Saturday, 12 May 2012

Huffing and Puffing

"71 year old male, intermittent chest pain, in GP surgery"

I have recently had a few pops at GPs, in fairness with good reason, but in the interest of equality it is only right that I highlight the other side of the coin: How GPs sometimes view the ambulance service. 

After my recent blog 'GPs: Take Note' some of my sweeping statements were highlighted. I often make them without much thought and with little investigation! That's the 'hot head' inside of me. I think of something and write it and that is where it stays! Obviously GPs don't all work 9am to 5pm. I was reliably informed that in fact it's near 8:30am to 6:30pm which I promptly corrected! I was also asked how many extra hours on top of their 50 hour weeks they should be expected to do 'out of hours'?! Good point! I didn't really have an answer other than a sarcastic '80+ hours?!' In all honesty, it is easy for everyone to point the finger and say 'do more' and 'work more nights' but I'll be honest, I wouldn't. Despite my stupid hours I still average 37.5 hours a week over the year and anything over and above that I am paid overtime for. I suppose everyone just wants a GP whenever it suits them. Sure, they could all start working from 6:30pm to 8:30am but then we would moan there were no GPs during the day. It's a lose lose situation for everyone. It is how it is, but I'll still have a dig for my own satisfaction as and when the opportunity presents itself!

To that end, I was sent a link to a blog by Dr John Crippen, author of the now archived The Crippen Diary (2008) to look at my GP surgery moans from the other perspective. We are guilty of groaning when we see a 'chest pain' at a GP surgery pop up on our screen, but likewise, this post highlights the groan when a GP has to call an ambulance! It thoroughly amused me and I felt it warranted sharing. To be fair, he makes some excellent points! Enjoy!

"Once again, the best and worst of the modern NHS.

Last Thursday I arrived for work at about twenty to eight, to find Andrew and his wife, Mary, already waiting. Andrew is 71, retired, in good general health though he has (well controlled) hypertension and (well controlled) hypercholesterolaemia.

He looked well, and smiled as he sat down. He gave a history of three attacks of severe indigestion, two during the night and one whilst having breakfast this morning. Andrew is an intelligent man. He knew this was not indigestion. The history was the kind of text book angina that makes one want to run out and find a medical student and say “listen to this.” Andrew was now free of pain, with a normal heart rate and blood pressure. He is already on aspirin and had indeed taken it that morning with his BP pill.

This was classical unstable or crescendo angina and Andrew needed to go into hospital. He was not surprised. Mary was, but started fumbling for her car keys. The local hospital is three miles away. Now one of those taxing general practice moments which we all dread.

“I will get an ambulance” I said

Mary looked shocked and panicky. “But we have just driven down here and have been sitting in the car park for fifteen minutes”

I know, I know, it seems melodramatic, but I can’t take the risk that Andrew might have another attack on the dual carriageway. So I call the ambulance service. A very friendly operator answers on the second ring. I give all my details, my code number, then all Andrew’s details, his address, date of birth and then I am asked "the question". The same glorious I am always asked, read, as always, from the protocol.

“Is there a medical need for an ambulance?”

I resist the temptation to say “WTF do you think I am phoning” and merely say, “Yes.”

Even now, I know that there is about to be a problem. What is your provisional diagnosis? The word "provisional" is irritatingly gratuitous. “Unstable angina”. Silence. Operator switches to a different protocol. Do you want an immediate ambulance? Well, I certainly do not want to wait two hours, but this was not dire enough for me to have dialled 999. “Yes, please, but you don’t need to arrive with sirens and flashing blue lights”.

There is no such option on the protocol sheet and so my request is ignored I am switched to the 999 “pathway”. I am told that the ambulance is on the way but I have to answer some more questions.

"Are you with the patient?" Of course I am. “Is the patient conscious?”. Yes, of course he is, if he was not, I would have dialled 999. In fact, he is sitting in front of me smiling. “Is he breathing.” “Has he changed colour.” And so it goes on. These are the 999 protocol questions for the layman. They are not questions for experienced doctors but they are always asked and have to be answered. By the time I get to the end of the ludicrous questionnaire I can hear the siren and soon I see the flashing blue lights through the window.

I go out to meet the paramedics. Two very keen young men. I give the history to them, and tell them the important things. Andrew is pain free, stable, in sinus rhythm, with a normal blood pressure. Then we have to play the ECG game.

