Friday, 8 March 2013

The root of all queues

THIS news story relays the current problems we are all facing but I have heard many times that this is fairly common with WAS. However, look at the story and read it carefully. The problem was caused, in my opinion, by the GP and the structure of the pathways set in place for such ambulatory patients.

How did the GP diagnose a fractured spine? He clearly wasn't absolutely sure but had suspicions, so he arranged for an ortho bed and an MRI to be carried out, to see exactly what the extent of the damage was to this lady's back. That is all fair enough. The GP has to act on his experience and knowledge and the given set of signs and symptoms surrounding his patient. But it sounds like he either used an emergency ambulance service, (which is solely for immediately life-threatening illness and injury), just to expedite his patient's journey to hospital, where other means of transport, such as A&E support or Patient Transport Services, were available (in other words he dialled 999 for a patient who was not being admitted for immediate life-saving intervention)... OR, as I suspect, there is simply no option available to him. There are no other transport pathways and so everyone ends up dialling 999.

The woman's daughter even stated to the Press "Admittedly, my mother was not an emergency case, but nevertheless during her long wait she was unable to go to the toilet and was getting increasingly tired and fed-up", before going on to describe the intolerable wait her mum had to endure, and the obvious frustration of the crews, even though they were professional and patient.

The irony is that if she hadn't been sent to hospital, essentially for a scan, by emergency ambulance via the 999 system by a health care professional, the queue would not have been quite so long, because they would not have been in it. The patient coming in behind them would not have had to wait even longer than they did, due to their presence, and the crew may have been saving the life of a seriously ill patient elsewhere.

Without alternative pathways; other means of taking patients to various different departments in hospitals without the need to call 999 and have them go through our already stretched Emergency Departments, this problem is only set to get much, much worse, until, soon I suspect, someone will die in the back of an ambulance because their undiagnosed triple A ruptures, while various GP referrals and District Nurse referrals - Health Care Professionals (HCP) using 999 as a means of transporting non-emergency patients - are brought in by exhausted and frustrated crews who will wait for hours outside hospitals with patients on-board who remain stable for hours. It's madness.

In my opinion, the problem is one of two things when it comes to HCP referrals. They either don't realise what they are doing when they take an emergency vehicle away from genuine emergency calls to transport stable, non-emergency patients. Or they don't have a choice, because there is no alternative.

This lady couldn't get herself to hospital and a car or taxi would have been a non-starter, due to her condition. A fractured spine is serious but it is not necessarily immediately life-threatening. A critical asthma attack, a serious head injury, unconsciousness, neck fractures, vomiting blood, central chest pain, cardiac arrest.... these are all 999 calls. But how do you get this patient to hospital for a scan if you have no safe means of transport? She needs an ambulance with a trolley bed (and a spinal board) and a crew that knows what to do.

The voluntary services offer non-emergency transport services, so what about them? Or private ambulance services... or the NHS Trust Patient Transport Services.

Here's the rub. Many hospitals have contracts with private or voluntary ambulance services but, when it comes right down to it, the HCPs who want their patients taken care of simply don't seem to trust these services and prefer to call 999 instead, knowing that they are going to get a professional front-line crew. I've even heard preferences for paramedics to take care of patients, even though there is no need because the patient did not require paramedic intervention of any kind. The transport services used by hospitals are usually the cheapest quoted and the contracts are decided by management, not necessarily clinicians.

We have a major problem. If this continues, not only will our system fail and patients start to suffer, but ambulance crews will begin to lose heart. They will also become unwell due to exhaustion, stress and frustration. This will have a knock-on effect and before you know it, we will be struggling to cope with the system as it stands.

HCPs aren't the major culprits though. The general public still attend Emergency Departments for the most insignificant problems. Everyone's emergency is personal, I know that, but when are we going to start educating people properly? First aid should be taught in every school - to school students, not just staff. And it should be taught by professionals who have actually done the things they are teaching you to learn. That way, a more realistic perspective is taught and kids might just start growing up taking ownership of their minor injuries and illnesses, instead of assuming that the health system is there to solve every little problem.

If you want an example of how bad things are getting, consider the 14 mile journey I undertook - on blue lights at a doctor's request, so that a patient could have a tooth replaced.



Amanda said...

