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Bottom of the heap

It was a moment I will not forget. He was three years of age. He was on the examination couch. He was not responding. He had the classical blue eyes, blond hair and beautiful complexion.

With authority and decisiveness, I told the secretary to ring 999… NOW. The boy was limp and could not be woken from his slumber, which we had hoped it was. All my pressing of pain sites and slapping of his face came to nothing. His pupils were distant but responsive to light. His heart rate was not alarmed and his breathing was calm. Eerily so.

At this stage his mother and relatives were in hysterics.

I had hoped the secretary would say: ‘The ambulance is on the way doctor and will be here urgently.’

Instead I heard: “They want to talk to you, doctor.” I dragged myself away from a dying child. The ambulance man began the questions: “What is his address, what age is he, what is his state at the moment? What is his… this? What is his… that?”

I interrupted the flow of questions because I truly believed he was mistaken about what was unfolding in front of me. I explained that “I am a doctor and I am in an after-hours clinic and I have a dying child here.”

“Yes, but I have to ask you these questions.” He was getting irritated.

I had been here before and so I knew where the questions were going and each second delay by protocol was a second lost to this boy, and possibly forever.

I stopped partaking in his delaying conversation. I passed the phone back to the secretary. He knew our address. The only thing that might awaken his stupor, out of protocol madness to medical urgency, was for me to get back to work. I now knew we were on our own. The ambulance might come. I felt sure it would come. But when?

I decided we were on our own, deserted by the system. “No rash,” I said, “but still maybe it might be meningitis and maybe a penicillin shot might make the difference between life and death”. It was the only thing I could consider in the absence of help. Do something. So I could say I tried everything.

With panicking relatives in the small room, I went to another room to draw up penicillin. They probably thought that I was fleeing the scene.

Watching the boy, flaccid in my arms and hearing the wailing cries in the background, I remembered how your life can flash in front on your eyes in a very short space of time. I travelled, in thought, through my past, my present and my future, like A Christmas Carol. In a split second.

The future? The final acknowledgment that he was irreversibly dead. The inquest. The relative’s pain. My isolation and powerlessness. The unfairness of it all. The acceptance that this is part and parcel of a medical career. The sense of failure. The acceptance that I did all that could be done in the tragic circumstances. Acceptance that this may not be enough in a system that likes to blame professionals for simply being on the front line when, inevitably, tragedy occurs.

The present? I was speechless with confusion and anger at the ambulance service. But I also recognised that this is not a new problem. I have seen it before, even 20 years ago in Australia. I have spoken to other GPs over the years. It was not like this when I started out. There was some respect and teamwork. A doctor’s opinion meant something. We were top of the heap. Now it appears we are bottom of the heap.

The advice from other GPs since that event is that this situation is real. It is not just me. It is a problem. The perception is that it is better for a patient to ring the ambulance service directly rather than the doctor ringing. There is more respect. More pragmatism. But maybe only a little more.

Why is this? Is it another symptom of putting the priorities of administration over clinical care?

So what happened next? The ambulance came, on time, and as life would have it, the boy awoke like some Lazarus. Making liars of us.

The ambulance boys were a welcome sight. I struggled between slight embarrassment at a now less-sick child and not wanting to give these good professionals a tongue-lashing for forces outside their direct control. Professionalism and teamwork won the moment. This time. I kept my counsel.

I rang the following day, as I sometimes do. The boy was home after being kept overnight. What a great gift for the family and for me. It could easily have been such a different start to the year.

We have choices to make here. Changes. Who will make them? Who was this lesson meant for?

