A couple of weeks ago, the QA (Quality Assurance) man brought round a copy of the new AMPDS (that is, the system call takers use for triage) protocols. It got a hearty thumbs up from just about everyone. AMPDS’s biggest problem is the inclusion of the question “Is s/he breathing normally?” in just about every protocol. If the caller answers no, it tends to decide that the patient has “severe respiratory distress” and churn out a Cat A response. The trouble with this is that if the patient is puffing with pain, or upset and crying, of course their breathing is going to be difficult from normal – but not in a medically relevant way. Yet AMPDS treats someone who is hyperventilating at the pain of their papercut the same as someone with a life threatening asthma attack.

Well, not any more! The infamous “are you breathing normally” question is completely gone from a lot of protocols, and when it IS there, a “yes” only results in an amber response, not a red. The rationale, which I totally agree with, is that if the breathing was that much of a problem, they’d have told us at the beginning of the call!

I can’t wait for this new protocol to come in. It is going to decrease frustration levels in call takers, allocators and ambulances crews no end, and more importantly, we won’t end up having to waste ambulances on rubbish when people who are really sick are still waiting.

Unfortunately, the new protocols weren’t in in time for the delightful young man who called last week to say he had a cotton bud stuck in his ear. Was he breathing normally? Apparently he wasn’t. Category A call. FRU despatched.

The FRU in question called us on the radio.

“Cotton bud in ear?!” he said incredulously. “How on earth is this a category A life threatening emergency? Do you really want me to run on this?”

“It’s the old ‘Are you breathing normally chestnut’,” I said apologetically. “Severe difficulty breathing… from a cotton bud in the ear. Perhaps this guy breaths through his ears? Sorry about this, but I’m going to have to ask you to continue…”

“But…” said the FRU. “I had a cotton bud stuck in my ear this morning! I got it out myself!”

“You should be an expert in the field then!” I said. “Clearly the most appropriate resource for the job!”

“I walked right into that one,” grumbled the FRU good naturedly, and continued on to the call.

Allocators do have some leeway in using their common sense, so, for instance, if there had been another more serious call for the FRU to go to, I would have been able to cancel him from Cotton Bud Man and send him to that. Unfortunately, refusing to send at all is not permitted. Even though the REAL purpose of FRUs is to get to the life threatening calls quicker than an ambulance can, it is sometimes helpful to send them to the “rubbish” calls that have come up as a high priority. That way, the FRU can ring control and tell us that the patient doesn’t have any difficult breathing, and that an ambulance isn’t needed, or that it is needed but not in any great hurry (for example, if the patient had perforated his eardrum with the cotton bud.) If an ambulance arrives straight away, they tend to take the patient to hospital (they are not allowed to refuse) so the patient gets their big white taxi and doesn’t learn their lesson.

You will be pleased to know that our brave FRU managed to deal singlehandedly with the offending cotton bud, and no further resources were required.

Published Feb 19, 2009 - 16 Comments and counting

16 Comments on “Cotton Bud in Ear = Life Threatening Emergency”
  1. Auntie Jane Says:

    I wonder how high the Cotton Bud man’s IQ is? Perhaps a phyciatrist should have been sent instead? Or the ‘men in white coats’!

  2. Viking 83 Says:

    The rationale for not asking about breathing difficulties makes a lot of sense, any caller who has a patient with DIB will state that at the begining of the call.
    Hopefully.
    There will be that one in one million who will start talking about a leg graze and completely fail to mention the patient is now cyanosed because they can’t breath properly.
    Having said that, the change is long over due and I hope it reduces the number of minor calls that get a CAT A response. The basic rule in first aid is common sense, why does that not always apply to more advanced systems?
    And speaking of a FRU having to solve their own cotton bud emergency, I had a colleague who used a scalpel to remove an ingrowing hair. Hospitals, bah!

  3. Always Tired Says:

    In our area we have a local protocol which allows us to ask if the patient is breathing abnormally because of the pain rather than because of something else. Nine times out of ten we can say with no problem the patient is breathing normally (especially when you can hear them screeching like a banshee in the background!)

    I will however admit that I have indeed had a cotton bug stuck in my ear but did not need an ambulance to deal with it. I got myself to the hospital and had an ENT specialist fish it out (I did try myself)…more embarrassingly I was 18 at the time and should have known better

  4. AmbEMD Says:

    If its Version 12 of AMPDS, Yes, the changes are good :)

    However Falls now have a stronger chance of becoming A Cats (Red calls) – when least expected. And now wont refer it to the Clinical Desk if they are still on the floor, as we have to run anyway.

