Sunday, 19 September 2010

Change is Coming

I've just mentored a student. Four weeks of trying to improve their skills, teach them all I know, and introduce them to the world of ambulancing. And whilst I'm at it, enthuse them about this job of ours. And therein lies the problem.

I love my job. I love everything about it. Everything, except:

The politics.

The lack of decent vehicles.

The lack of equipment.

The lack of training possibilities.

The lack of pay.

The lack of respect from other medical professionals.

And most importantly -

When people, including me, complain about everything that's lacking. Yes, including me.

I'm overly, sickeningly positive about EMS. I can be, because I try my damnedest not to let the things all around me decide how I'm going to treat the people I meet. After all, they're what this job is all about.

There are always frustrations. The recent plethora of them has made me write this post in the first place.

It's wrong that I have to provide some of my own equipment because there are those who are dishonest enough at best to lose the kit and not report it, or at worst, steal it.

It's wrong that we're driving around in some vehicles that are nearly a decade old.

It's wrong that some of the calls we are asked to attend don't even come close to qualifying for something that needs an ambulance.

It's wrong that there is such a strong anti-management culture.

Equally, it's wrong that it seems as though that feeling is mutual.

A recent tweet from someone I follow, someone relatively new to EMS, mentioned that 90% of our calls could be attended by a horse and cart. I don't think that that's even close to being true, but it does show that this negativity is reaching and emanating from all corners, old and new.

Not all our calls are life-threatening emergencies. Not even the majority. From personal experience, and being one who tends to attract trouble when it's around, I'd say that the number of these calls is lower than 15%. But that's not all that our job is about.

There are loud mutterings in the ambulance service that this job isn't what it used to be.

I'm pleased to hear it.

I don't want to go back to the days of being just an ambulance man.

A recent shift with a different student showed me why. Their regular mentor was having a day off, so I was filling the gap. This student was enthusiastic, hungry for knowledge and experience, yet being mentored by someone who repeatedly claimed to be "just an ambulance man". This mentor started this job whilst I was still at school, when ambulances did nothing but pick people up, take them to hospital, and let the doctors there decide what was wrong and how they would treat them. The student, despite their enthusiasm, was being drawn into a world that I just don't want to be a part of. A world of pessimism, of negativity, of apathy.

I was trained by someone who said that our job isn't to diagnose, merely to take a history, treat only what we see, and transport. The Happy Medic has a post about paramedics diagnosing. I'm with him on this one.

We are so much more than we used to be. And we can be so much more.

Change is coming to the ambulance service. There's going to be much more of that stuff we're told that we don't do. You know - diagnosing. There are going to be paramedics trained to a higher level so that they can assess, treat, and refer to a much higher standard, all as necessary. And not necessarily transport. Some of the calls we'll be attending in future, are those that were traditionally seen and treated by GPs. The truth is, we're already attending them. We just don't yet have the system in place to do anything but transport them to hospital. That's changing too.

There are those who see these changes reflect an admission of defeat by the ambulance service. Rather than educate the public about who we are and what our role is in the health-care system, we are adapting to what we think the public would like to use us for.

Personally, I'd like the two ideas to meet in the middle.

I'd like to see more education for the staff, more training, more ability to treat at home and refer if necessary. Who hasn't thought about simply gluing the little kid's head wound back together, or the 90-year-old for that matter. Then they can stay in the comfort of their own home, rather than endure the trauma of several hours of an A&E visit for a ten-minute consultation and treatment.

I'd like to see more back-up from the system when we do leave patients at home, whether it's our decision or theirs.

I'd like to see that ambulances are waiting for calls, not calls waiting for ambulances. Why?

Because I'd love to see that we have time and the resources, like the fire-brigade for example, to go into schools, summer schemes, mother-and-toddler groups, anywhere, to educate the masses. Both about what we do, and about what they can do to help themselves and their loved ones.

I'd love to have all the latest vehicles, fully kitted with the best equipment, and attending calls that truly require our knowledge, our expertise, and our passion.

Until all that happens, I'll work with what I've got, to the best of my ability. And strive for more.