  1. Jay on January 15, 2018 at 11:17 am

    @Fran.
    Firstly, your comment on what business a CFR has commenting on this article is the very reason comments are here in the first place. This doctor looks down on us and you obviously look down on CFR’s. As an advanced paramedic you surely should be familiar with the research & evidence that supports CFR groups and the truly life saving work they do. This is an open forum for ALL people interested in patient care and therefor ALL people should be allowed to comment and share. We are all a large team working for better patient outcomes.
    Secondly, our colleague that highlighted his education was doing so to demonstrate that “ambulance boys” is not appropriate as many of us have pushed our education forward up to and including PhD level. As you should know there are a number of PhD educated paramedics in the country and that number is rising every year.
    To address the article in question. Although we all have frustrations at some systems of work, the procedures in place is what we have until something better is put in place. If the GP has an issue with the NEOC system he should contact them to obtain training/education on how it works and why. Everyone must answer the questions on the 999 system so an appropriate level response is initiated with appropriate level practitioners as needed.
    In regards to the sick child. Although I wasn’t there it certainly looks to me that the GP was the person panicking. As a previous poster stated there was many things that should have been done before considering a penicillin “shot” if it was truly indicated.
    UCD run many excellent courses for GP’s to manage situations like this and this GP would certainly benefit from them, or if he wanted I’m sure some paramedics or advanced paramedics would be more than happy to assist him in brushing up on these skills. After all, believe it or not, we actually do train doctors in some areas also.
    Finally, I am no where near perfect and as a prehospital practitioner I am very aware of how my decisions can have a lasting effect on the patients I encounter. But, as we all work together and educate each other with patient safety and needs central we can collectively make the proper decisions.

    *Tell me and I forget. Teach me and I remember. Involve me and I learn.* -Benjamin Franklin.

  2. Jay on January 15, 2018 at 11:05 am

    @Fran.
    Firstly, your comment on what business a CFR has commenting on this article is the very reason comments are here in the first place. This doctor looks down on us and you obviously look down on CFR’s. As an advanced paramedic you surely should be familiar with the research & evidence that supports CFR groups and the truly life saving work they do. This is an open forum for ALL people interested in patient care and therefor ALL people should be allowed to comment and share. We are all a large team working for better patient outcomes.
    Secondly, our colleague that highlighted his education was doing so to demonstrate that “ambulance boys” is not appropriate as many of us have pushed our education forward up to and including PhD level. As you should know there are a number of PhD educated paramedics in the country and that number is rising every year.
    To address the article in question. Although we all have frustrations at some systems of work, the procedures in place is what we have until something better is put in place. If the GP has an issue with the NEOC system he should contact them to obtain training/education on how it works and why. Everyone must answer the questions on the 999 system so an appropriate level response is initiated with appropriate level practitioners as needed.
    In regards to the sick child. Although I wasn’t there it certainly looks to me that the GP was the person panicking. As a previous poster stated there was many things that should have been done before considering a penicillin “shot” if it was truly indicated.
    UCD run many excellent courses for GP’s to manage situations like this and this GP would certainly benefit from them, or if he wanted I’m sure some paramedics or advanced paramedics would be more than happy to assist him in brushing up on these skills. After all, believe it or not, we actually do train doctors in some areas also.
    Finally, I am no where near perfect and as a prehospital practitioner I am very aware of how my decisions can have a lasting effect on the patients I encounter. But, as we all work together and educate each other with patient safety and needs central we can collectively make the proper decisions.

    *Tell me and I forget. Teach me and I remember. Involve me and I learn.* -Benjamin Franklin.

  3. Fran on January 14, 2018 at 11:42 pm

    As an amendment to my comment below, I didn’t read the end and thought that the child had passed away. So grief at losing the child was obviously a mute point but I stand by saying we should recognise that this practitioner was dealing with an extremely stressful situation and shouldn’t be demonized on this or any other forum by paramedics or CFRs waiting to have a dig.

  4. Fran on January 14, 2018 at 11:34 pm

    Firstly what business has a CFR commenting on this article? Secondly to the paramedic with the degree, your not going to be doing a master’s to become an advanced paramedic but thank you for waving your educational accomplishments at us. Now I am an advanced paramedic, I was also an advanced Emergency medical dispatcher for a period so I may be in a position to comment.
    I will agree with the GP who penned the letter in that the current system used by NAS and DFB for medical dispatcher has no bypass protocol to allow them to click call from doctor or significant emergency and bypass the usual questions to speed up the call. Now I will also say that the questioning system when used correctly is fast and usually efficient but is flawed. A big part of the problem is that in both NAS and DFB this system is pushed as the be all and end all and there is no human thought or initiative allowed. The newer dispatchers are exactly that just civilians brought in and trained to go through the mantra and are threatened never to stray from what is on the screen under pain of death, it’s all about key point indicators and reaching targets of what the system deems a good call rather than doing the right thing for the patient and at times the person making the call. Where it used to be trained paramedics taking the calls so at least we had experience and the ability to bypass the system when it was warranted the new guys cannot and it leads to frustration at times. The GP in question should be commended for taking the time to call himself as he obviously cared enough to think he could pass the relevant information on in better manner rather than a receptionist. We should maybe take time to consider when training GPs, that teaching them that they don’t have to make the call might help in situations like this. Lastly I will say this I’ve been doing this work for 14 years now, I am not a superhuman, I am not cold and unmoved by loss of life especially when it’s of a child I’m caring for and maybe just maybe the GP who wrote this article was feeling the weight of fighting to save this child’s life and maybe he is now venting as he’s been deeply effected by this inability to save a life. Maybe that’s why he is now feeling like the bottom of the pile. So maybe instead of retaliation and disgust, maybe we should ask why this man feels so low?

