Please consider this in a spirit of general discussion rather than specific
challenge.
> If the Ambulance Service calls a Senior Doctor out from the "local" hospital
> then I would expect the paramedics to take the advice of that person. He or
> she then takes the responsibility for the consequences of that advice.
Yes, I would agree. But this would suppose that the crew knew that the
Communications Centre had called you! (Specifically here Ray they did not,
and I suspect that the WYMAS / LancAm split may account for this.)
You say for advice. Absolutely. In general there is a wide breadth of
pre-hospital experience and clinical skill, and very few doctors have both (I
know that in this particular circumstance Ray does - but the crew didn't!)
Yes, the doctor's decisions are his/her responsibility, but that does not
mean that they are solely accountable for the whole scene and all the
decisions made.
> My point for initially sending the mailing was to illustrate the point that
> "speed" isn't everything. The patient must be transferred safely. Once the
> patient's airway was secured she was safely transferred to hospital.
> Emergency surgery was not needed on either patient.
I would agree. Early optimisation of oxygenation and tissue perfusion
followed by early definitive treatment are the keys. The ambulance crew
believed that they were able to maintain the airway and adequately oxygenate
for the 8 minute transit to a "neurosurgical" hospital and that this was
preferable to a 30 minute land transfer to a "non-neurosurgical" hospital.
The presence of a person capable of chemical airway control clearly changes
the available level of scene intervention available, but should it change the
triage destination? The conflict is "definitive airway control and 30 minute
land transfer to DGH" or "ventilation without a secured airway and 8 minute
air transfer to neuro centre". Difficult!
I was not there and so will not challenge the judgement call by a colleague
with experience. In this case, the aircraft and paramedics could not take a
paralysed and ventilated patient and it affected the subsequent scene
disposal. We are working on this.
> The Flying Squad vehicle from Lancaster is clearly signed and I was wearing
> appropriate gear identifying me as a doctor.
Absolutely, but I stand by the original comment that the crew did not know
you, even by reputation. They should not take competence in the pre-hospital
environment for granted. We have had close calls on this front in other areas
of our "patch" before and they are wary as a result. Allowing for this, they
should have taken steps to avoid confrontation and utilise the evident
clinical skill of all persons on scene. Automatic transfer of all
responsibility to the arriving doctor is not the way.
Best wishes
Darren
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