Direction

There are a couple of reasons why the public like us – the biggest reason is that when they call us they are the centre of attention – they are sick and now two people have turned up and are giving them their undivided attention. We don't have more patients to look after, we don't have to run off to bed three to give someone a bedpan, we don't have to drop everything for a drugs round. Instead that person is focused on 100%, no distractions.

Of course, when they hit hospital they take their place behind all the other 'generally unwell for two weeks' patients that found the idea of a GP appointment just too much effort. Certainly more effort than dialling 999.

And really, it was your choice to wait four hours for treatment in A&E rather than get a GP appointment, so don't blame me for taking you out to the waiting room to burn some hours with the multitudes who think the same as you.

This, in my eyes, was common knowledge – however a recent article by Professor Richard Ashcroft has shown another reason why us ambulance types rock your world.

Patients and families seeking help on how to live with long-term conditions such as autism do not always get the clear advice they seek.

Any diagnosis of a serious medical condition or impairment is hard to take in at first.

What you need after that is reliable information, and co-ordinated clinical care and social support.

Co-ordination is not what you get.

'Hints and clues'

Professionals are trained to be “non-directive” when they advise or counsel parents.

n my work, I teach current future doctors and lawyers about medical ethics and law. I teach them about informed consent.

I think empowering patients to make decisions in the light of their own values and interests is really important.

But I don't think “non-directiveness” achieves this.

Essentially, nurses and doctors are told to be 'non-directive', to not tell people what to do as that would be seen as taking away the other person's independence and right to self determination. That to be 'prescriptive' is some sort of abuse of the power relationship that folk in uniform have over the general public.

When I was training to be a nurse I suggested that perhaps we should be directive, as after all we hopefully have the full facts of a person's illness and the skills to deal with it.

I was told by my lecturer that by saying that I was acting like a Serbian war criminal. A badge I wear with bizarre pride.

That's something that us traditionally educated ambulance staff have never been told (I have a horrible suspicion that this is not the case for the new training regime) – in our training we are told that we are to take control of a situation as everyone else will be looking to us for direction (normally followed by a few unkind words about brickheads, dripstands, Trumpton, our firefighting colleagues).

No – what we do is direct. We turn up and make the chaos into calm, the fear into peace and the uncertain become certain. We tell people what to do, we tell them what we are going to do and we can often explain what the hospital is going to do. People surrender into our loving embrace and feel better because we are there to help and the other people present can abrogate responsibility to us.

That is what we do, and people are happy for us to do it.

15 thoughts on “Direction”

  1. I think, in the heat of the moment, that is exactly what you need – to be able to just follow instructions while your mind processes what has just happened to cause you to phone for an ambulance. I can see why it might be more appropriate to be 'non-directive' in a hospital though, where the need for the short-term stability and direction is replaced by the need to make decisions about your long term care.

  2. I think there are two contrasting scenarios being discussed, the (true) emergency scenario and the stable scenario.In a true emergency, untrained people effectively go into a state of acute psychological anxiety: their body is flooding with noradrenalin and adrenalin, and I know in the past when I was in that situation I couldn't cope psychologically with the whole picture. People in that state tend to focus on small details in order to maintain a grasp on reality (which is of course a carefully constructed psychological unreality!) and attempt to keep their dignity; I remember being really worried about my glasses although actually the blood dripping down my head would have been a more appropriate focus for my concern!

    In this circumstance, I don't believe that the individual truly has capacity and it's the role of the professional to make decisions which are in the patient's best interests (obviously to the limits of knowledge about the patient) until they are capable of making their own informed decision.

    Trained emergency services personnel are effectively desensitised to the trauma so that they are able to step back, take a view of the whole picture and decide priorities. In the scenario that affected me (RTC, low speed impact car vs pedestrian, and I was the pedestrian), I needed the crew to take control because I couldn't.

    However, once the adrenalin had worn off, I was able to make properly informed, undirected decisions in the ED, which involved me consenting to stitches etc… In theory, the staff could wait while I processed the information and came to a decision in the ED whilst on the road that was a non-option. In addition, on the road questions like “What would you do?” are easily and appropriately answered in a directive manner, but in non-emergent situations, it's less appropriate for the HCP to project onto their patient.

    Ultimately, it comes down to ensuring that all times one acts in the best interests of the patient (not of oneself, the HCP), to promote health, recovery and survival and support the patient by giving them all of the information necessary for them to make a decision which is right for them. And those interests and support have very different meanings when the patient cannot achieve that goal themselves.

  3. Absolutely – which is why I drew parallels with how people are happy with us when we deal with them because we focus on them 100% and then get the hump when they join the morass in hospital.Basically us ambulance folk have it easy…

  4. Whilst attending the scene of an emergency, I, like my colleagues focussed on the job in hand.Going through the mental checklist of ABC, history, details, perhaps reviewing a patients mechanics of injury precluded any thought of semantics whilst employing treatment to aid the patient, required clear direction, and positive action.

