Ambulance or Nurse?

The Independant have an interesting story where, due to the shortage of ambulances the plan is to send community nurses first for patients over the age of 65 who have had a fall.

This is a bad idea.

But first, as a quick update on my career, I went from nursing into the ambulance service, and then returned to nursing. At the moment community nursing. So I’ve done both of the roles that the article is talking about.

The ambulance role is very much different from community nursing. When a community nurse sees a patient, it is not in an emergency situation. If you have a leg ulcer, or cancer, or a surgical wound that’s not healing as it should, then the community nurse is ideally placed to see to your needs. However if you have fallen and either can’t get up by yourself, or have broken your hip, then what you need is an ambulance.
This isn’t to say that comunity nurses don’t already keep people from going into hospital. Community Treatment Teams (CTTs as they are known in my patch, your acronym may vary) work hard to stop people with chroninc and acute conditions from needing to visit A&E. Unfortunately trauma is something entirely different to the heart failure, asthmatic and palliative patients that these teams see.
An ambulance crew are trained to deal with these acute traumatic incidents. Community nurses are not (as an aside there was some research about how nurses are really bad at first aid. And they are bad).

The plan is for a nurse to give a painkiller, including morphine, and then wait for the ambulance. At least I assume they are supposed to wait. I know I’m not going to give Doris with her fractured hip 10mg of morphine and then leave her on the floor. A big problem with this is that, as a community nurse, my day is already packed with patients (and as the government wants to kick more patients into the community, that will only increase). It is more common than not that I work through my lunchbreak, just in order to do the bare minimum for my patients. Community nurses do not have the time to play at ambulances.

What happens if the nurse overestimates the amount of morphine to give the patient, they’ll need a BVM, and training in how to use it and naloxone and how to give it, maybe some other drugs to counter potential bradycardia. And remember, a nurse doesn’t then have the option to load the patient into the back of an ambulance and whizz off to hospital. They’ve got to sit there.

And then who is going to supply the morphine, where will it be kept? Morphine is a Controlled Substance and needs to be kept in a special locked cupboard inside another locked cupboard. Who is going to provide a stock of morphine just in case it’s needed.

And then there is…

…but you get my point.

This is, yet again, an example of short-term thinking to patch up huge holes in the NHS that have been caused by successive governments. Both the ambulance services and the community nursing trusts need more money, and odd blue-sky thinking by people who are several steps removed from actually meeting patients is not the way.

2 thoughts on “Ambulance or Nurse?”

  1. Mr. Kellett;

    First off, I enjoyed reading “Random Acts of Reality” for many years and don’t even recall how I stumbled upon it, but spent a great deal of time immersed in it.

    I returned to your blog today as my wife and I (mostly I) were discussing community medicine and what has become termed “community para-medicine” on this side of the pond (Pittsburgh, Pennsylvania, United States). An article on medscape.com (https://www.medscape.com/viewarticle/892055?nlid=120628_544&src=WNL_mdplsfeat_180213_mscpedit_emed&uac=261015CV&spon=45&impID=1558310&faf=1) brought to mind a post of yours about an older man whom it seemed you assisted into or highly suggested he transition into an assisted living facility while employed by the London Ambulance Service due to it being a better fit for his situation. Several hours before I read that, I had struggled far more than my co-corkers would bother, attempting to do the same thing during my shift overnight. Here, doing that is very difficult compared to your post.

    We routinely discuss/vent frustrations/debate/etc. our last shift as our personalities are thoroughly wrapped up in what we do for a living. She is a step-down ICU nurse and I, still a paramedic. We met working in EMS and last week marked 21 years of marriage.

    In the States, this was something properly envisioned (in my humble opinion) by nhtsa.gov as a Community Health Professional who was to hold a duel role providing Emergency Medical Services and Community Health Services. Post 911, there seemed to be a power struggle in Washington over who would administrate EMS at the level of the Federal government between multiple agencies. The whole idea of community medicine and EMS involvement seemed to be abandoned until fairly recently.

    It is a good fit from the outside but needs to have much better definition over here, as well. Long believing EMS has much to contribute to our health care systems, it definitely could be better integrated.

    We have a shortage of EMS providers here as well. The reasons don’t seem to be very straightforward to some in administration and responsibility in the failure to address the matter is well distributed among the administrators and the providers.

    Economics is probably predominant factor in declining EMS personnel as many motivated EMTs can find better employment outside EMS and frequently do. As EMTs in this country are the primary source for potential paramedics (versus people outside EMS deciding on that career path), the pool of personnel to draw from is by default smaller. A lower percentage of EMTs now go on to be paramedics as the length time for training has doubled, fewer pass testing of increased difficulty to certify now, wages have been dictated more by survival of the EMS services in general and not demand for personnel, and nurses start out making about $24 US per hour as opposed to the $16 US hourly the paramedics typically start at in our area. Nursing is clearly more intense training than that of a paramedic. Yet, it seems a larger number of folks than in the past forgo becoming paramedics, instead becoming nurses or leaving EMS. I’m led to believe our wages are also lower than the rest of the nation as we do have lower cost of living in this area than most of the country.

    As fewer people exist to staff for a steadily growing demand for a service that seems to be relevant to a progressively aging society, fatigue brought on by overwork grows as well. This contributes to increasing burnout that adds to the expanding factors affecting the attrition problem, too.

    Nursing in our area however, seems to be getting much better at dealing with emergencies and the role that EMS plays in respect to them as well. My wife finished nursing school several years ago and the longest, most difficult part of the program was “Critical Thinking” which was critical care combined with emergency medicine. They referred to us in the curriculum as EMTs and paramedics, not ambulance drivers; and actually do a reasonable job of describing our health care roles, capabilities, as well as decently differentiating the difference between EMTs and paramedics.

    Similarly, nurses used to see patients in their homes and call EMS for potentially life threatening and life threatening conditions, but were seldom present when we arrived. More than a few cardiac arrests I had started that way. Now it is the norm for a nurse to remain there, correctly provide required care, provide us with valuable information, and try to help us as scene as well.

    Another shift seen in home nursing here is most of the agencies were an assortment of smaller for-profit private companies. Now that is rare as most of the home nursing services are provided by the largest health care system in our region. The same health system embarked upon system wide quality initiatives and had partnered with a very successful home nursing service from a partner hospital as a matter of business consolidation, to better “contain” health care costs. They seemed to recognize this was really good thing that worked well and adopted that system as their own.

    It is still a joint agency run by both the large health system and that single hospital, despite the single hospital becoming part of a “competing” health network.

    I agree with most of the opinions I read and heavily related to the old blog. Thanks for the new blog as it too, as it is a joy to read and also parallels my thoughts and observations.

  2. Good to see you are still writing! I am a service improvement analyst in NHS Scotland; with personal interest in the Ambulance Service (mainly because they ultimately take the full force of things when other parts of the patient pathway break down). I had a past with an English Trust but have spent most of my working life up here; where services are far more joined up and integrated with each other. And we INCLUDE social work in that equation when we can. Blue Sky thinkers are largely redundant up here, and low level thinking has led to all our successes; or maybe that is just more communication and sharing of information maybe?

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