Posted by: medicblog999 | March 5, 2009

Do patients always come first?

crossroads

I was working on the rapid response car the other day for a 0600 – 1800 shift. I was dispatched to a lady with chest pain at the end of the shift, Cat A, approximately 7 miles away. Upon arrival at scene I was met by a man who showed me to his wife who on initial impression looked ok:

Good colour, no sweating, not short of breath (although hyperventilating slightly), pain persisted but was described as a sharp and burning sensation running up through her oesophagus and into her mouth. The lady was on the large size and also had a history of diabetes, Type 1, and various gastric problems. 

This lady obviously had some anxieties and had been virtually constantly taking her BP, pulse and BM readings throughout the day and had taken great care to record them so that she could show them to me. All were within normal limits and non drew any concern from me. It was obvious that she was anxious and stated that she had suffered with anxiety attacks before but this seemed different. 

A crew arrived to assist and transport the patient, however, after taking a 12 lead ECG, completing a full examination and history and with discussion with the patient and her husband, I let the crew go and decided that I would liaise with the out of hours GP to see if he would come for a home visit or see the patient in a local out of hours centre.

By  now the time is 17.50 (remember, I am due to finish at 1800, 7 miles away) and I knew I was having another late finish.

We have excellent access to GP advice in our area as we can contact the out of hours provider and after a quick summary of the history to the call taker, the call is put through to the GP as a M.A.S call (Medical Advisory Service). This virtually guarantees a phone call from a GP within 5 mins, and usually quicker.

No sooner had I hung up, than the GP rang the home number. I provided a handover of all of my findings and thoughts to the GP, but although the GP agreed with my provisional diagnosis of ?Oesophagitis/gastric reflux, he stated that he would be happier if the patient had a run up to the A&E department to have his Troponin- I level checked. (for those who dont know this is a highly sensitive enzyme marker that specifically shows any cardiac damage. It is especially useful in cardiac patients who have no findings on their ECGs but they are found to have raised Trop I levels which proves that they have had a heart attack)

The Gp admitted that he was only being cautious due to the risk factors that the patient had (i.e obesity and diabetes).

Now, having just sent the crew away 15 minutes before, hoping that I was going to get a GP out, I now had to get back onto control to ask for a crew back again. I didn’t deem this as an immediately life threatening detail so requested it as a Cat C response. This means the crew will be coming but not on lights and sirens and if another higher category call came in and the crew that are coming to me are the closest one to that detail, then they will be diverted.

I only had to wait 20 minutes before the crew came (now 18.15), but as they arrived I realised that it was an ‘urgent’ transport crew. These vehicles are staffed by pre-hospital staff who are trained to a certain level but do not have the additional training or skills that a paramedic does. They are more than qualified to transport the vast majority of jobs that come in to the ambulance service (as a high proportion of these do not require an A&E ambulance), but this put me in a bit of a quandary.

Even though I am happy with the clinical appearance of the patient and I am also happy that the only reason that she is going in is the GP covering all bases, I still am aware that ‘going by the book’ or rather ‘in my own paranoid head’ I should really travel with the patient to A&E just in case something happens (no matter how unlikely). If I travel to hospital, I know that I will not get home to see my toddler before he goes to sleep, I also know that I will not see much of my wife, as I have to be up for 4.45am the next morning for my next shift. 

I stand by the side of the ambulance going through scenarios:

” How many of my colleagues would travel with the patient to hospital?”

“What could go wrong , no matter how unlikely”

“What will it look like if something goes wrong and the crew report that the paramedic was happy for the patient to be transported by the urgent crew”

But the clincher for me was –

“If it was 3pm and not 6.20pm, what would I do?”

The honest answer is that I would definitely travel to hospital with the patient.

So that’s what I did. I jumped in the back of the ambulance whilst one of the urgent crew drove the rapid response car to hospital. Absolutely nothing happened en route, other than I had a nice chat with the patient and her husband. We arrived at A&E, I handed over the patient, then collected my car and headed back to station. By the time I had got back on station and got sorted out, showered and back home it was 20.35, but I felt good about it.

This isn’t a post saying ” look at me, look at how good and dedicated I am”. Its just stating the fact that I was chuffed with myself that I put my patient first and not my want to get finished on time. Or for the cynics out there (and to be honest, me as well) there was a tad of self preservation in the decision too. I love my job and I am not going to do anything to put that at risk. It would be sods law that the one time………..

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  1. […] Do patients always come first? « Medicblog999 […]


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