    The luxury of 'philisophical' thinking, while soothing family or friends shocked by events was irrelevant. Our duty and compassion was/is reserved for the patient. How this wonderful ethical consideration was disseminated after the acute care could not be realistically a component of the service provided by ambulance crews.

    By the way the unkind reference to the window cleaners, sorry I meant firefighters was duly noted. (he said smirking)

  5. Our current Chief Exec (not LAS) said at a “meet the staff” thingy a couple of years ago that according to a survey, what the public want from us is 1. To turn up quickly and 2. to sort it out, whatever “it” refers to in their current situation.Seems to fit your view (and mine).

  6. Well I guess that explains why over the past 3 years of me having been trumped with MRSA and spinal nerve damage, not once has anyone told me how to fix it (hint: pumping me full of painkillers and turning me into a zombie will not fix it). Hell, not once did anybody even tell me what was actually wrong in the first bloody place! I had to work it out myself with the help from a friend who is… surprise surprise… an EMT.I wonder how often their faffing about not wanting to hurt anybody's feelings has ended up with some poor sod kicking the bucket.

  7. When I had chest pains and had pins and needles in both arms during an asthma event, my employers decided to call an ambulance. A guy on a motorbike came first. He started telling me things and most of it went in one ear and out the other because I was still rough, yet when he cleared all the staff out of the area and took control I settled down a lot. Thankfully someone grabbed my coat and wallet (I was keen to get before going off A&E being 7 miles from home) yet the ambulance staff were all for the off.When we got to hospital the nurses hooked me up to a machine and wandered off. The doctor told me it wasn't a heart attack and discharged me. When I asked what it might have been she told me to see my GP because she wasn't allowed to tell me.

    When I had some tests recently I asked what they were testing me for and was told the protocol says you must ask your gp.

    So for my experience the ambulance service is great yet the hospitals are less than great and the car parking is a rip off.

    Oh and all the women at work are waiting for the next emergency so the guy on the bike can turn up in his leathers.

  8. So…over there, you're expected to accept treatment (tests) without being informed what it's for? So as to manipulate you into going to the GP, I suppose. And that doesn't undermine your right to self-determination, but hearing an educated opinion regarding the next step will?

  9. In the preesure cooker that is real life endured by front line staff, might I please say the following;1. Draesk-well said, but still I am there for YOU.

    2. bootedsw. Still there for you, but in your shock, the 'focussed ones' will take care of your needs.

    T

  10. I think there's a time and a place for being 'directive'.As other posters have pointed out, when you're a seriously ill or injured person in an event that you haven't encountered before, you need somebody who has encountered the situation before and knows what the appropriate course of action is – and you need them to take that action, quickly and decisively, rather than laying out the options of HEMS/hospital/aromatherapy/non-intervention and politely awaiting your informed decision while you gradually bleed to death.

    But I think in the longer-term, when patients have an ongoing condition that they are going to have to live with, there does need to be room for two-way conversation, understanding, and figuring out what works best for the individual in the unique circumstances of that individual.

    I agree that from the sources quoted it has gone too far the other way. I go to see a doctor because they know more about medicine than I do – I want the benefit of their informed opinion! But I also need to be able to say things like “this medication has me throwing up every morning, are there any other options?” and not be ignored.

    (As a result, the long-term painkillers I eventually got settled on aren't the best available in terms of killing pain, but they are the best painkillers I've tried that also let me remain functional enough to cope with my life. That was a balancing act I needed to have the final say over.)

    I'd like medical *advice* that falls somewhere between the two extremes of, on the one hand, doctor's *orders*, and on the other hand, vague fluffy suggestions.

  11. I know that this is less than helpful, but I thought that Professor Richrd Ashcroft was the lead singer of The Verve.

  12. As a patient, I have found 2 problems when the professional goes all non-directive and asks you what you want to do. Firstly, it often boils down to being a technical question and I feel ridiculous trying to answer it – go on, just tell me which is the better option. But secondly, they often signal the “right” answer with their tone and body-language. And this creates a strong social pressure to go along with it (ironically, probably more so than if they came out and stated their position clearly, in which case you could have a straightforward discussion.Having said all that, I have to say that my GP practice is really good at treating me as a rational intelligent adult.

    And finally, yes having the ambulance arrive is like having a grown-up come who's going to take care of everything.

  13. During a recent bad-health episode I reverted to BUPA (sorry!) but in order to do so I needed a GP referral. Local NHS hospital said there was nothing wrong and didn't want to pay for more tests.GP asks me to choose a consultant. I say I don't know any, and who does she recommend? She says she isn't really allowed to recommend anyone: would I like to choose a hospital? I say I'm not really fussed, I just want to get a diagnosis and treatment asap. Finally I “choose” a general surgeon, and the referral can be completed.

    Genuinely I wanted her to say “Right, I'll send you to Mr X” which is what she would have been able to do five or ten years ago. This “choice” malarkey has gone too far.

    At least EMTs/paramedics say “I'm going to give you some morphine now” rather than f*nnying about waiting for you to ask.

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