Sunday, 9 August 2009

Out of control

How annoying is it when you can't even park your Penny Farthing without having to chain it up?

Day shift: Six calls; two by car and four by ambulance.

Stats: 1 Chest pain; 1 Stiff leg(!); 1 Fractured hip; 1 Period pain; 1 Abdo pain; 1 Fractured arm.

N’s second shift with me and she’s scooting about Central London like a native now – except for her give-away activity of taking photos of everything remotely interesting, including a CRU colleague, although he did take a good picture to be honest.

Today must have been someone’s first day in Control because the call categories were skewed way off the patient realities. The first of the morning, across the river, for a 31 year-old woman was given as ‘pandemic’ and therefore categorised as Green2 (quite right) but when I got to the car in which she was sitting with her husband, I was told that she had chest pain, a recent heart attack history and was not sneezing, sniffing, vomiting or suffering a high temperature. Her husband stated that he had told the call-taker that his wife was having chest pains but this little nugget had somehow slipped the net and I had moseyed over to the call on the basis that I was in no hurry for Swine Flu (still on lights and sirens though – public place). This call was a Red for sure and now there was nobody coming to take her to hospital and because re-categorisation rarely seems to occur when I ask for it on air, I decided to take her across the bridge myself. It took two minutes to whisk her off to Resus – it may have taken twenty minutes for an ambulance to do so.

The next call was given as Amber but there were no priority symptoms given for the 80 year-old man who ‘can’t get off his chair’. When I got there, he was plonked on a stool, in his yellowish underwear, waiting for me like someone would wait for a taxi or a meal with wheels. He had no DIB, no SOB, no D&V, no MI and no CVA... he had a stiff leg. In fact, he’d suffered from that affliction for years so this morning was nothing new. The call should have been Green or given to a taxi driver ... or meals-on-wheels but an ambulance was there within a few minutes and he got the full NHS treatment for ‘rigid-leg syndrome’.

My colleagues in the Emergency Operations Centre (EOC) work hard and under stressful conditions at times, so I don’t knock them as people but even they would agree that the two calls I’ve just described were categorised (by man or machine) quite ineptly, either through dumb reasoning, the dumbing-down of the facts as they were heard or by the caller’s inability to get his point across properly. Call-takers are on a timer, you see. They have a limited time to get the call cleared and off to Dispatch (usually via the computer) so they are under enormous pressure to get the answers they need in as short a time as possible. This, in my opinion, can lead to what I call ‘factoid-deafness’ and inaccuracies in detail (or lack of them) and to make matters even worse, we are being sent a set of co-ordinates before a call has been fully screened and are expected to start running on it even though we don’t know exactly where it is or what it entails. Someone is going to get hurt as a result – a patient or a front-liner. But it all feeds the need for greater speed and efficiency, thus the upper echelons and the Government, whose idea this was in the first place, get their pats on the back when the figures come in. Target, target, target. Don't achieve anything, just get it on target.

Imagine a call being taken and the person at the other end being able to absorb every detail properly, with no pressure. Then imagine that call being despatched to me and my colleagues and we are able to check everything about it as we run on it. Imagine a country where the system isn’t overloaded by abuse, ignorance and public stupidity...

If your mother fell in the road, broke her hip and was in extreme pain, would you want her to (a) be taken by ambulance immediately to hospital or (b) lie there in pain for as long as possible?

A 60 year-old Nigerian woman suffered 40 minutes of agony, some of which I managed to relieve with entonox and morphine, after a tumble in the middle of the road left her neck of femur (NOF) broken. This is a nasty break in any circumstance but she had to be dragged across the road and laid against a car by members of the public to save her from being run over as well. The pain must have been excruciating.

I arrived to find her with a large family group that had gathered around her when they found out what had happened. The call was Green and the day just seemed to be so predictable. I knew that an ambulance was a long shot and this time I insisted again and again that it should be upgraded. It took three calls for this to happen but my MRU colleague on the desk managed to finally get things moving for her. I couldn’t convey, that was for sure and I’d been sent by the desk to assess and give pain relief because the clinical person there (MRU) had seen the potential in the call where someone else had not.

Again, if this was your mother, wouldn’t you want to have her treated quickly? Instead, an old man with a stiff leg gets an ambulance and this lady gets to wait. The system makes helping genuinely ill and injured people very difficult. Clinically trained individuals can screen most of the calls coming in and make fairly sound judgment calls about their priority status but the human element is completely removed by computers and nobody at the end of a 999 call in the Control room is allowed to change that without permission.

Calls to period pains annoy the hell out of me. This is not an emergency. I sympathise and I get a lot of flak from women who like to tell me how I will never know how bad it can be BUT it happens every month and there are ways of dealing with it. So, the 16 year-old Japanese girl who writhed about at an underground station after generating a Red call for an ‘unconscious female’ (which she clearly wasn’t) had me listening to a German doctor telling me that she had abdominal pains and that I could ‘take her away’ when her handover had been completed. This tourist (doctor or not) had literally pushed the underground staff member away when he attempted to give a report to me and then arrogantly proceeded to treat me like I was simply here to take the patient to hospital and no more.