“Have you done an ECG, doctor.”


“Do you have an ECG in your practice?”

Tempting to say mind your own business, or ask if they have oxygen in their ambulance. We have both an ECG machine and a defibrillator but neither has been needed, thank God. It is not possible to make paramedics understand that it is not necessary nor even helpful in this situation to do an ECG.

“Why on earth would I want to do an ECG?” I ask

The paramedics look at each other and back at me. “To see if he has had a heart attack, and to see what rhythm he is in.”

I know what heart rhythm he is in (well, OK, he could be in steady atrial fibrillation or even compete heart block but it is not likely) and you cannot exclude a heart attack at this stage by doing an ECG so, whatever it shows, he needs to be in hospital. Might as well just take him. We are not on Dartmoor. The paramedics do not carry clot busting drugs. The hospital is only a few minutes away.

The paramedics huff and puff.

Andrew refuses to get on a trolley and insists on walking to the ambulance. The paramedics do not like this and huff an puff some more. I keep a straight face. Not a sign of schadenfreude from me.

The ambulance then sits in the car park for eleven minutes (just over). I timed it. Stay and play. Do an ECG. Follow the ritual. The ambulance service insisted on sending a blue-light ambulance which, all power to them had it been needed, arrived in less than five minutes. They then waste eleven minutes doing unnecessary tests. Stay and play probably killed Princess Diana. Fortunately it did not kill Andrew.

He arrived at the local cardiac unit a few minutes later, alive and well, and still pain free. By mid afternoon he had been fully investigated, ECG, blood tests, angiogram and stent. He was discharged home the following day.

Andrew has almost certainly been saved from a full blown heart attack or worse. He appeared at the Health Centre at 7.40 am and thirty six hours later was back at home, well, stented and pain free. Whatever one may think of protocols and government targets, this is an excellent outcome.

Criticisms? Well, a few.

Andrew was in and out of hospital so quickly that he did not really take it all in. I had to spend half an hour translating all the medical jargon on the discharge summary and explaining the medication to him. Mary was still frightened and wanted to rap him up in cotton wool. And I hate doctors who are too frightened to use their own name. The “cardiology team” is not a consultant.

But, all in all, a good result. I wish they would treat psychiatric emergencies in the same way, but hearts are glamorous. The mentally ill, apart of course from Stephen Fry, are not."

We do huff and puff! A lot! As a service we are obsessed with ECGs and with good reason. I think we often lose sight of the point of them though. The problem is, like Dr Crippen alluded to, we have protocols. Shit loads of them! On top of that we are judged on our paperwork, and if the words 'chest pain' appear anywhere on our paperwork there has to be an ECG! Why? Because we are told too and as a result some people do them at inappropriate times. It does often seem pointless in some patients and personally I wouldn't have done one on this guy unless it was going to change my plan.  In this case it wouldn't have. He was already going to a cardiac unit. Doing an ECG on someone not in pain was not going to change a thing in this instance. If he wasn't booked to the cardiac unit, even if the ECG shows some kind of cardiac event he would still go to an A & E because the criteria for going straight to a cardiac unit is central chest pain for more than 15 minutes with some exceptions, none of which he fits into. We also do an ECG if a patient's blood sugar is above 10mmol/L. Not 9.9, oh no, 10.1 makes all the difference! In reality it is a number. I will do an ECG if  I think it's indicated or if a patient will benefit from the investigation, not because of a difference in 0.1! Some people will see a BM of 10.1 and just do an ECG but why?! It's all relevant to history. If a non insulin dependant diabetic who's BM sits between 10 and 14 normally has called for a back injury doing an ECG won't change much! Some of the things we do are over the top and it doesn't surprise me in the slightest the GPs get annoyed with us but they are over top for a reason. History has taught us to be over cautious for a reason. They have years and years of training and we are certainly not placed to second guess a diagnosis or decision, but can ignore and make our own ones! Obviously we can share an opinion about leaving ill patients alone in a waiting room with a letter in their hand, but we certainly shouldn't be questioning whether or not an ECG has been done. If we think one should be done, we'll dam right do on!