On Monday this week my father was unwell (short of breath) so we went to the GP's, who sent him for bloods and a chest xray. Luckily, xray was quiet and we got that done straight away, then we had to wait a while to get the bloods done. His GP phoned us with the results (Ddimmer 6.0?) later the same afternoon and advised he wanted Dad to attend A&E for further tests and to call into the surgery to collect a ltr he had written for them. The GP also called A&E to say he suspected a possible PE and could they take Dad. We drove over, collected the ltr and continued to A&E booking in at 5.15pm. Dad was finally seen at 1.30am - some 8 hours later!! Even then there were no beds, so he spent the rest of the night in A&E before being moved to a ward in the morning, but still no bed only a comfy chair. They did finally offer him a drink and some food at lunchtime on the Tuesday after discovering he hadn't eaten or drunk anything since Monday lunchtime! They did a scan later that day which thankfully was clear BUT what a wait. Also whilst we were waiting I did overhear a man complaining he had dialed 999 because his wife had a nosebleed !! Can yu believe that ??? Well I guess YOU can. Anyway, they didn't attend which is what he was complaining at. So glad you are back - take care, Amanda

Anonymous said...

Sounds to me like educating 50,000 GPs and the general public is not really going to work in the short term. The answer seems to be to have the 999 dispatchers decide and dispatch the correct resources.

There you go. All fixed!

Now you're probably going to say that the 999 dispatchers don't control the other assets. Also easily fixed. Get them to.

What you need is a one-stop-shop where the GP or uneducated public can call, and get the correct resource/advice. You need to stop turning up for non emergency jobs, and direct people to a GP or clinic as required.

Also, instead of waiting hours at a hospital, why not just dive to the next one, and balance the load better? Seems much more sensible than sitting outside a full hospital.


angel gonzales said...

Great post. I totally agree it all boils down to educating people. I think it is basic and that even at an early age people should already be taught the basics of first aid.


Anonymous said...

Sometimes I'm glad that in my County at the big hospital things seem a lot more sensible. GPs can direct people to wards, rather than ED, and VAS crews like myself can be used instead of emergency NHS ambulances. The hospital is part of a trust that includes a specialist orthopaedic hospital, with an MRI scanner - I suspect the lady in the article would have been taken straight to this hospital, and maybe even straight to the scanner.

Your mention of the blue-light tooth journey reminds me of one we didn't do, but could have with slightly more joined-up thinking and less delays.
We were in the next-door County, part of the same Ambulance Trust,working for them on A&E support, taking a patient to what can be a very disorganised ED.
As we were at the nurses station attempting to find out where they wanted our patient, we heard a doctor telling a nurse that the child in one of the cubicles needed a blue-light journey the 20 miles to our "home" county, to have a replaced tooth fixed.

Because we were unable to clear quickly, and therefore not available, a paramedic crew took the child over to the ED.
This journey meant that the paramedic crew were late off, and we were sat around out of county drinking tea in their ambulance station rather than taking a patient to a hospital nearer where we were due to finish.
We had a blue-light driver, and as all the child needed was a fast trip to the specialist centre, we could easily have done it.

Derek Buck said...

I fully agree with you Stuart, I felt stupid a few years back when I went to hospital with a cut finger (by parent taxi not ambulance I will add), I did end up with stiches but I strongly suspect it would have healed okay without them (had stopped bleeding and the two halves stuck together by the time I got there, though the doc split it open again by pulling on it) and only went because I was nagged. Yet there were drunks and minor injuries arriving by ambulance and complaining of waiting times. The doctor was really nice and assured me I was right to go but I suspect he was just been nice and would have said the same if I only had a splinter.

Only time I've used the hospital since is when I drilled my finger and only went because I wasn't sure if I had managed to clean it out correctly, this time I drove myself though wasn't easy as any pressure on the injury hurt like sin.

All other injuries I'm happy to say I've taken care of myself.

I made it a point of getting my Cub Scout pack trained up on first aid, their bandaging leaves a lot to be desired but at least they know the difference between a minor cut and a need for 999. One of our local Beaver packs has also had first aid training, though they only got the very basics (don't ask them to put a bandage on unless you want to look like a mummy).

I'm glad to say most Scout groups still make it a point of teaching first aid and the groups I work with know the difference between a taxi journey and a ambulance ride (heck, the Scouts and Explorers still practice removing a patient from "the wilds").

I agree it's a skill that should be taught from a young age but unfortunatley most schools seem reluctant to even use plasters so what hope have we got (I've already had several discussions with parents about how schools are idiots and are allowed to put plasters on children)

Xf said...


In defence of schools, the fear of using basic first aid skills and common sense often arises from the bullying they experience from parents, who are unable to relinquish control of their children and allow school staff to do their jobs.