    And best of all … ‘how to escape from sinking/sunken Vehicle’ Instructions :)

  5. Mark Myers Says:

    Why are falls more likely to come out as Cat A? Didn’t notice that bit.

  6. Dullahan_999 Says:

    The other thing to look forward to is the subtle change in the chest pain question. Instead of asking the very leading question “Do they have any chest pain?”, it’s changing to “Do they have any pain anywhere else?”. Which should also cut down on false Cat-A calls.

    As for cotton buds, I used to work in Audiology many years ago and ears are not meant to have things shoved down them! They’re self cleaning and the only reason they bung up is because people push things into them, giving the desire to further prod and poke because of the trouble caused by the first prod and poke! It’s a vicious circle! If they do become bunged up, see a GP who can syringe them out. (Although you shouldn’t flush an ear canal with water unless you can make a visual verification that the ear drum is intact, which you can’t because it’s bunged up with wax … but that never stops a GP and is a rant for another day)

  7. AmbEMD Says:

    On V12 Is he/she completely alert (responding appropriately)? lots more people now seem to be answering no, which brings out as an A Cat.

    Have you changed to new version already?

  8. David Waldock Says:

    Even a perforated eardrum doesn’t require an ambulance. Medical care, yes, but it’s not an emergent condition or trauma.

  9. Dorota Says:

    Apparently, most GP these days are unwilling to syringe ears out routinely – it’s too invasive and dangerous if the eardrum is indeed damaged. Instead, to clear your ears you’re supposed to put in a few drops of olive oil twice a day for a few days. That’s it. Sometimes you can’t even see the earwax coming out, it just sort of dissolves and disappears – it works, I tried it out myself.

    On a very different note, do call takers often get 999 calls dialled by mistake? For example by a baby playing with a phone? My 9-month old daughter managed to do it today – needless to say, I apologised profusely to the call taker, and felt very guilty afterwards!

  10. Stuart Says:

    It’s (not) amusing that ear syringing can actually stimulate your vagus nerve…and cause some folk to vomit, and others to have their heart stop. Invasive and dangerous is correct!

    I assume calls that state that there is a problem with breathing, that still gets a Cat A call?

  11. Mark Myers Says:

    David Waldock: you’re right, but if the patient has a genuine need to go to hospital, even if it’s not an ambulance requiring one, we tend to send. Or get the FRU to stick the patient in the car and take them up the hospital.

    Dorota: Yes, but they usually get dealt with by the operator or the police. We only get calls if the caller explicitly states “ambulance” or describes an ambulance-requiring emergency to the operator. Of course, if your daughter was old enough to say “ambulance” you might find one turning up on your doorstep!

    Stuart: Yes, the protocol for actual breathing problems hasn’t changed significantly.

    AmbEMD: Ah, I see! Still, at least it will generate false cat As for old people lying on the floor instead of 20 year olds with flu – somewhat more deserving. No, we haven’t changed over yet. Not sure when it’s going to be but I think it’s soon.

  12. Jo Says:

    I am so pleased about that change! I’d had to dial 999 for a colleague about eight months ago – she’d suddenly got tunnel vision and was hyperventilating in panic; it ended up being a form of migrane and she cancelled the ambulance during the call and making her own way to hospital. I’d had to answer the “breathing abnormally” question as “yes”, but qualified it with “hyperventilation that is now calming down” and actually became normal breathing during the call.

    I got paranoid that the ambulance was coming out as CatA (mainly because of all the ambulance blogs I read!) due to that initial “yes”, particularly with the rest of the questions including “How long has she had difficulties in breathing?” “Does she still have difficulties in breathing?” etc.

    I’m so glad that you’ll be allowed to use common sense now!

  13. GLK Says:

    I think all services should get version 12 if there is less chance of getting the AMPDS red code, I’ve not noticed many callers saying fall pnts are not completly awake but that could be solved by maybe putting the levels of concsiousness that are in sick person in every single card that asks the question that should help.

  14. Dewi Morgan Says:

    If there’s a chance that BNoF’s won’t have to lie in pain and their own urine for hours, then I reckon a raise in the priorities of falls is flippin’ excellent, personally.

  15. Redemption Blues » Britblog Roundup 210 Says:

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    Nee Naw was a blog about life in the London Ambulance Service control room. It was written by Suzi Brent from 2005 to 2010. The blog is no longer being updated, but the archives will remain here.
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