It all comes down to the age old problem with the NHS. Services not working together! There is not a big enough understanding between job roles and policies in different areas of the NHS. Yes, a GP should be able to say 'I need an ambulance, don't worry about lights, but as soon as possible would be great' without having to answer pointless questions! Likewise the GPs need to understand why we have to do ECGs and wait around for 11 minutes when it appears we are simply delaying definitive treatment. We don't delay for fun and it isn't simply a box ticking exercise. We do it because we have the knowledge and equipment to be able to form a more comprehensie history and picture of a patients health and in 'staying and playing' can benefit a patient in the short and long term. I doubt it will ever change, everyone has their arses to cover and everyone thinks their job role is more important than others. That's just how it is. We will all continue to love to hate each other and engage in professional banter wherever possible! 

Full article: The Crippen Diary - 2008 : January (2) | Trusted.MD Network
Visit Our Health Blogging Network Trusted.MD

NB: I have made some edits to this post following comments which showed the point I was trying to make had been lost. I am not making editing notes. This is not a scholarly article, a journal or anything other than a personal blog. Just be aware that most of the comments were made before my edit which were merely the re-wording of a couple of sentences. I stand by what I say, like always. 


  1. OK, I have held off long enough... but its time for some hard truths here.

    Lets run with some quotes then some comments shall we-

    "if the words 'chest pain' appear anywhere on our paperwork there has to be an ECG! Why? Because we are told too"

    No!, no no no no no.. We do an ECG because we are aware of the additional information it can give us. We do ECGs because once you actually have some time under your belt, you will realise that there are many many patients out there who have subtle abnormalities which you can pick up and pre-empt a sudden deterioration in their condition. There are ECGs out there which may well differ to what the patient states their symptoms are. I have had many patients accepted into PCI who have atypical chest pain, who due to me "being over the top with ECGs" I have had the sense and knowledge to look further than the presenting symptoms. I guess you would miss these patients as you haven't been told to do them in these types of patients.

    "I dont do something unless it will change my plan" - You are flying blind. You will crash. Maybe not today, but sometime in the future. I have been there. I have missed things as I have not been thorough, but I have learned from them, and I passed some of these experiences to others through my blog when I was writing it. I hope that others will learn without having to question what they have, or have not done for a patient.

    "Doing an ECG on someone not in pain will not change a thing" - Wow....really???? Not looked after any silent MI's then have you? It may not change a thing for you (unless you are found out, then it may well change your career), but it sure as hell will change your patient’s outcome.

    "Even if the ECG shows some kind of cardiac event they would still go to an A & E because the criteria for going straight to a cardiac unit is central chest pain for more than 15 minutes" - Maybe you need to talk more to your cath labs? Are you really saying that if you phone the cath lab and send an ECG showing hyper acute T waves with chest pain that has been present for 10 minutes, that they will not accept them? I would be battling to get them in the cath lab, not going to A&E.

    "We also do an ECG if a patient's blood sugar is above 10mmol/L. Not 9.9, oh no, 10.1 makes all the difference" - You are right, the difference between 9.9 and 10.1 is tiny, but what are your guidelines telling you? To be aware of silent MI's in Diabetic patients, yes? But then I guess you wouldn't do an ECG anyway as you don't do ECGs if the patient doesn't have chest pain right?

    "but we certainly shouldn't be questioning whether or not an ECG has been done “- YES, yes you should, because you are the patients advocate. The GP may not have an ECG machine. If you are trained right and if you have done some additional learning, I will guarantee that you will be better at reading ECGS than a GP is (although maybe not you, because you don't do many ECGS apparently!)

    I guess you can tell I am a little annoyed?

    I don't read this blog much at all, only when one of my followers points out another blatant breach of patient confidentiality, or another unprofessional blog post. They are bad enough "Ella", but when you have a large following like you do and you start preaching about not needing to complete a full and thorough patient assessment, that really does cross the line.

    Student paramedics read this blog; people interested in becoming paramedics and going into the service read this blog; You may want to kill your patients, but lets not show others how to do it as well!!

    To be continued in next comment......

    1. Hi there,

      I was on a night shift last night so havn't been able to reply until now. I take on what you say and clearly your previous advise about sitting on a post for a few days would have been of greater benefit here, however I do feel you have missed the point of my post and the thoughts I was trying to convey. That is partly because I didn't explain myself very well and partly because once you 'see red' it's hard to see anything else.

      You've put me in a bit of a no win situation here. I can try and justify myself but looking at the comments further down its too late in the day for that to mean anything. It appears I am already being accused of 'back pedalling' without saying anything. As i'm not one who likes upset people I with explain myself but I won't apologise for my content. I have made a few little edits to sentences to make my stand point clearer as I feel the essence was lost but general view I wrote stands.