I'll keep enthusing about my work to anyone who'll listen, especially students.


Change is coming.

So are we going to fight it, or are we going to take the lead and steer it in the right direction?

Change is coming.

The question is, are we afraid of it, or are we willing to embrace it, pioneer it, and grow with it?


Pie said...

I want all of these things, but also I want paramedics to have more power to refuse to transport patients who clearly don't need A&E. I want somewhere other than A&E for the drunks to go.

oneunder said...

We have 2 fundamental problems.
There is no trust between staff and management so anything that is proposed is assumed to be to the determent of road staff. Our history has shown that this assumption is right too often.
We run on a finite budget and the call rate just keeps going up so we have to change to try to meet the demand for our services.

I'll add in that we are now driven by government targets that financially punish the service if we fail to meet these artificial targets. These targets have nothing to do with patient care.

TOTWTYTR said...

I'm on a different continent, but I see some of the same problems. Since our system is structured differently in financial terms, I see things in a slightly different light. The biggest system abusers we see are those who get their medical care at no cost to them. It's part of the change I hope to see in this country, but I can't say that it will help in your country.

The subject of leaving people, or refusing to transport them, is very contentious. In this country patients being inappropriately triage out is a subject of substantial litigation. The doctors don't want to do it because they see the liability risk that they run if they discharge someone and that person has a bad outcome.

There are a lot of problems in EMS, but unfortunately no one seems to have a lot of answers. At least not answers that don't involve more work for us at the same pay.

Anonymous said...

Getting rid of ECP's...

Need I say more?


Tom said...

I started my service on the cusp of the transition from the 'swoop and scoop' culture, to that of the 'stay and stabalise' system of patient care.

I recall spending off duty hours in shops milling about with a collection box tryng to raise funds for a LifePak (defib) and an I and I kit for the crews and vehicles. The service would not provide the kit, but would pay for the training.

The pleasure I took from watching the service evolve from the 'I'm just a mobile porter' mentality into the highly professional body of EMS personnel today, is tempered by the knowledge that there is still a negative element within the ranks of the service.

This is truly sad, as I watched with awe the outstanding ability and professionalism displayed to a friend's family barely a month ago.

Please fight it as best you can.

Anonymous said...

Best post I've seen in a long time

InsomniacMedic said...

Pie - Drunks need to go home and to bed - to be cared for by their nearest and dearest. Unconscious or unable-to-stand unaided drunks, will need medical aid. Unfortunately that'll never change. It's the first category we need to do something about. Agreed.
OneUnder - The trust problem exists and has done for years, which is exactly why we need to do something about it. When the front-line staff start being part of the decision making teams, things can improve. For now, we are at constant loggerheads - leading to resentment and mistrust. We need to convince the management that we are interested not only in our personal gain, but also in what is best for the patients and the organisation, as well as its future. The targets we are set are clearly manufactured, we all know it, management and staffside alike, but that's neither's fault. We have a government that likes to measure success, and whereas with most places targets are easily measured, we're in an "industry" where this is difficult to categorise. I'd love to see our success measured in terms other than the time it takes to push a button, but for now, that's what we have to work with. Fining the ambulance service for not reaching those targets, makes it all the more difficult as the reason we're not hitting those targets, is so often down to underfunding...
TOTWTYTR - thanks for commenting from across the world! The system here, as you know, is free to all. Charging people often comes up as a subject for discussion, but there is no way this'll happen any time soon (like the next decade at least at a a guess). You're right that the answers are hard to come by, but fighting against everything definitely isn't it... Which is why sometimes fighting FOR something, is much more successful than fighting AGAINST something else... As far as leaving people at home, there is a strong push here at the moment to avoid taking patients to the ED, and rather find alternative, more suitable care pathways for them. However, should something go wrong, even if it is totally unrelated to the original call, there is a strong suspicion amongst the frontline staff that they will receive no support for their decision. That needs to change.
MM1 - I know. And it is regrettable. This is, IMHO, down to poor planning when the system was originally put in place. It was brought in with the hope that everything would eventually fall into place, which unfortunately it has failed to do. ECPs had (and have) such great potential, both for the service and for personal growth, and I suspect that it'll be brought back when someone sees the idea for what it is, and uses it to its full capability.
Tom - I plan to keep fighting. I hope your friend's family member is doing well. It sounds like this was the sort of call we're trained for and hope for. I don't want people to be sick or injured, I just want to be there if they are...
Anon - Thank you! But who are you??? Pls put some identifying mark, even if fake initials, then I can keep track! :)
Thank you all for commenting. Keep 'em coming.

