Sunday, 8 January 2012

Tick Tock

Times, they are a-changin'. Or so said Bob Dylan. Personally, I'd reverse the lyrics. Over the past few months I've had the opportunity to work with several student paramedics, either as a working crew, or when they're out on vehicles and I'm on the car. Some are good, some less so. Some who are too young, whilst others are either mature students or have maturity beyond their years. All, however, seem to have arrived bamboozled by the power of the clock. 

I'm going to be honest. I don't give a damn about the time limits we're given, particularly when it comes to turn-around times at hospital. It's probably best that I don't give a damn, because I suspect that my turn-around times are probably giving my management team nightmares. I do, however, give a damn about my patients, so I get to the call as quickly as I safely can, I treat them as best I can. We have fifteen minutes in which to hand our patient over to hospital staff, clean the ambulance, restock the missing bits of kit (if possible - sometimes it's a bit of a challenge to do anything short of reallocating resources from either hospital or another ambulance), use the bathroom if required, grab a quick drink and sometimes a bite to eat, and, of course, complete the paperwork. 

Admittedly, the fifteen minutes on which we're currently assessed don't start until our patient is on a hospital trolley or in the waiting room, so the three hours(!) I waited the other day with a patient on our trolley bed won't count against me. I do realise that we don't have to have a coffee or use the facilities after every call, but the pressure of this quarter-of-an-hour time limit has led to what, at least in my eyes, is an ugly new trend, particularly amongst these new paramedics and students. 

The trend? Completing the paperwork before we've even left the scene of the call. Not just the basic details, but every last bit of paperwork.

I hate it. The patient is in the back of the ambulance, a history has been taken indoors, observations checked and rechecked (after all, every patient must have two sets of obs - yet another box-ticking nonsense in many cases), the patient has received treatment if appropriate and/or required, all whilst the family are standing outside wondering what's happening. Often, the patient is wondering the same thing too. 

The patient is in the back of the ambulance for one reason and one reason only. You've made the decision that they need to go to hospital. Well, either that, or the patient has made that decision themselves and aren't going to be persuaded otherwise. In either case, the reason is the same. That patient is going to hospital. They don't want to be sitting on their own doorstep for an extra fifteen minutes with the blood pressure cuff aimlessly inflating automatically at five minute intervals. They don't want their family standing outside the ambulance concerned that something terrible has happened. They certainly don't want to be ignored for the time it takes to complete the scribbled account of everything that they've just told you. 

They want to go to hospital. 

Many (most?) of our patients need no treatment on route to hospital other than a smile and some friendly, calming banter. Talk about the weather, talk about their children and grandchildren, talk about their wartime experiences, talk about the football or last night's garbage television. Talk, and write. And if you can't do both, then just talk. If your patient isn't interested in conversation, then you can just write, but be on the move. And if, by the time you get to hospital you haven't completed your paperwork, do what I do, and take whatever time it takes. 

Paperwork, as well as being the bane of the life of any paramedic, is a legal document. If it's not written down, it didn't happen. Standing in front of a coroner and claiming that you provided treatment but failed to document it will leave the coroner with no choice but to accuse you of lying, so you do need to make sure that everything is written down. It is, of course, helpful to write down the patient's details as they tell you their name and date of birth. But as far as the story, the history and the symptoms are concerned, just listen, make mental notes or even quickly scribbled ones on a notepad and then write them down properly later, once your patient is no longer yours. If you can do it in the allocated time, all well and good. If you can't, if you need to pay extra attention to detail, if you need to ignore the clock, just do it. 

Concentrate on your patient, not on the clock. It takes a while to learn the knack of writing and talking at the same time as being on the move across the pot-holed London streets, but it's a skill worth learning. But if you can't manage it, then just wait. Arguing that completing the turn-around in the allocated time is beneficial to other patients by being back in service quicker, is no more than complete nonsense. If you've taken exactly the same time to complete the call by standing outside the patient's house for those precious minutes, then you're not back in service any quicker. 

Concentrate on your patient, not on the clock. It takes a while to develop a system that ensures that everything that needs to be written down actually makes it from thoughts onto paper, but it's a system that's worth having. If you can't manage it within the precious time allotted to you at hospital, then just take a little longer. Each patient is worthy of your personal attention. That tick-tocking noise in the back of your mind should come a distant second. 

