Nof An Emergency

Peter Canning has written another excellent post, this time about fractured hips.

We get a fair few fractured hips (or #NOF for 'fractured neck of femur), most common among the elderly, it's one of those things that I feel that we as an ambulance service don't deal with as well as we should.

Apparently the thought is that this isn't a 'medical emergency', but explain that to 'Doris' when she has been lying on a hard floor for six hours with a broken bone causing excruciating pain.

Part of the problem is how we prioritise calls, using much the same computer triage system as Peter mentions these calls often come out as one of the lowest, or 'green' categories.

This means that they have to wait while our limited resources deal with 'Red' and 'Amber' calls – an example of a recent 'Red' call for me would be the man in his twenties suffering from a hangover.

So Doris continues to get pressure injuries from the floor because every move is agony.

'Green' calls don't need to be attended to on a 'blue light and siren' response unless they are in a public place (because people waiting for an ambulance in view of the public is obviously a clinical risk…ahem).

Personally as soon as I see that there is an elderly person on the floor I'll respond on blue lights, call me old fashioned but I think that leaving old people on the floor, sometimes in their own urine (for many fall after getting out of bed at night to visit the toilet), is just not the right thing to do.

Of course, I also think that a blue light response to a hangover is a bit excessive, but then we do tend to over-prioritise most calls.

Peter talks about the lack of painkillers being given to these patients, like his service we also have Morphine to give and, I would suspect that some paramedics are a little reluctant to give such 'strong' analgesia to a frail patient – but I have no experience or evidence of this.

My pet Paramedic and I are more than happy to dose up little old ladies with some high grade narcotics…

(No prizes for guessing the Prodigy song that runs through our heads when we do this)

When I was a nurse we set up a pathway for #NOF, we would x-ray, give fluids and analgesia, refer to the surgeons and book the orthopaedic bed all in one go – it was designed to get these patients, vulnerable to pressure sores, off the hard A&E trolley as quickly as possible. All of which boosts their chance of survival.

Yet, in the ambulance service we leave them on the floor.

It's one of the things that I've mentioned before – that the government grades us on how quickly we get to calls, but it doesn't grade us on the relief of pain, or the appropriateness of our telephone triage system.

Perhaps that needs to change.

13 thoughts on “Nof An Emergency”

  1. get real, says management: oh well, it's only an old person, unlikely to create a fuss or have someone create one for him/her; so who cares? shock, haemorrhage, fat embolism, pneumonia, hypothermia, dehydration….not worth spending money on, are they? very often, even if they escape the worst of the complications, they'll be so shaken up that they won't be able to go back to independent living; they'll only block a bed for us for weeks.

  2. I noticed this with the local ambulance service when I was a first responder. Femoral fractures were treated as a low priority by the system, but beause the local first responders were activated by voice (fairly informally) if there was going to be a long delay, the controller would send us around. I've sat with an elderly lady once for over an hour as she slowly descended into clinical shock. Fortunately the crew arrived just as I was on the phone to reprioritise this as a Cat A (using the magic phrase “altered consciousness”).In our local Mountain Rescue teams, femoral fractures are treated as life-threatening requiring immediate and rapid evacuation, preferably by helicopter. Reading the comments, any injury where the blood supply is compromised is also treated as the same priority – I suppose it's nice that we can use common sense when dealing with these.

  3. I can't believe “the system” doesn't seem to take into account the huge internal blood loss there can be from a fracture like this. If that much claret was leaking on the floor it'd be a much higher priority, I'm sure. But no, of course it's not life threatening. It's not like little old ladies die from broken hips, do they?

  4. Can you tell us more about your transition from A&E nurse to paramedic? I'm in process of the same and would love to hear more…

  5. The appalling AMPDS system used to “triage” calls (or – more correctly mis-triage) needs a severe shake up. As everyone who has been trained on it knows, it was invented is the US solely as a way to stop ambulance services getteing sued by patients or their families.It has little or no medical value – especially in the way in which leading questions are asked, which only serve to over-categorize minor illnesses or injuries. A possible neck of femur/hip fracture is a Green call, because it's not “considered” life-threatening. However, if “Doris” has been on the floor for more than six hours the injury is – stupidly – considered an “old” injury, in the same way a cut which stopped bleeding hours ago is an old injury. It takes no notice of pain, possible confusion, hypothermia, lying in a pool of urine – all for over six hours.

    What is even more bloody galling (and I'm betting TR will bear me out), poor old Doris will apologise for “bothering” us.

  6. My mum had a broken hip and that is no fun at all, especially since 5 years later when she died, it still caused her a great deal of pain.I think someone/thing needs a kick up the backside that a hangover gets blue-lighted and Doris does not.

    It's not about need, it's about who can shout the loudest.

  7. 'tis how my father died, hit his head on the bath going to the toilet in the middle of the night and took many hours to get him in to the operating room and then had his final heart attack one of many. He was 88.ah! that “…….” computer!!!!!!!!!!1

  8. Not to speak for Tom, but given that smack is a drug term, I find it likely that's the one. It is probably the track that people are more likely to have at least heard of.

  9. Hi there,Couldn't agree more with you Tom. It's so frustrating the way our stupid CAD system works. All that 'non dangerous proximal body area injury ' cr*p etc, not to mention the classic 'unconcious patient who is concious and breathing' ?!. Makes us go 'huh?!?' alot.

    I attended an elderly lady who had a '?#/dislocated ankle following a fall from height (down some stairs in garden), Cat B'. We were coming from quite a distance away and passed another ambulance, on blue lights, going to where we had just driven through and they had had to drive past the job we were going to…hmm. They would've been there 15mins before us, but they were going on a higher priority call (Dr's immediate for a ?meningitis that turned out to be a 30yr old man with prickly heat.Yeesh). So we treated our poor lady, who had not fallen from height, she'd gone over on her ankle, done the damage then shuffled her way across her garden and down some steps. She'd been there for about 40mins before her hubby came home and called us, and she had a severe injury, critical skin, no pedal pulse. It all turned out ok for her, thankfully. But when I spoke to despatch about the coding of it, why didnt' they swap us and the other ambulance, they told me that a # dislocation of the ankle is only a Cat C, unless there is a qualifying factor like falling from height. As it's not life threatening etc. Call me old fashioned, but, even though it's not life threatening, I think it's probably rather nice and convenient to have both of your feet in working order and preferably connected to your legs. So that poor lady could've quite easily been waiting for rather a long time and suffered irreversible tissue damage, while we fannied about with someone with prickly heat.

    Grrrrrrrr. Time to remove the governments earplugs methinks…

    Sorry to have rambled on a bit.


  10. Apropos of nothing, spouse has gone off in an ambulance with a badly cut hand. As ever, the ambulance workers (too flustered to see if one was a paramedic) were wonderful. I remembered to thank them both.And even as I type I hear (through the wonders of the internet) that he's had his stitches already.

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