Graham K said...

Just want to leave a comment about "Get rid of ECP" In my service they have been a god send! not only gluing the 90yr old head in the comfort of there own home but we have them triaging calls in control. they listen in, interupt the call, and if appropriate tell the caller they are not getting an ambulance and they can refer on to another care pathway(OOH GP, ECP, Community Matron) When Im on a RRV you can tell when the desk isn't manned because we get sent to the toothavhes and pulled muscles!

bluebandage said...

It's a big blow to our profession that LAS have decided to discontinue the ECP role as it managed correctly has massive potential to be taken further forward. However I see the argument that it's not the ambulance service which benefits directly from ECP's - it's more the PCT's and it costs a fair amount of money to train a ECP. If the LAS don't get the appropriate funding for providing this service then in the current economic climate it's an easy thing to cut.

I have a suspicion that the LAS ECP's will leave the ambulance service to work for Out Of Hours services or a Walk in Centre where they can use their ECP skills more widely and have the opportunity to develop their clinical skills even further. This will damage LAS even further as they will loose a great number of it's more highly qualified staff.

Without the ECP role what do paramedics aspire to be clinically? I really hope that other UK services don't follow in the wake of LAS.

SaintPara said...

There's a new role being trialed in the LAS - Something called "Advanced Paramedics" - From what I understand, a car (and only that car) with an advanced paramedic will be sent to every job (excluding Red 1 / Red 2's) and will then assess the patient and call in the appropriate resource (Paramedic ambo, A+E Support, PTS) or refer to other service (GP, OOH GP, WiC, MIU etc). This is what I understand (so don't quote me on this..)


1) This sort of system has been trialed in many other countries and it has been shown by a MASSIVE study of 20 INTERNATIONAL trials to be flawed, something pointed out to the powers that be (ptb) by some quite senior and cleaver people - but ignored by management.

2) Without the trust between staff and management, who is going to be leaving loads of people at home?

3) Try getting a job description / skiill set / training program from the PTB and you can't. I would assume that as this is a more senior role and your are taking on more responsibility that it would be a Band 6 job, not Band 5 (er... weren't ECP's band 6... hmmm) but again this info can't be gained from anywhere.

While I welcome the idea of the trial, and makes sense to me, the fact that it has had a large meta-study concluding that it is flawed leaves me quite concerned that we are going to be putting people at risk.

I for one am up for fighting for change with InsomniacMedic, so long as it is the right change. Lets hope the LAS and all EMS services change for the benifit of the patient rather than the benifit of the accountants.

Anonymous said...

I have read this post a number of times. I am due to start my training in the near future having been lucky enough to secure a place. When the time does come to get out on a station and on the road I hope that I have the good fortune to have a mentor who holds the same sort of work ethos as yourself.


Anonymous said...

The UK AMbulance Service is actually being seen by the government to be the cure to all their ills.
Treat and keep patients at home, thus avoiding unnecesary admissions, let the Service be the central point for all Community services. In theory this would be brilliant. Clinical desks rerouting inappropiate calls to the right places, encouraging callers to make own way to hospital, or even telling callers that they don't need an ambulance or even to see other medical professionals because simple selfcare at home would suffice.

The potential for the Ambulance service to be a central focal point and hub for all out of hospital services is tremendous.

What needs to be done is public education, masses of it. Sadly this costs money..alot of money so very unlikely to happen.

The public will have a shock when every service implements clinical triage desks and callers are told politely to get a grip and be responsible for their own welfare instead of relying on statuatory services to come to their aid. I think the Nanny culture in the UK has become so great that people cannot think for themselves anymore and just take the easy option...calling 999