‘I’ll tell you what happened here and then you can take her away’, she’d said. I was a wee bit annoyed with her.

‘She has period pain’, I said before the doc could finish.

‘No, she hasn’t – she has abdominal pain’, she replied.

‘Well, she’s just told everyone its period pain’, I said after hearing that being said more than once.

‘Oh, well, I have to go now anyway, so yes, you take her away now’. And with that, she walked off with her friend behind her.

The girl played this out to the point where she grabbed me so hard as I tried to stand her up and walk her to the car, that she tore into my flesh with her nails. She had her own pain relief for this but it was a Japanese remedy, her male friend told me. I had no idea whether it was an analgesic or some sort of natural herbal concoction. Whatever it was, it wasn’t very good and this wasn't her first period - she'd had many before.

My intention was to take the girl to hospital (if she insisted) in the car but an ambulance showed up and the crew were most welcome to take her. I had endured enough of her floor-wriggling performance. I’m sorry if this offends you and if you think that, yet again, Stu doesn’t care but I do, I care about people’s mums when they break their hips; I care about chest pains in cars – what I care less about, I’m afraid, are monthly episodes of discomfort that cannot be dealt with any better in hospital than they can at home.

Standing in the street, propped up by two walking sticks and a girlfriend, was a 39 year-old man, recently diagnosed with liver failure and possibly hepatitis. He had been instructed to call an ambulance if his pain became acute and now he waited for me to arrive after following that instruction. The call was given as chest pain (hmmm) but in this case, that seemed okay because he got a priority response and his pain was real. His liver was palpable under the skin and he looked unwell.

An ambulance arrived fairly quickly and he was taken to hospital. Throughout my short interaction with him, he remained stoical and well-mannered and I felt truly sorry for him as he hobbled into the back of the ‘truck’; if his liver was shot, he had little hope of a replacement.

The last call of the shift was a revelation in the mediocrity of human nature infused into the very core of certain people. To start with, I arrived and couldn’t see the patient, or anyone who wanted to show me where he was. The call was for a 15 year-old male with a broken arm. I was outside an arcade complex and one of the security men stood there, right in front of my car, without any indication on his face or body that he was waiting for me. He just stared in at us with that poker face. I called Control to ask for directions and the guard moved slowly towards me, staring in at me as if I was supposed to telepathically detect his request for me to follow him. He was probably the surliest looking individual I have ever seen in that profession.

I got the hint and pointed to him and then to myself in a ‘are you waiting for me?’ gesture. He neither shrugged nor moved a single facial muscle. His hands were stuck in his pockets and they remained there all the way up two flights of stairs and along seemingly endless corridors within the guts of the large complex. N and I followed him and our bemusement at his cant-be-bothered attitude and his apparently handless arms was magnified ten-fold when we met the patient.

Inside a little room, a teenage East European boy cradled his arm as a CRU colleague explained that he’d been using one of those punch-ball machines when he’d misjudged his aim or gone overboard with his machismo. His relatives (I think) stood with him and the dour-faced security man, hands in pockets, hovered, protecting no-one in particular.

The boy had a broken arm – there was little doubt about that because the bone was quite deformed – but he’d live. He didn’t display much in the way of pain and he was stable enough to go in the car.

‘Yeah, can we go now’, he rudely interrupted as my colleague attempted to complete his handover.

God, I thought, he’s moody and ill-mannered as well. I knew taking him in the car was going to be a treat for everyone. It was busy traffic-wise and his trip would take twenty minutes or so.

We went back down to the street with our hand-pocketed man ahead of us and were shown the exit with as much interest as he could muster – none. I packed the boy and one of his relatives (I think) in the back of the car, while the other one was asked to walk the two miles to A&E.

During the journey, my fractured teenage patient complained bitterly about how long it was taking and then cheekily told (not asked) me to put my lights and sirens on. I could have put him and the period-pain girl together on a date. I would pay good money to see how that one panned out.

When we got to hospital, he was booked in and the other relative (I think) walked in a few minutes later (that’s how slow London traffic can be). ‘Where is that young boy?’ he asked me. Now, I thought the two men with him were blood-relatives. I had made that assumption and I’m sure I had been told this but when he said that, I felt more than a little unsure about who he was. Maybe the man in A&E with him was a relative and this guy was just a friend but surely he’d know his name?

The shift transposed the emergent needy and the not-so-needy and I felt hollow about that. I wanted to do my best for the three genuine patients that I’d been called to and was forced to rush about on lights for three that could have taken care of themselves (yes, even a broken arm is a lesser emergency – Green call in fact). But this is my job and I still love it, no matter what you read here. Those who know me understand that. Without this diary, I would have no other place to dump my opinions and frustrations which, until the witch-hunting do-good minority get a hold of them, are still mine to expose as I please.