A little more of the personal touch and a little less of the clock-watching paranoia can turn a good paramedic student into a great one. Try it. You may be surprised at the results. 


Anonymous said...

Not completely related to this blog post but you mention: "Some are good, some less so." for student paramedics. As I'm an aspiring student paramedic and also a mature student, I'm curious to what you think makes a student a bad paramedic and vice versa.

Anonymous said...

Couldn't agree more, stuff the clock, it's the patient and the care you deliver to them that counts! The coroner or the HPC won't care if you cleared in the allotted time.
We are now constantly harassed out of the A&E by a HALO. When this happens we document it with the officer's name.

Anonymous said...

I was trained as a Medical Assistant to work alongside the nurse and the doctor in the office. I had to work a year in the field before I could take the certification test. I still remember my ma instrictor saying "document, document, document! if you do not, it didn't happen!" So documenting with date, time, and the KISS method became my forte. Love your stories. I have a retired paramedic daughter, and her friend is a paramedic, also an instuctor. I have heard similar stories (without names for privacy) from them. The docs in the office would ceaselessly complain about time constraints preventing them from doing thier best (I am in the USA).
Your writing is among some of the best I have seen on the blog. perhaps you can place these stories in a book. "Selected Stories from the Insomniac Medic".

Anonymous said...

I tend to complete the top half of the PRF on scene (although I'm not opposed to doing obs en route, as I don't see that the two sets need to be done before leaving scene) and I tend to complete the bottom half (free text) on the way to the hospital and/or while waiting in the queue at a very well known hospital :P
I do keep in mind what a very good PPED once told me, if you have nothing written on your PRF before you arrive at hospital, and you are in an accident on the way to the hospital and are incapacitated yourself, then the crew coming to your aid knows nothing about the patient.

The other thing you need to remember is that with the Uni Students, they have to apply for a job once they are qualified, and if they come to London their times will invariably be held against them in the recruitment process ;)

See you soon!

Anonymous said...

As a nearly qualified (fingers crossed) student paramedic i agree that the patient is the most important part of our job. If only the managers saw it that way - i got told by management not so long ago that when it comes to applying for a job they wont see the patients they will only see the figures we produce therefore i do everything to get not only the 15 mins but less than the 15 mins.

But having been witness to several student paramedics i constantly am in amazement that they often don't talk to patients and instead its head down paperwork done! patients need to feel relaxed and idle chit chat can quickly diffuse the nerves and anxiety they feel.

So yes talking is our priority but sadly for me so are my figures! an unnecessary pressure!

Anonymous said...

I agree with not watching the clock. It's been my experience that an arbitrary time limit often leads to sloppy documentation perpetrated in the name of speed. I'm fortunate to work in a relatively small community, where our main station is located across the parking lot from the local hospital. If I need an hour to write, I can take it. sometimes, I NEED that hour. A properly documented call ought to take priority over all else. Not only is the run report a legal document, it's how we bill for the call, which we all know is what management wants.

Anonymous said...

For an outsider, please what's a HALO. To me it means something like High Approach Low Opening in military parachuting! Perhaps you wish your HALO would do just that!

InsomniacMedic said...

Every single comment anonymous. That's unhelpful people... :S

Anon 1: I'll write a post about it. Will be easier.

Anon 2 & 7: I have deduced that HALO is Hospital ____ Liaison Officer. Right?

Anon 3 & 5: Saying that if you crashed, died, fainted or any other such unforseen event is a little extreme, and I'm not sure that that's good enough to justify not talking to a patient.
It does, I admit, take time to learn how to talk about everything and nothing all at once, but it's worth it.
And I understand the need to prove your worth by quick turnarounds, but there are ways and means of proving your worth over and above that... Your colleagues will often report more things about you than your times will... :)
Anon 6: Now there's something I didn't think about - billing. Luckily that's something that in London we don't have to worry about on the front line!

ambogirl said...

I agree totally, chatting about nothing in particular puts frightened patients at ease, calms children and is sometimes the only company an elderly person gets.

Incidentally, our locality has just changed the handover to clear time to 5 minutes...