      So, to address the points you made, firstly the doing of ECGs. Of course I do them for all sorts of patients. I was talking about the patient in the blog I was writing about. No matter what the ECG shows he was already going to a cardiac unit, so nothing will change. The same stands for your second point, it was patient relative. I am extremely thorough at work, more so than most, and do an ECG on anyone where it may be of benefit. Unfortunately because I didn't explain myself properly you have come to a conclusion that I don't understand the benefits of them and I do. I am aware of silent MI's and I was meerly trying to say that people need to look at their patient and do the necessary tests based on a history and presentation, not a protocol.

      Regarding the questioning of GPs I disagree with you. My point is that if an ECG needs doing we will do it. I don't think there is any benefit from being a know it all to a GP. Let's get on the ambulance and then know it all!

      I do take your points on board and despite what you may think, I appreciate all comments I receive. I don't appreciate or condone the abuse I see you have received and I will address that. I do feel however some of what you said as gone beyond a constructive criticism and a criticism. You may well know who I am but I don't think it is fair for you to discuss and question my anonymity. In doing so it has caused for your friends and allies to publicly give away who I am and insult me and I don't think that is fair. You may not agree with what I say or like it but you don't have to. I think those comments over stepped the mark.

      Likewise, I don't appreciate you saying that I blatantly breach patient confidentiality. I don't and I could confidently defend any post from that standpoint. If you disagree please email me what posts you are talking about.

      I know that you are respected in the blogging and professional community and that is why I asked for your advise and suggestions. You must also know that because of your back ground there are people who will read your comments and attack me basically on your say so and I don't think I have been given a fair chance to answer. I hope you re-read the one paragraph you had issues with, see the few words I have added and see that the point of what I was saying was lost. Did you never write anything that people didn't read as you meant it? I'm still learning and still have much to learn but I write from the heart and sometimes my point gets lost in the moment.

  2. I will not be coming back. I am sure that some of your loyal followers will have something to say about my post, but I am intensely proud of what I did in my profession up until January of this year. I am very proud of what I have been able to accomplish in the care of my patients and the lengths that I went to to ensure that they received the very best care possible.

    You continue to bring the profession I love into disrepute, despite the "friendly words" we have had in the past.

    Somethings got to give....You are not anonymous, you know that as much as I do.

    You need to think about what you are doing, its not big and its not clever, and it certainly is not professional.

    I will be sharing this blog post with some of the more professional blogger out there. It would be interesting to see and hear their thoughts on your “musings”, although I wonder if this post will still be here when they look??

    1. You love the sound of your own voice don't you Medic999, I suppose someone has to.

    2. Well, all I can say is at least I stand behind my views and don't hide behind anonymity.
      I would welcome your thoughts and comments once you have the courage to stand behind them.
      But then I guess not, eh?

    3. Confirms your arrogance. The point being its not your place to welcome thoughts or comments here, this isnt your blog, if I wanted your angry rantings I would read your blog, oh wait...

    4. Ok, just state a couple of points to finish...
      This is a blog. Even though "ella" is anonymous, this blog is in the public domain, the comments are open, and therefore this precisely IS the place for my thoughts, as is the place for anyone else's comments. (even yours)
      If you ever did read my blog (which you obviously didn't) you would know that there were never any angry rantings as i conformed to the bloggers code of ethics and conduct. The reason I ended my blog was that I was starting to feel a little burnt out and some negativity in my thoughts. THAT is why I stepped away, before I wrote something that would damage my integrity.
      So, in conclusion, I am not being arrogant in the slightest. I am merely stating another opinion, but one based on clinical experience, rationale, evidence based practice and 20 years of continued learning in the health service.
      Rather than just complain about my comment, I would be very interested to hear your defence of Ellas stance, with your rationale (assuming you are qualified to make that defence?)

    5. My rationale is purely that there are ways to disagree and state opinion and your comments went beyond that, it is clear you had your reasons but expecting all to conform to your way of thinking is arrogant and your tone condescending, some lead others follow, its not all about everyone thinking, acting and writing the same.