N has now experienced the difference in London but for her Service and every other ambulance Service in the country (the world in fact) the emotive element of the job requires no explanation other than it’s all the same and all very, very different.

Be safe.


Jo said...

This sad story is doing the rounds here in Bristol at the moment. I obviously don't know the full facts, only what has been reported in the Beeb (link above) and the highly emotive Bristol Evening Post (

Essentially, an 87 year old lady was left waiting for an ambulance that didn't show up at all. Her case wasn't an emergency, but had been requested by the GP. Unfortunately, she later died, and her family are claiming that her 11 hour wait before her 85 year old husband drove her to hospital was a contributing factor to her death. (in the BEP, but not on the BBC, her husband has said that if he'd known the ambulance wasn't going to appear, he'd have taken her sooner, but each time he called, they told him to wait)

Unfortunately, it was a Friday night, and we all know the "emergencies" that ambulances have to go to on a Friday :-(

Fiz said...

I actually used to have period pains that were worse than second stage labour pains (hand on the bible), but I just used to lie on the bed, writhe, moan, throw up, have migraine etc. Childbirth had an amazing effect and they were never like again. but calling an ambulance? Hell, it took me till I was 18 to pluck up the courage to speak to my GP (who gave me the most useless pills!). Honestly, what is it about all this public drama about petty aches and pains? Too damn soft,this generation, Xf, shove 'em in the army!

JB102 said...

Hey Stu-Fru! Can't explain the amber stiff leg for you. If you ever get the ampds codes from jobs you find odd I can tell you what the caller said to get the response. I can't explain the green chest pain either. I haven't used the pandemic card but I think it's supposed to account for history of cardiac problems. I'll check when I can.

Tom said...

I think the old adage, less haste more speed is the answer.

It's vital that the units responding have all the pertinent information to hand, but the absence of effective prioritising, can as you've just related above, cause inadvertant suffering to a patient.

al said...

good blog hope you dont mind ive put a link on my site.

las_emd said...

The swine flu (card 36) card has a LOT to answer for. Chest pain? Must be swine flu. DIB? Swine flu mate. It's only recently they've made some changes as to what ages we use the card on. I speak for myself and many colleagues who have taken it upon themselves to break protocol and keep chest pain calls for elderly people a red and not go through the swine flu questions. I'd personally rather get a bollocking than risk that sort of thing, to be honest. I think the blame lies with people higher than EOC, with a bit more brass on their shoulders with this one for bringing in the new card.

Anonymous said...

I'll agree with Fizz about period pains - much worse than labour (which was a doddle) - although the after pains with child no. 2 were pretty awful.

Can't disagree that 'it happens every month' but that doesn't always make it any easier.... Pain relief from the GP was absolutely useless - and sadly the good old advice of 'taking two paracetamol' was totally ineffective. Sorry Stuart! ;-)

Anonymous said...

Another EMD here.. Late to the party so no one will read this anyway..

We were told to send all chest pains through flu/36 and they come out with a green. I'd even seen allocators on my logs cancelling the crews assigned at the end of questioning when it went to a Green2. Pissed me off quite a few times. And since we were on 36, we didn't have the option to give them aspirin as on chest pain/10..

Recently (thankfully) all chest pain goes back to card 10. Although still leaves us with breathing problems and headaches on 36.
And to be fair, they have very recently adjusted it so we can still select 6/breathing problems if they have asthma/copd/emphysema.

It really was embarrasing to sit there talking to a mum as her child was having an asthma attack asking her (LITERALLY) 15-20 questions about if he had a fever, sore throat, cough or a blooming runny nose! Same goes for some old grandad with a ?MI.

I guess since I've only been in the service 8 months I wouldn't understand the real reason behind this complex system. But it really stank of "we have a lot of calls at the moment, so if we make them all Green2's we won't miss those ORCON targets".

Xf said...

Response to all EMDs and calltakers:

The Swine Flu problem has indeed caused a lot of confusion about which card is appropriate for which call and out on the frontline someone with a real illness is going to suffer as a result, but what is the answer?

The general public are mostly to blame for this - they simply wont accept, thanks to the excitable media, that most of us will get mild symptoms and need to treat this as simple flu. The slightest cough and they are dialling 999 - or being re-directed by the Government's mongrel 'Flu hotline' because their cards are also simplistic and stop short of actually being able to help anyone.

My colleagues and I don't want to become the first victims of the heat that will be generated by this stupidity and you guys are stuffed too because you can't even use common sense or logic thanks to this short-sighted system, created solely to clear these calls.

The bottom line, whether you agree with my opinion or not, is that someone's mum, dad, child, gran or grandad is going to die because we focus on the numbers and not the problems. Let's hope its not yours or mine.