Ambulance Al said...

The Service I am with gives us 20 minutes to hand off the patient and be ready to go. Otherwise if we are still holding the patient because of delays in the hospital getting a bed then we charge the hospital at $200+/hr. Even with that incentive some hospitals still don't expedite the off load process.

Anonymous said...

A very pertinent and well written post as usual IM. I think some of the time driven management stems from employing senior managers who either haven't done our job, or haven't done it in such a long time that whatever practical experience of it they have is no longer relevant. Having only recently qualified as a paramedic I definitely understand the pressure to conform to the ticking clock, and i still try to, but I have learnt to multitask my care and my paperwork on the way to hospital. However it did take some time to learn. I think there's also value in teamwork and delegation, we work in pairs after all. It makes me sad when I see a driver sat on their own in the front whilst the attendant is alone in the back doing everything themselves. For our newer staff I think that setting a good example and helping them develop their time management skills is one of the best things we do for them to boost their patient care. A lot of students feel isolated and undersupported in their clinical development (especially HH SPs) so end up becoming focused on management targets to prove their worth. Showing them a good example of patient care above all else will help more patients than the 15 minute handover to green time ever will!

theSmurse said...

Ok heres my view:

1: Most definitely need to talk to you patient, patient communications are a skill that cannot be taught, one you need to have, its one of the reasons I'm against direct entry healthcare courses, but thats a rant for another day

2: I like the Irish pre-hospital emergency care councils take on things: "Patient care documentation is an integral part of patient care, but should not get in the way of treating a patient, if the practitioner is unable to document care as it is given because they are providing care it should be completed as soon as possible afterwards" or words to that effect.

3: One stumbling block to this, our PCR's are in duplicate, when you hand patient over, triage nurse signs it, top copy stays with patient and goes in their hospital chart.....therefore it should be completed before patient handover or else there will be a discrepancy in the 2 copies. Now obviously in the majority of cases we can walk in and when handing over say "listen ill have the pcr in a couple of minutes for you" but we just need to be cognisant of the fact not to dilly dally.

4: I forget stuff...I like to write as I go along, its easier, for me. But I just scribble on my glove, yes I know I shouldn't but I do.

5: I have no idea how you cope with constant time limits imposed on you by management etc, fair dues to you IM for saying no, but I see where the student para's are coming from, they need to be squeaky clean. They have a lot to learn from the likes of you, take then under your wing they'll go far

OrlandoMedic said...

You said that you have 15 minutes from the time the pt leaves your cot to the hospital cot or waiting room... consider that a luxury. We have exactly 20 minutes from the time the truck goes into park at the hospital until we have to be back in service. Even if the hospital is on delayed offload, we are penalized during our yearly evaluations for not being in service at the 20 minute mark. And then they start paging us wanting to know why we are delayed when they can go to the EMS board (which is always loaded on a computer) and see why we are delayed without making me use my cell phone minutes to let them know what they already know. Lucky.

TAZ THE AMBO said...

Same sh_t different hemisphere.
This topic must have been stewing for a while with you good to see you've vented your spleen now.

Take care Dude.

Brown Bev said...

I take it none of you are using EPRF's yet then? We get 45 mins to handover and it is often not enough time. In my eyes it is wrong to have your head down writing/tapping away. Our pt's often need our calming and reassuring conversations. Then again, if we all take far longer than we should to handover/go clear who is out responding?? Kilo zero once again!!!

Flora Gardens said...

Agree completely with this post. I have worked LAS control and on the road. Remember being told re Clock Watching "Get there in seven minutes and pat dies - management happy. Get there in nine and pat lives - management unhappy."

Anonymous said...

Well Mr InsomniacMedic, if I gave you my name tehn you'd (or rather they'd) be able to identify me and the same for any pseudonym that I'd use ;)

However someone up there did make a very good point...Hannibal House SPs are extremely undersupported compared to Uni SPs.
- HH don't get allocated PPEDs like Uni, we have to find our own.
- HH also become second rate as soon as Uni steps onto an amb and everything becomes about signing the Uni off to the detriment of the HH. In the words of David Cameron 'We're all in it together' though most PPEDs seem to forget this...