  5. Patrick on January 14, 2018 at 9:58 pm

    As a GP who teaches other GPs prehospital emergency care, I am embarrassed by the comments of my fellow GP. Understandably Dr Heslin was very concerned by the clinical condition of his patient and like many other people in that situation wanted the ‘cavalry to come over the hill.’ I completely understand the dispatch process and understand it’s relevance (only out of an interest in Pre-Hospital Care) but not all of my colleagues appreciate its significance. I understand how he could’ve been exacerbated in this situation. I do not agree with him that GPs are at ‘the bottom of the heap’ in this regard however. These questions are necessary and could’ve been answered by a lay person or the secreatary in this case. This would allow the GP to carry out their primary assessment, addressing issues as they arise and moving onto secondary assessment. There were many things other than a shot of penicillin which could be offered as supportive treatment in this case; airway adjuncts, PPV, oxygen, IV access, IV fluid bonus, blood glucose etc. I hope that my prehospital colleagues: CFRs, EMTs, Paramedics, APs and dispatchers don’t feel too annoyed. The majority of GPs are delighted with the leaps, bounds, clinical acumen and professionalism of the NAS and community responders when they come to our aid in our hours of need. It’s a longtime since ‘ambulance drivers’ were on the scene!!

  6. Simon Taylor on January 14, 2018 at 9:16 am

    As a CFR I find Dr’s generally very dismissive of our role and have also seen them been equally dismissive of the Paramedics and APs on a call. My understanding is that often an ambulance will be dispatched while the questions are being asked and crews updated enroute. I have often been enroute to a call and while talking to control have been told to hold on for further details as the caller is on the line. Sounds to me the dr was overwhelmed by his patient and forgot the basics but then if they are ambulance boys god knows what he thinks of CFRs. The only person who matters is the patient and this top of the heap or bottom of the heap shite drives me mad when we all work together to keep the chain of survival strong patients have good outcomes.

  7. Damien on January 14, 2018 at 4:35 am

    A Doctor who was “top of the heap” once directed me to administer intra-thoracic adrenaline. He also became angry at me due to his ignorance, when I had refused.

    Paramedics, advanced paramedics and EMTs are at the very top of the pre-hospital field. They haven’t been “ambulance drivers” etc for some time. 20 years I believe this doctor alluded to. The ignorance which he has displayed in this article to both the ever improving pre-hospital field and to his own practice is disturbing. He exhibits an almost cavalier approach to medicine. They’re expecting me to do something so I better be seen to be doing it. He shows no evidence of an appropriate assessment of the child before reaching the decision to just throw a penicillin “shot” into him. No cannulation, ECG, bp, temp, assessment of kernigs or brudzinkis signs, mottling or cold hands or feet. Nothing. Just concerned about how he looked and that the bad ambulance man didn’t do what he told him.

    But what would I know, I’ve only an ambulance driver for 13 years. This Doctor is a risk to the public and needs to be investigated. Paramedics have our clinical governance and on-going training, by Doctors. We are licenced to practice and bound by strict rules of practice.

    It must be nice to be top of the heap and looking down on everybody. Hang your head in shame Dr. You have done yourself a great disservice today and the internet remembers!

