Monday, 31 August 2009

Advice Please

You're a solo responder on a FRU/Rapid Response Unit.
You're called to a nursing home.
You have a poorly patient who needs constant monitoring and fairly rapid transport to hospital.
45 minutes after you arrive, you're still waiting for an ambulance, but none is yet available.
Control tell you that they have nothing to send for at least the next twenty minutes, not even another solo.
Then you're told that at the other end of the corridor is another poorly patient.
Very poorly.
Breathing at 60 times a minute, sweating buckets poorly.
With one pair of hands, one set of equipment, no further resources available, and the patients 200 feet apart, what do you do, other than hope that the 20 minute extra delay is somewhat reduced?


slmiller72 said...

Tough one, really tough one... ok, here goes!

Firstly inform control there are now 2 poorly patients.Don't ask for another amb, TELL them you need one.

Ask for the most senior clinically hands on member of staff in the home to be present to assist you. Expain the situation to them.

Tell the staff at the home that they must bring the other patient to you so that you can keep an eye on them both in the same area.

At this point you are gonna have to go back to basics - A,B,C and correct/manage accordingly. Most nursing homes have some equipment - O2, defib ( unless it's the local one to our station, ahem!) etc - use their kit and their staff, these are the only resources available at present - it's better than nothing!

Consider another call to control and ask to speak to a clinical lead - ask them what you should do - bounce it back to them - it's your registration after all!!! Update them on your findings, make ambulances 2 and enquire just how long you are going to have to wait.

Then you pray, pray hard. Pray that you get the resources in time. Pray that this never happens again to you and pray that it never, ever happens to any member of family/ those dear to you...

Keep calm and carry on with what you are doing.

This is a clinical incident/risk so the relevant forms need filling out - off the road, DSO requested ( to vent your anger)loads of form filling, not forgetting to find out what happened to your patients once they were conveyed!

Unfortunately, this is all too commonplace. I've had to give this some real thought as I work on the cars occasionally too and the advice i've given is what I would do.

I would hope that I would remain patient and focused enough to ensure my treatment wasn't hindered in any way...

Hope this helps??? :)

The Happy Medic said...

Move them to the same room.
Manage both as well as possible while preparing both for transport.
Our rigs have a bench seat that can accommodate a second patient on stretcher or backboard.
I would prepare the least sickly of the two on said board and have the ambulance transport both when they arrive.
Then I would prepare a lengthy scalding letter to whoever thinks we have adequate resources.

I have such a letter ready to go if you want it.

Messy Girl said...

Are the nurses allowed to move patients? Have them move the least-sickly patient into the more-sickly patient's room and watch them both as best as possible.

Just like HM all the ambulances I've seen have the capacity for a second patient. Hopefully you have that and now that you have two patients control will upgrade you.

But whatever happens, as long as you provide the best care you can, the outcome is not your fault.

Ckemtp said...

This situation, at least in the US, meets criteria for a "disaster". Really, it does:

You are presented with multiple casualties (ie "Sickly" patients - I love you Brits) and your resources are not adequate to deal with the sudden influx of such casualties.

That's the criteria for a disaster according to US Governmental sources. So, the strictest rules of operation can be bent a bit in the best interest of patient care.

With that said, I agree with the above. Move the patients closer together (them beds got wheels, don't they?) and enlist the aid of the medically trained staff. This is a triage situation, so use your equipment accordingly. Work with your control to arrange for alternate transport if possible. Get on a cell phone, not a radio because then you can communicate more clearly.

Then, put forth a display of paramedical goodness the likes of which you've never seen.

Ben Yatzbaz said...

I had this exact experience a while back, but had a very similar one a few days ago, which is what made me write about it. The more recent one at least had another solo responder available, so there was one extra pair of hands.
I tried the idea of moving one patient, but stupidly the beds were wider than the doors, so that was out the question. Apparently the beds are built once they're inside the rooms. Fire hazard came to mind, but anyway...
I called control, told them that if they didn't find me at least someone else, solo or otherwise, that I'd declare it a Major Incident. By the strict definition of having more patients than resources, they couldn't argue it. (I guess that this is what Ckemtp means by disaster) Our ambulances only have room for one patient (casualty/poorly person...), so I still needed two of them. I had the most senior manager in the control room on the phone within 30 seconds begging me not to do it. It would cause complete chaos for all concerned, ambulances and hospitals alike. (It also probably means they'd have to wake up some VIPs...) I was in the mood for chaos, as once again I felt let down by the system, and wanted to exact some revenge on it, but I was promised that the next two ambulances that became available, wherever they were in a 10 mile radius, would be mine, so I decided against.
Despite the fact that I was in a nursing home, the nurses were somewhat reluctant to do any "emergency" nursing (my letter to their management and ours would cause more trouble later), so I got a couple of the HCAs (Health Care Assistants) who were able, willing, and didn't mind following instructions on my side instead. I had no option but to run between the two, keeping in phone contact with whichever HCA I'd left in charge of the other. I'd alternate every few minutes, or every few seconds depending on what was being reported to me.
Eventually, almost an hour and a half after I'd arrived on scene, two ambulances arrived at the same time.
Just in time to see me start to ventilate one of the patients who'd gone into respiratory arrest.

slmiller72 said...

I would have declared a Major Incident!

It's about time our bosses knew just how much pressure we are under and just how much they are putting lives at risk by inadequate resourcing.

A review of the no send policy wouldn't go amiss either - maybe then this situation would not have arisen...

Ckemtp said...

Oh, if this was the US system, and where I work... I would have made approx $16 (US) for that display of paramedicine. The service would have billed over $1000

Yay economics!

Anonymous said...

an hour and a half wait for two ambulances with two critically ill patients, and the service is at REAP2, says it all really

medicblog999 said...

I really need to start commenting sooner! Its all these damn blog carnivals (thats my excuse anyway)

Everything I would have done has already been suggested, but I would tend to work with the skills available to me (i.e. the nurses and HCA`s), they dont necessarily need to do any treatment, but just monitor and shout if needed. Then just keep hopping up and down the corridor.

I LOVE the threat of calling an Major Incident though - great thinking!

Neldo said...

What if the same incident happened in a residential home, meaning that there's no nurses or HCAs present?

On a side note, has anyone else found that nursing and residential homes (esp. the latter), seem to employ staff with nearly no common sense? Frequently I get calls to the pharmacy along the following lines:

Home - Hi, just phoning to check if you gave us the medication for Mrs X?

Us - Did you look with the rest of the medication?

Home - No, thought we'd phone you first.

Us - Ok, try looking for it first, then phone us back later if you still can't find it.