Oh and yes, I can talk and write, I love to talk...just most of my patients don't want to talk to me. In fact anyone that really knows me would know that I much prefer chatting over doing any work ;P but no-one at work really does know me :)

However like I said, I have no problem completing the rest of the PRF while standing in a queue or waiting on the receptionist to bother booking me in.

You talk about chatting to your patients etc so I'd like to know what your take on this situation is (of which everyone is guilty):

When standing in a very long queue of ambulances awaiting triage at a reasonably sized District General Hospital, possibly in North West London, all the LAS staff huddle together having a great laugh and joke and catch up, yet suddenly it seems quite alright to forget about chatting to your patient and isolate them then because all your colleagues/friends are there.

Also, it's my right to be vigilant of my times and if I wish to work quickly then I shall do so.

InsomniacMedic said...

Finally, someone who wants to put up a bit of a fight. Good.
Mr Anon, I understand your need for anonymity, even though you clearly know who I am. All I ask is that you use some form of ID. I don't care if you just put your best friend's initials, but that's all besides the point.
I have never noticed the difference between HH and Uni students, at least from my standpoint as a PPED (Practice Placement Educator for the uninitiated), and wasn't aware that there seemed to be this discrimination. I have worked with both types of students and given both the same hard time and guidance. In fact, unless I bother to ask, I don't tend to know which is which, neither does it make any difference as far as I'm concerned.
I did say that if your patient doesn't want to talk - then go ahead and do your paperwork.

As far as your dig at crews who stand around chatting whilst waiting to hand over - you have a very valid point. I'm not sure if your dig is a personal one, but I know full well that I'm sometimes guilty as charged.

Many of us, me included, have a long way to go to portray the professional image we're trying to do. None of us is perfect and sometimes we all need a reminder that there are areas that need looking at, so thank you for the reminder. It's something I'll be more careful of.

And as for your final point, no-one is criticising you for being vigilant about your times, or your right to be so. My point comes to highlight that when tick-boxes and time-targets come before patients, then we're doing something wrong, and it's something I'd like to change.

Now, if you want to identify yourself in private and continue this discussion, I'm quite happy for you to email me - . If you don't, then that's fine too.

In fact, I look forward to it.

Anonymous said...

Not relevant to this post, but as a long time subscriber I saw this & thought of you . . .

Scroll down to 'Earn' & you'll se what I mean. Dunno if he's a reader too, but he's obviously had contact with you or your colleagues in some way.



Jait. said...

Don't you get the option of increased wrap up time if you're going over the 15?.

HALO - Hospital Ambulance Liaison Officer.

HH? Couldn't see an explanation.

It used to be the case in our trust that some crews would be available to clear but spend half an hour grabbing a brew & chatting. Doesn't happen now unless its been a proper working job...

Anonymous said...

Hi Jait, sadly these days we just get pushed to go 'green' after being at hospital for 30mins (or earlier if they are holding calls nearby, which I guess is reasonable). The average handover to green time that is being discussed is taken from our paperwork (I think?)so is a measure taken when the PRFs are audited, it is then uploaded into performance management software where the station management look at it and decide whether to write a letter to us telling us to work faster, this is where people feel like they are being pushed I'd say.

HH = Hannibal House, the in-service training school for the LAS. They do things a bit differently the the local universities and some of the HH student paramedics have felt a bit left out as they don't get any dedicated mentoring time short of their initial basic EMT training. That said they aren't paying tuition fees like the uni students do, and they are on full time pay. Both ways have their merits, and both create paramedics at the end of the day.

vidar said...

It seems wrong to me that ye are been judged so heavily on times. Im a Garda in Ireland (police) and god help us if they ever tried that crap of time indicators with us! They would be so far of their targets it would hurt :)

I am also an EMT with a vol ambulance over here and I agree that patient care should come before documentation, if a patient has been hurt and have never been ion a hospital before they will be scared and talking with them can help that fear.

JPJ3ss said...

Here in Vic, Australia, we're no longer to complete paperwork while moving - apparently, having the laptop on laps was causing neck injuries, so it's now an occ health and safety issue. We can take notes on paper, and then transfer them to the ePCR when it comes to it, but no typing in the ambulance!