    6. Anonymity is a powerful weapon.

  3. This comment has been removed by the author.

  4. Ella, I enjoy your blog but I have to agree with Mark. This post portrays us as protocol driven ambulance drivers who are unable to think for ourselves. Yes there are protocols but as you know most of what we do is based around guidelines around which we can use evidence based research in order to deliver the best possible patient care, not just for the time we are with them but for their ongoing treatment and care. As Mark said, an ECG is another indicator of a patient's general condition and can help to predict deterioration. I too have had many patients presenting with atypical symptoms who have actually been suffering MIs and I only knew this because I performed an ECG!

    Nothing like a good debate eh?! ;-)

    1. Yes, I know! I didn't make my point clearly, I have made edits to a few sentences which hopefully puts what I say into context. I appreciate your comment and yes....nothing like a good old debate. Wish I had been around to reply as the comments came in, hopefully then I could have defended myself! Thanks again!

  5. To be honest if you want to stop reading this blog, then just bloody well do it!! Don't f*** about and start writing nanby panby bloody comments it's just sodding immature!! So sodding well grow up!!

    1. Troll.. I hope you don't work in the profession.

      I think it takes some guts to put your views out there, like Ella does. You might get criticism; you might start a healthy debate. Mark makes some valid points and I'm interested to hear what she has to say.

    2. 22:34: As much as I appreciate you staunchly defending me and my blog I must say that everyone is entitled to an opinion and I wouldnt want to discourage anyone from leaving them. I don't think it is fair to verbally abuse someone for their comments.

      Evan: Thanks for your comment, I have replied to Mark above and made a couple of little edits. I too enjoy healthy debate! Thanks again!

  6. Apparently neither DiagnosisLOB's author nor the GP understand the importance of serial EKG's on a cardiac patient. It's called the "standard of care" for a reason. I'm expecting that if Ella and I ever met, I'd learn how truly inexperienced a patient care provider and advocate she is. This article unambiguously relates how stable the patient is. That equates to the option to stay and play in Emergency Medical Services. There is sufficient time to establish baseline vitals, then elicit a complete history and physical from the patient, because there is a slim chance the patient may tell the medics something the physician is unaware of, or the physician, in their haste, because they would never intentionally omit useful information, may have accidentally forgotten to tell some cardinal information to the EMS crew. There is also time to complete said serial EKG, obtain informed consent, and least of all, establish an IV (and this is for two reasons: 1. is because the ER nurse will most assuredly gift an earful of complaints to the medical director's office and staff for arriving at the ER without an IV, much less on a cardiac patient, and 2. because the medics don't want to get caught with their pants down if their patient spontaneously does not comply with the textbook atypical and asymptomatic cardiac event).

    I assume neither the GP nor this article's author have experienced (nor would I wish them to experience) having their asymptomatic patient code as they are backing into the ambulance bay. I, being the good little prepared medic I am with my protocols (read: standard of care) list check-marked, did have this happen, and had delivered stacked shocks, pushed his ACLS protocol-driven (read: standard of care) meds, trans-thoracic paced with electro- and mechanical capture, and had the patient's pulse back in less than one minute, with the patient fully cognizant.

    This is why I have successfully made it through 18 years of EMS, and treated, literally, thousands of cardiac patients, with never a foot set in a courtroom to defend my actions or inactions. I didn't do that by giving in to a non-emergency provider's opinion of how to do a job he wasn't trained for, or at least never bothered to do more than was required to maintain his license. I didn't get that far by listening to someone, proclaiming their expertise, who shows others how to cut corners based on their opinion and not on facts, science, and industry-accepted standards of care.

    1. Please read my reply to UKMedic 999 and the few little edits I made. My point was lost a bit. Clearly I am not as experienced as you like you pointed out but personally I don't think that make my opinion less valid. I fully undersand the benefits of ECGs and I do them day in day out like you. I doubt anything I say will change your opinion of me. Sorry for the delay in replying. Thank you for your comment

  7. You cannot argue over good, sound clinical judgment.

    You cannot lose your job over good, sound clinical judgement.

    You can however, lose any shred of respect someone has for you by being sloppy, unprofessional & acting like a petulant child. Do your job. Do it properly & stop back pedalling.

    1. Bit of a weird comment. I am not sloppy at work, I am certainly not unproffessional at work, and I fail to see how I am acting like a petulent child. I do my job and I do it properly and that has been recognised at work. And back pedalling?! Really?! I hadn't replied to any comments so I fail to see how I was back pedalling. Thanks for staying anonymous though. Lets just hope I dont 'back pedal like fuck when challenged' eh. I'm guessing learning from errors you make in life is frowned upon by you. If defending ones self and learning is back pedalling then I am happy to pedal backwards.