  8. Mitch on January 13, 2018 at 10:54 pm

    I can see both sides of this.
    Firstly my educational background I’m a paramedic with a honors degree in paramedic studies from the graduate entry medical school and I’m currently about to undertake a further two years masters degree to achieve Advanced Paramedic, six years of education and yet this is recognized by physician colleagues as Ambulance Boys or Ambulance drivers is a tad insulting.
    Now to get to my point the AMPDS system the twenty questions asked by NEOC are designed to correctly field or triage calls from members of the public and it’s purpose is to prioritize limited resources for the most critical calls. a more suitable system would be to adopt the national early warning score used nationally by hospitals as a way of fielding or triaging health facilities calls including gp calls as it means something to the prehospital clinicians who are going to render care and makes such calls, auditable. This is important as the NAS and DFB EMS are often seen as transportation and not for their modern role.
    It is known anecdotally that regular “callers” to the service both members of the public and health care services alter or exaggerate symptoms to ensure the nearest Emergency Ambulance. The system is flawed but it’s flawed because of high demand, increased clinical scope and the limited resources.
    There exists a situation where there is a bilateral attitude reminiscent of the emperor has no clothes. On the NEOC and ambulance service side, it’s down to a blind belief in an AMPD tool that’s totes claims that do not stand up to Scrutiny of the experience of the clinicians who are on scene be it paramedic or physician, similarly there is an unwillingness of the medical profession to acknowledge the evolution of a profession that has a high educational foundation and high clinical scope and responsibilities

  9. Jen on January 13, 2018 at 9:24 pm

    I certainly do hope that lessons have been learnt here. That the doctor above has now realised that he alone may have delayed appropriate care arriving to the child by refusing to assist the ambulance service to properly triage the call. Perhaps that should be investigated. How many other of his patients has he delayed pre-hospital care for?
    The questioning process used (recognised internationally as the best system for triaging ambulance requests, and used in multiple services around the world) was developed by doctors, and helps the ambulance service to obtain information about the injury or illness to ensure the most appropriate care is sent, and in the appropriate timeframe.
    By delaying the answers, he directly delayed the help that the little child required.
    He speaks of the lack of respect, but the only lack of respect I see here is his complete and utter lack of respect for the National Ambulance Service. A lack of respect for Ambulance Control by the refusal to answer simple questions such as the address of the emergency (he mentions in error here that he was asked for the patients address, perhaps a typo, or more likely confirmation that he wasn’t actually listening to the questions being asked), and a lack of respect for the Paramedics and Advanced paramedics, by his use of the derogatory terms like “ambulance man” and “ambulance boys”. Should he be referred to as Stethoscope Boy?
    Perhaps it should be mandatory for GPs to have more knowledge about pre-hospital care systems. That knowledge is clearly lacking in this instance.
    I hope that Stehoscope Boy realises at some stage how ridiculous he sounds in the above article, but alas, due to his obvious egotistical nature, I fear that it will not be any time soon.
    Yours,
    Ambulance Girl.

  10. Dave on January 13, 2018 at 9:17 pm

    It appears the only one getting irritated and panicking was the GP.
    Reckless comes to mind when this GP decides to administer Penicillin with no clinical signs of meningitis.
    This Doctor decides to lash out at a system, flawed in places, yes, but only because he is frustrated by the fact he cannot diagnose or treat the patient.
    In my opinion GP’s are bottom of the heap when it comes to not making a decision and relying heavily on the Ambulance Service.
    As for his derogatory comments in relation to his description of the Paramedics, I am sure his own regulatory body would have an opinion.
    If any one needs a tongue lashing it is the primary care services who seem to believe the Ambulance Service are there for them when they decide not to attend a patient.

  11. Dave on January 13, 2018 at 3:09 pm

    “There was some respect and teamwork. A doctor’s opinion meant something. We were top of the heap. Now it appears we are bottom of the heap.”

    It appears the Dr in question is annoyed that the pre hospital environment has rapidly caught up with and even surpassed what was traditionally in hospital only care(or care given by doctors)

    I hope in future he would refresh his memory on triage and realise what it means, where he has one patient to deal with, regionally/nationally the ambulance service is dealing with hundreds of patients at the same time. A call taker/ dispatcher could have a short professional yes/no conversation which would involve no more then 10 quick questions taking no more then a matter of moments.

  12. Ash on January 11, 2018 at 11:43 am

    Perhaps this doctor should do a bit more research into how the ambulance service works.
    This is not a “flaw in ambulance protocol” it’s a flaw in a doctors knowledge about a service. While they were talking to the call taker answering vital questions an ambulance would have been contacted and dispatched simultaneously. The questions are to give the crew on route information so they know the best and safest way to drive to the call and also an idea of what the call is about to prepare themselves. Those questions can be vital.
    I find the term “ambulance boys” offensive and just highlights the doctors lack of knowledge about the service. They are paramedics not ‘ambulance boys’. And they are who YOU called for help with all your medical training to help save a life, have some respect.

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