Sunday, 4 July 2010

More Thoughts on The Tree

You may recall that my last post was about how I had to think very hard about where to take a young child after his fall from a window. While the resultant comments were very interesting, and demonstrate very clearly that, on occasions, these blog entries develop a life of their own, I wanted to be able to write a bit more about the new directions that trauma care in London are heading, and how it affects me and my colleagues.

There are now three Major Trauma Units in London, The Royal London, Kings and St Georges, with St Mary's Hospital coming on line some time soon. Now, for those of you who don't know, this leaves my patch quite isolated. My jouney time to the 'local' Major Trauma Unit could be as long as 45 minutes. That's a long time to have an unwell patient in the back of the ambulance. And yet, for a discussion about the pros and cons, read a little 'story.'

"He had fallen out of a window, onto the driveway. Another child, this one only 9 years old. This one was accidental - the boy had been trying to open the window because he was hot, and had fallen out when he succeeded. When I arrive on scene he is stable, but not responding appropriately. He is very agitated, and, despite his eyes being open, they are not fixating on anything or anyone. The back of his head reveals a large swelling. He needs urgent care, but where from? We are outside of the LAS (London Ambulance Service) territory, and this crew will go where I want them to. I'm a few minutes away from my own hospital, and yet we don't have neurosurgery on site. The nearest neurosurgical unit that deals with paediatrics is one of the Major Trauma Units, 45 minutes away. I am not happy to travel all that way with a child that I will have to intubate if we are going that far.

And another point to consider: I am currently on call for my A&E Department. I have a contractual duty to be available if I get called. If I commit to a 45 minute journey on Blues in the back of the ambulance, I will probably be unavailable for the job I am paid to do for 3 hours or so. I decide; we are going to my own hospital, 5 minutes away, with the child awake.

The journey is easy and uneventful. He is intubated soon after arrival, and we get him up to scan. Damn! He has a depressed skull fracture and some bleeding in his brain. Now he needs to be transferred. 2 hours after arriving at the A&E Department, he leaves for the neurosurgical centre, and arrives there almost 4 hours after his accident. If I had taken him, he would have arrived there an hour after his accident. 3 hours wasted."

This really has set me thinking about my role, and about how it interacts with my work in a very busy department. If I attend a job while I am on call, and take a patient to a Major Trauma Centre, then I run the risk of a disciplinary which could result in me losing my job. If I attend a job while I am on call, and take a patient to a hospital that is not a Major Trauma Centre, the patient is not going to get the best possible care.

It's more complicated: if it is an LAS crew, they will, if I am not there, take the patient to the Major Trauma Centre. Therefore, the patient will potentially be disadvantaged if I attend. If it's not an LAS crew, then they will go to the local hospital, even if I am not there. So, if I attend those, I can provide immediate care and take them to the local hospital, knowing that they have not been disadvantaged by my attending!!

So, I am now prepared. I won't go out on ANY jobs for LAS when I am on call, but will go to other calls. I am ready for the long haul: if I go to a job when I am not on call, I will make sure that I can get the patient all the way to the Royal London, and that's a long and scary way! Watch this space.


  1. Very interesting post. I had no idea that you could attend a BASICS call when also on-call for your own A&E. Here in Aus we are lucky to get a doctor at all if we want one, and in my State the HEMS flies with Paramedics for primaries, rather than doctors.

    Given a 45 minute run time are there other options such as HEMS or their RRD's you can call on? If you're pretty sure that someone is going to need transfer from your local hospital at what stage can you commence to organise it? We have a centralised retrieval system that will take a provisional diagnosis, so the teams can be getting ready whilst you're doing the scan and 'packaging' the patient.

    Dilemma's abound and there is obviously no easy answer!

  2. Im quessing this was during the Ash cloud chaos if HEMS wasnt an option.

    Could another BASICS doc that wasnt on call not have accompanied the boy to London?

  3. Hi Broken Angel. As I am so far out of London, there isn't anyone else around. Remember also, that there are only 10 active members in the whole of London, so the chances of another member being around and close enough to take over is quite low.

