to touch, mottled, no dorsalis pedis pulse, cap refill - ages! and pain +++.
    I arrive at A&E to have one nurse waiting for me who before doing anything spends about 3 minutes searching for a pulse in the foot. I say "there isn't one, is the vascular surgeon coming down?" she says "oh no, let's just see what we really have first!" she then goes off for 5 minutes to the the Doppler then final comes back in, can't find a pulse and then says "I think I'll get vascualr down"
    All the while I'm screaming in my head "Just bloody believe what I am telling you...!!!!"
    she ended up having an emergency fem-pop bypass!
    Not a one off experience though, not by a long shot.
    Weirdly though, I find the consultants trust our judgement and provisional diagonsis far more than the junior docs and the nurses. Maybe they are just more comfortable and confident in their own abilities that they don't feel threatened by a knowledgeable paramedic.

  5. Unfortunately, this sort of thing happens way too often, and on this side of the pond there many of us that don't have access to RSI in the field. Granted, MD's aren't on 911 ambulances here, but there are places that RSI is available. Just not in my area. And I had a situation a little over a year ago similar to yours but with no tools.

    Patient was a 20 year-old male that was struck in the back of the head with a rather large piece of lumber. He was quite combative as well, and we were about a 10 minute ride from our area trauma hospital. The medical control doc wouldn't authorize chemical restraint so that I could secure his airway, so I did the best I could. But with all of that said, between the damage to his brain stem and the bleed that was induced by the blow, the kid had no chance.

    Needless to say, the M&M round for that call was interesting. And I had my say. So maybe someday - we'll get RSI. But - I'm not holding my breath.

  6. I presume this is why my 47 yr old husband was blue lighted to the major hospital but then left in a cubicle for five hours without being seen by a doctor - not even an aspirin given.
    The ambulance crew had mouthed 'stroke' to each other before deciding where to take him, this was at 4 pm on a Friday. My 18 year old daughter went with him as I had to get hold of respite team for younger son - so didn't get to to hospital until after 9 pm - and had to go and find a doctor myself. He was by this time, fully conscious, but not able to use left side of face/body, or be understood.
    During the night, those on duty totally ignored the information I had given them about his lumbar spinal injury. They tried, unsuccessfully, to do a lumbar puncture FIVE times before giving up.
    Neurology were not contacted until Sunday......

    Full marks to the ambulance crew - who were wonderful, both with extracting him from an awkward place (another time I will be unscrewing the door while waiting for the ambulance!) and re-assuring daughter. Zero to A&E at major hospital.

  7. And I thought it was just a US problem to have the ER (A&E) people not take us prehospital monkeys seriously.

    A paramedic is one thing.. but a doc?? Wow. I've gotten in trouble more than a few times for letting the ER staff know that I expect them to "snap to" when I want them to. For a while, after I gave a "snap to" speech concerning a patient I was taking to the floor and wanted to divert to the ER who coded and died in the hospital elevator after the ER refused to take them, I was listened to.. now it's a new crew.

    A wise medic once told me that every so often a medic has to "whack them on the nose with a rolled-up newspaper" in order to get the ER staff to do their job. Guess it's not just a US thing

  8. I'm pleased that a Doctor has seen this as I can only echo what the other front line guys have said before me.

    This happens very often to ambulance staff regardless of qualification.

    If we didn't think there was any point in putting a call through we wouldn't waste our breath... when we do, we expecta little more than tumble weed to meet us in resus!!

    If we all keep chipping away and blogging about it we may see a difference one day!

  9. I completely agree with all the above. I have experienced it all so many times as well. We have a sister in our local department that ignores you and even yawns and walks away if you don't sum up the handover in less than a sentance (i.e. male, chest pain is pretty much all you can get in). Very annoying and unprofessional!!! One of the other things I find is that the lack of belief that patients can actually make a recovery as a result of our treatment :-) So when we provide a red call requesting a trauma or medical team in rescus, it is possible that the patient may have improved by the time we arrive. It does not mean we were lying about the initial condition, I do get sick of the complete disbelief in the staffs eyes sometime, he he :-) Like we would go to the effort to actually make it up!