Acting Out(side)

I look at my patient and consider my choices, either I act outside the policies that the LAS have set me in the best interests of my patient, or I follow the rules and provide sub-standard care.

What do you do?

Our patient is a fiercely independent woman – well into her eighties every morning she walks to the shops, has a potter around to buy her papers, has a chat to the shopkeepers and then returns home.

She'd had a fall because the strong wind that day had blown a door into her, one of our first responders was already there and had patched her up. We took her to the ambulance and completed the assessment. She had a cut like half of a 50p piece on her shin. Sometimes you can get quite nasty skin tears, but in this case it was more of a gouge, and therefore easier to fix up.

There was one problem, our patient didn't want to go to hospital and after she told us why, I cold only agree with her.

No problem, it would be a simple job to steristrip the wound closed, something our ECPs are well equipped to do.

Except there wasn't one working on this shift.

Now, as long time readers will be aware, I used to be an A&E nurse. Wound closure of this sort is something that I would do regularly when working in the minor injuries department. I could easily do ten such closures a day, all without supervision. Our doctors would tell me to clean, close and dress the wound and the choice of how to do this was down to me.

But with this lady, if I were to follow our policy, she'd be left with a cut that would be left open with little more than a bandage over it. This would not only cause scarring, but would also have a higher chance of becoming infected.

It just so happens that I carry some steristrips in my personal bag.

So, of course, I used my nursing knowledge and closed the wound using my steristrips. It is a low risk, high outcome intervention that I am competent in. At the end of the day I can justify taking this course of action to anyone who questions me, and more importantly, to myself. I can guarantee that I've done more wound closures of this sort than any of our ECPs.

Us ambulance staff work under guidelines rather than the more restrictive protocols these days and this means that we can do pretty much anything, just so long as we can justify it. While I've been been told that I shouldn't use my nursing skills (like cannulation) I can't see anyone having a problem with my course of action.

I sure that my patient was happy.

18 thoughts on “Acting Out(side)”

  1. I was trying to describe it in a way that showed it wasn't a pre-tib lac – more a gouge type wound with good blood supply to all parts.And also what was the advice I gave? See your GP, or have them come out and see you – same advice I gave to the warden at the flats.

    Oh, I'm not daft…

    (And then I re-read your comment and realise that this probably wasn't the point you were making, and so I think I'll just head off to work now…)

  2. Except I've been told that 'guidelines' doesn't mean 'use your nursing skills'.Ho-hum.

    Meanwhile I would guess that my nursing registration means that I *should* use my skills, as far as I remember we *have* to provide aid, even when not at work.

  3. I can't see any problem with it either, but I know where you are coming from. I used to work on A&E abroad and do up to 10 ABGs per day, specially during the winter season. Then I moved on to midwifery. Two or three months ago I took pity of this woman who had being stabbed 6 times already by our very nice (but very green) SHO. Unfortunately someone told my manager….

  4. Why should there be a problem? There WOULD have ben a problem if you hadn't closed the wound as she would have probably developed a horrible infection and end up in hospital anyway. As you said as long as we can justify why we did something then it's all ok. 🙂 I think you did what most people would have done.

  5. Sounds like “Pirates Of The Caribbean:””The code is more like guidelines, than actual rules.”

    At the end of the day, you have to do what is right for the patient. Unfortunately, too many of the people in charge that make the rules have never worked in the field themselves, or have not worked in the filed for so long, they have forgotten what it is like.

    I also think of that line in the 60's flick “Airport,” the chief mechanic pushes the 707 beyond what the rulebook says are its design limits. He tells his very junior colleague, who could not believe what the plane just did, “That's the nice thing about the 707. It can't read.”

    Always do right by the patient. The rest will take care of itself.

  6. why should there be a problem… the patient did not want to go to the hospital… at least here in Austria we can not force them…If we think the patient is not in a situation so make this choice, eg when the patient is drunk, we call the police, they call their doctor, the doctor desides. If the patient still makes troubles, the police joins us on our way to hospital.

    If we believe that the patients able to see the consequences of his choice, we do as the patient wishes. We just need a signature for legal issues.

  7. Weird.Cos I'm sure that midwives can do them at our Trust if necessary? I could be wrong of course. Mind you it's like I remember being on nursing placement on gynae, and everyone having a big faff cos someone needed bloods taken and there was no phlebotomist and NOBODY HAD DONE THE COURSE!!! yet I took blood on my first week as a first year DE student. Daft.

  8. Not quite sure what the fuss is about here – as you say they are guidelines which is a very positive and very significant thing in the modern world of tight regulations and idiot-proofing… You can clearly justify your actions so go ahead.Tom, I know you are pissed off but this actually seems to highlight a positive change in the ambulance service.

    (PS I'm not from management, just an occasional interested and pretty satisfied customer whose job is far less satisfying than yours I'm sure!)

  9. Dear, oh, dear, this is exactly the sort of 'quactitioning' certain absent medics get so excited about.Pre-tibial lacerations are notoriously prone to complications – lets say the flap becomes necrotic, then requires grafting, or infection supravenes, progressing into the missed hairline fracture [after all, nearly all 80yr old females are osteoparotic].

    What about continuity of care since pre-tibial lacs usually take weeks and sometimes months to heal ?

    Oh, I could go on, but you get the general drift……….

    It takes a brave man to stick his head above the health & safety parapet nowadays – how long before the Obergruppenfuhrer for risk management will be knocking on your door to check your papers ?

    Of course, as a self-confessed quack I couldn't possibly comment about whether or not we should be taking our health services in this type of direction ;o)

  10. I'm going to wear shin pads when I'm old, 24/7; my mums mates have been falling like flies from infected wounds, one with a MRSA, was soooooo very poorly.A question, would the GP's practice or an 'out of hours' drop in thingymebob have dealt with this?

  11. Is there a reason why you haven't taken the Paramedic qualification (apologies if I've missed this in an earlier posting)? With your experience plus nursing background, you wouldn't find it too tough, I'd have thought

  12. (a) Can't be bothered – I've done too much study in my life already.(b) I'd have to give up my crewmate

    (c) I'd have to give up my place at a station that I love

    (d) The pay ain't much better

    (e) It wouldn't make any difference to the way I practice.

  13. I agree, you had the training and the experience required to best serve your patient. Just out of interest how did you document your treatment?

  14. (I forgot to add that people only look at our paperwork for non-conveyed patients if something goes horribly wrong. So far, in the last 2 years I have had *one* piece of paperwork audited…)

  15. We discharged a 19 year old patient from my ward yesterday. Once he was gone his MEWS chart (which was mostly filled with my observations) were filed into his medical notes. I remember thinking that this lad was likely to live a very long life and in that time its likely that no one will care about or read that MEWS chart. That was about the time in the shift when a morbid sense of futility swept over me.

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