    As far as HEMS is concerned, yes, when it's daytime, HEMS is a fab resource for us. But, as most of my jobs are at night, when HEMS doesn't fly, it's not as easy...

  4. there is a lot more than meets the eye and thanks g,d there are people like you on this earth - Mirelle

  5. I'm a bit concerned that the LAS system is either so restrictive, or the crews so scared, that they are not prepared to use their clinical judgement, and worse, not take the word of a highly qualified doctor saying local is appropriate.

    To change the scenario a little, what would you do if you were on call, a non-LAS crew turn up, and the patient needs a trip to the Royal Free (not too far) or to a major trauma centre? Especially given that your non-LAS service will most likely adopt some kind of major trauma system at some point once the DGHs sort themselves out sufficiently.

    It's an unpredicted and unfortunate consequence of the trauma system that the number of BASICS docs available at any one time may well be reduced by the "tree". We have few enough of you as it is.

  6. I don't think that the Tree has reduced the number of available BASICS doctors. When we are at work or on call, we have a duty to our hospital. When I have in the past gone to a job while at the hospital or on call I have been in effect breaking that contract and putting myself at risk. Many BASICS doctors wouldn't do that even before the tree. For me, the consequence is that I would be away from my base hospital for far too long, and the risk that much higher....

  7. So you made a mistake by offering your services when on-call for A&E. We all make mistakes. Some of us learn from them. You and I have both read a range of papers on why structured protocol based trauma care increases survival. In my opinion one of the reasons is because it takes away the "we must get them to the nearest hospital" at scene attitude and the "they're probably going to be OK" belief (in this case because you were worried about your job).
    Next time let's hope you think about whether you should be on-call. You can't save the world, only the bits you meet when you should.

    All that said. I respect your continued dedication to providing prehospital emergency care as a volunteer. And equally your family for being so accepting of it.

  8. On the same page as David here, would it have been possible to fly the kid to a major trauma centre? Obviously outside the remit for London HEMS but would it have been possible to contact another HEMS team to transfer the pt?

    It would be nice to have national coordination for HEMS so that someone (e.g. basics) on the ground only needs to contact one centre to have the most appropriate and nearest helicopter sent to them, hopefully with a doc on board so you're not off your patch for 3 hours.

    I also wasn't aware you did o/c for your hospital - is this because you're a consultant, or is it also expected at more junior levels? I suppose it's another argument for non-volunteer doctors to be responding? Can you see it being feasible that PCTs would employ doctors solely in a prehospital care role? Not sure how Tayside trauma team works but from what I've gathered, that's pretty similar?

  9. Thank you , Chris, for your comments. I don't see what I did as a mistake. I have always responded to incidents close to my own hospital, even when I am on call, or possibly especially when I am on call. If I don't go, then I will be called to the hospital soon after, and find a less salvagable patient than had I gone to scene. I count this as part of my responsibilities as the Consultant on call for the local community's health. What has changed is the increasing awareness that these patients are best served by being in a Major Trauma Centre, rather than a DGH. And, in answer to the HEMS question, I often get HEMS to fly a patient out. However, at night, like in this instance, none of them fly...

  10. Sorry, BK, didn't forget your comments! Yes, I am on call for my hospital as a Consultant. Junior doctors don't do on call; they just do a shift in the Department. I also have the issue of what do I do when I am called for a job and am at work at the time. I usually balance the clinical needs of my department with those of the patient, look at staffing levels and distance to scene. And then I go!

  11. I think it's fantastic work you do, and have been lucky enough to observe BASICS a couple of times. It must be frustrating knowing what can be provided, if only there was more money in the pot, and the PCTs provided for BASICS in the first instance!
    I wonder whether todays news about GP's holding the purse strings in the future might prove beneficial? It sounds like Andrew Lansley plans to hand over some decision making on health expenditure, and since many BASICS doctors are GP's, could this proposal be good news for pre-hospital care charities? They might suggest government support. I know it was discussed years ago in the house of Lords, tabled by Viscount Falkland and I’m sure you’re more than aware of this. Unfortunately nothing came about from this. What do you all think? Oh, and sorry to degrade your wall with talks of politics!