Friday 13 January 2012

Success or Failure?

In the 1990's the government introduced the response time targets that all ambulance staff have grown to hate. I'm yet to meet someone who thinks that they work or who thinks the time itself holds any significance to patient care whatsoever. For a patient in cardiac arrest 8 minutes is too long and for a patient with difficulty in breathing from a panic attack the time won't effect the outcome. You can't tell me that if I arrive to a patient in 8 minutes and 1 second from when they rang that their care would be adversely effected had I arrived 2 seconds earlier. Regardless of my opinions the target remains. It's the measure of success we work to and at the end of the day it is what we are judged on. In the vain hope someone in politics reads this I thought I'd offer a comparison about 2 jobs I have done in recent months and how they were effected by the targets.

"69 year old male, not acting normally, breathing problems"

Category: Red 2
Call connect: 20:57
Dispatched: 20:58
Distance: 5.2 miles
On scene: 21:06
Target: Missed

We walked in the front door and were ushered upstairs by the patient's daughter where she gave an excellent handover of his medical history. In all honesty he didn't look well, he was sweating, his pulse was slow and weak and he was wheezing. He also had slurred speech. We treated as we found. We gave Salbutomol for his breathing which had little effect. We gave a second dose with Atrovent. After 10 minutes or so his breathing improved. Whilst the nebuliser was at work we had tested his blood sugar. He was hypoglycaemic (low sugar). We gave glucose IV and he began to come round. He told us he had chest pain too. After a brief assessment and further history we gave him aspirin. His blood pressure was too low to give GTN so fluids were given instead. A 12 lead ECG was done in the house and sure enough, he was having a heart attack. We gave Clopidogrel and once he was on the ambulance and his blood pressure was raised we gave morphine. On way to the ambulance he was given Entonox for the pain. A blue call was put into the local cath lab. It was a 10-12 minute journey on blue lights. On route he went into cardiac arrest. Pads attached and 1 shock given. Airway inserted, oxygen given and CPR started. We gave a second shock. We got him back. Under close monitoring we continued to the cath lab. An update was given on his condition and we arrived with no further problems. He was taken straight into the lab and had an immediate primary angioplasty. The clot was removed, a stent was fitted and a week later he was discharged from hospital. The government deem this job as a failure.

"7 year old female, drowned, CPR in progress"

Category: Red 1
Call connect: 18:09
Dispatched: 18:09
Distance: 1.3 miles
On scene: 18:12
Target: Made

This job is everyones worst nightmare. A paediatric cardiac arrest is by far the hardest thing we have to deal with. No amount of training can prepare you for it. This particular job has affected me more than any other and it still chokes me to write about it. We flew round to the house at god knows what speed. The information on the screen was detailed enough for us to know this was a genuine job. Grabbing every bit of kit we could we ran to the open door (This remains the only time I've ever run at work). We heard a woman screaming for help upstairs so up we went. Lying on the bathroom floor was the lifeless body of the girl. Her mum was doing CPR. I took over. We stayed on scene for less than 5 minutes. The patient was intubated, IV access gained and 2 cycles of CPR completed. Asystole. In layman's terms, there was 0 heart activity. We ran. The hospital was about 2 miles away so we left. The mother went with the second crew that arrived as we were coming out the house. I spent the 4 minute journey doing CPR and ventilating her just staring at her. I didn't need to think about what needed doing. It just came naturally. A member of the second crew was in the back with me. She was also doing everything possible. We ran into the resus. room and gave a handover. They instantly began working on the girl. They did so for over an hour. She was declared dead at 19:31. The government deems this job as a success.

8 minutes. It isn't life or death. It's a number. It's a number that someone or a group of people decided on. I'd like them to tell the mother who lost her child that the ambulance service were successful. I don't feel successful. I'd also like them to tell the guy who walked out of hospital that the ambulance service had failed him. I don't feel like I failed him. But I don't set the targets. Success and failure cannot be measured on a stop watch but it is. Patient care has very little to do with it but I'm sure if the policy maker's family needed an ambulance they would rather the outcome be measured by what I call a success than what they do.


  1. So sad to here about the seven year old girl... *hug* :'-(

  2. I thank you and all your coleagues for what you do .

  3. The latest version of the response targets don't show the first call as a fail. You failed to meet the response target, but met all the clinical indicators. So overall it is a success. April last year saw a big change to how ambulance performance is measured - it is just a pity that a lot of staff still haven't been told!

  4. There has to be some way of "measuring" successs, with goals and targets.Whilst I agree the 8 min rule is not helpful, I wouldn't know how else to do it. How would you suggest this was done?

    1. True. It's a tough one, I just feel that there is to much onus on it. It should be something that is aimed for, not something that financial penalties are given for missing. When money is involved that becomes the soul focus for those in charge and patients get forgotten.

    2. Absolutely, you are right. As soon as money gets involved it can loose its original purpose. So are you saying without the monetary penalties it is helpful? All of us in all areas of employment have targets/bonuses/penalties and often they seem unfair, unworkable. I understand when dealing with life and death situations targets are ridiculous and can't and shouldn't go ahead of peoples safety. Also it should never be used to berate paramedics that are always doing the very best they can with the resources they have. But would maintain that at some point success has to be measured be that positive or negative. I just have no idea how else it would be implemented.

    3. The thing with the 8 minute target is that in an area like london you have X amount of ambulances working. With cut backs there are less and less ambulances. The target doesn't account for location at all. How the nearest ambulance can get 9 miles in 8 minutes I don't know. There is also time of day. Trying to travel 3 miles in 8 minutes through central london rush hour traffic is neat impossible. If call volume jumps without warning from 3500 a day to 5500 on a wednesday how can the same amount of ambulances answer such a surge in calls and meet targets. It isn't practicle. I don't know the answer but success or failure should not be deemed but time taken to arrive. Most calls we recieve we are on scene within 8 minutes of dispatch. Problem is the call is alreaady 5 minutes old so its a failure.

  5. As usual these targets and rules are devised by a committee who have little or no idea of the intricacies of the work they are ruling on. I should think if people are doing their jobs properly targets can only be met by the resources that are in place. If the resources are not there, the work can't be done.
    Eric Burrows.


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