  8. Ella,
    Your writing is like looking in a mirror. An old mirror, but a mirror just the same. This is your forum and you write what you want. No argument there, I do the same, but keep in mind your audience. Our shared frustrations and occasion wish to ask MDs (GPs) for their proof of completion of medical school, could be interpreted by impressionable followers as advice rather than venting.
    I've done more than my share of venting, heck my blog used to be titled "You called 911...for this?" and it was remarkably therapeutic. When I realized someone else was reading, I knew I had to watch what I said, if not for me, than for a reader who may not get my level of sarcasm or my angle on a certain post.
    I do not condemn your posts, post on.
    I do think you owe UKMedic999 one hell of a big apology however. Reading your blog is one thing, but taking the time to comment, and that comment is constructive, and supportive...and you dismiss it?
    That does not match your writing style at all.
    One voice. That's all the advice I can give. I stand behind every 912 posts I've written and will defend them to my service, my patients and my regulators if necessary because what I write is what I believe, and what I believe...I write. This comment will likely surprise my colleagues, but then again, if they know me, it shouldn't.
    Keep writing.


    1. Thank you for you comment. I appreciate it, I really do. Probably because you are the only one who hasn't attacked me! It was a poor blog. Not because of the content but I didn't explain myself properly and posting it was rushed. That I will learn from. I appreciate advice and any you have and are willing to give i'd like to hear by email. I must question your comment regarding an apology to UKMedic999? I have not dismissed what he has said at all. I was on a night shift and havn't replied to any until now. I have never filtered comment and have always replied to any criticism and taken on board anything constructive. Thank you again for you comment. I really do appreciate what you said.

  9. There seems to be a lot of directed animosity both here and on Twitter, it happens as not everyone is alike, it would be dull without sparking debate, but perhaps giving Ella a chance to respond properly would have been a good idea, its clear from tweets she was on a busy night shift so it appears to have snowballed before she's been allowed to clarify anything. Bit unfair.

    1. Thanks Gem! Yes! It certainly has snowballed! Oops! I have now responded to all! Nice to see a friendly face on these comments! Thanks hun! x

  10. I dont think I portrayed paramedics as whiney amateurs nor to I think comments on twitter like 'paramedic blogger who talks shite just got his arse handed to him by one of the most respected medics out there' is either fair or correct. I wrote a blog, he commented and I hadn't replied. It is a difference in opinion, that is all. It's not your place to say what you did.

  11. Well all I can say is "wow"!!
    Having amended your post, you fail to inform readers of this fact and have no amendment notes!
    You sail very close to the wind when you write and unfortunately that is why you come under so much criticism.
    This post took the biscuit some what.

    I take offence at the fact you criticise people for commenting anonymously when you yourself are annonymous?? I really don't get how you can stand on the moral high ground with that one?!?

    Anyway what is done is done and what has been said has been said! It is up to you now to decide what you do. But believe me when I say if you continue to write in this manner, it is only a matter of time before your employers find out who you are and reprimand you for bringing both your service and profession into disrepute!

  12. I wouldn't say I come under 'so much' criticism. You clearly don't like me or the way I write and what I write about and that is your choice. I don't see how i'm now getting criticism for editing my post. People highlighted areas which had come across differently to how I intended and I have corrected them. You are right about me supposedly being anonymous but when people make nasty comments on twitter to expose me I think that is unfair. Anonymity is my choice and not someones else's place to breach but I agree, I shouldn't judge people who comment anonymously. I have always replied to comments politely, I have never been rude or thrown insults at people and some comments from people have over stepped the mark and that is why I got frustrated at that anonymous comment.

    If I ever write something which is too close to the wind and someone tells me I make every effort to fix it. I can't do more than that. I dont write anything to purposely upset or offend. I say what is on my mind and occasionally that gets carried away I suppose.

  13. As far as I'm concerned, you're a paramedic who faces difficult people every day, and blogs about it! You came across a bad GP and blogged about it! I don't think you brought your service/profession into disrepute - writing in the Sun or another tabloid probably would, but this is your personal blog. What's the problem?

    1. Thank you, appreciate that. Just write the blog based around my experiences, thoughts and feelings!


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