The title of this post was mumbled to me by good friend of the blog Nick Williams, a Paramedic in South Australia. We were discussing refusal myths, the lie that is patient kidnapping and other similarities between our vastly different systems when Nick mentioned something that has been simmering in my brain ever since:
"It used to be we asked 'Are you well enough to stay home?' Now it seems we're too busy checking to see if they're sick enough to go."
Nick mentions a co-worker of his using a similar line to discuss the way EMS seems to have shifted focus over the years. We discussed the changes in our systems and went on to talk about beer, family, TV, the usual, but more than a few sleepless nights have me convinced that he's onto something.
When you are dispatched to a call, what is the first thing that pops into your head? Is it "I hope they're OK" or "This better be good?"
Why "This better be good" took over
I have written in the past that we're finally having an impact on public health. The most serious, sick patients of the past are farther and farther in between. We're nowhere close to where we could be but we're on the way. Along that way we became more and more upset at the BS calls. If you'll recall we renamed those Basic Service calls. These are the calls that seem to be below your disco patch and Mac 3 blade skills. I'm sure you're ready to apply every single medication and tool in your LED plastered rolling ED on wheels and your Racin the Reaper T-shirt, but your patients need those things less and less these days.
It is easier to walk in the door and cover the big stuff "Scene Safety, BSI!" quickly removing reasons for your skills to be applied than it is to sit down with Erma and figure out why you're there in the first place.
Why "I hope they're OK" needs to come back
Instead of working so hard to prove to Erma she doesn't have to go, why not follow Nick's advice and make her convince us she's well enough to stay? Too many Paramedics jump to the "Do you want to go or not?" question, often combined with a comment along the lines of "There's nothing more I can do for you in the Ambulance..."
Nothing more?
You're not trying hard enough.
Erma has a problem. She's having a bad day and you need to do everything you can to make it better. All better? Maybe not, but you can't solve a problem if all you do is apply a narrow list of questions designed to get you back in service faster.
If Erma is OK staying at home, she can stay. If she's not OK staying at home but still wants to it is your job as a clinician to explain to her the benefits and risks so that she can make an informed decision regarding her health. No EMS anchor is going to convince me that hand cuffing Erma to the cot and transporting is the right thing to do. Their consideration of that option already tells me they're lost to the process of transport rather than embracing the opportunity of assessment.
There is no law forbidding you from informing your patient of your opinion based on your assessment. If Erma doesn't want to go she needs to convince me she is well enough to stay home with her complaint/symptoms/concerns. That is all. If she wants to go, she goes. If she doesn't, well, do your best to convince her while being honest and helpful.
Not everyone who isn't sick enough for the ambulance is well enough to stay home.
It is your responsibility to make the decision WITH your patient, not for them.
When the bells ring tonight for the 30 year old male with chest pain at the police station, will you groan and start the assessment looking to exclude him from transport or will you assess him and help him make a good decision regarding his complaint?
I hope he's OK.
"It used to be we asked 'Are you well enough to stay home?' Now it seems we're too busy checking to see if they're sick enough to go."
Nick mentions a co-worker of his using a similar line to discuss the way EMS seems to have shifted focus over the years. We discussed the changes in our systems and went on to talk about beer, family, TV, the usual, but more than a few sleepless nights have me convinced that he's onto something.
When you are dispatched to a call, what is the first thing that pops into your head? Is it "I hope they're OK" or "This better be good?"
Why "This better be good" took over
I have written in the past that we're finally having an impact on public health. The most serious, sick patients of the past are farther and farther in between. We're nowhere close to where we could be but we're on the way. Along that way we became more and more upset at the BS calls. If you'll recall we renamed those Basic Service calls. These are the calls that seem to be below your disco patch and Mac 3 blade skills. I'm sure you're ready to apply every single medication and tool in your LED plastered rolling ED on wheels and your Racin the Reaper T-shirt, but your patients need those things less and less these days.
It is easier to walk in the door and cover the big stuff "Scene Safety, BSI!" quickly removing reasons for your skills to be applied than it is to sit down with Erma and figure out why you're there in the first place.
Why "I hope they're OK" needs to come back
Instead of working so hard to prove to Erma she doesn't have to go, why not follow Nick's advice and make her convince us she's well enough to stay? Too many Paramedics jump to the "Do you want to go or not?" question, often combined with a comment along the lines of "There's nothing more I can do for you in the Ambulance..."
Nothing more?
You're not trying hard enough.
Erma has a problem. She's having a bad day and you need to do everything you can to make it better. All better? Maybe not, but you can't solve a problem if all you do is apply a narrow list of questions designed to get you back in service faster.
If Erma is OK staying at home, she can stay. If she's not OK staying at home but still wants to it is your job as a clinician to explain to her the benefits and risks so that she can make an informed decision regarding her health. No EMS anchor is going to convince me that hand cuffing Erma to the cot and transporting is the right thing to do. Their consideration of that option already tells me they're lost to the process of transport rather than embracing the opportunity of assessment.
There is no law forbidding you from informing your patient of your opinion based on your assessment. If Erma doesn't want to go she needs to convince me she is well enough to stay home with her complaint/symptoms/concerns. That is all. If she wants to go, she goes. If she doesn't, well, do your best to convince her while being honest and helpful.
Not everyone who isn't sick enough for the ambulance is well enough to stay home.
It is your responsibility to make the decision WITH your patient, not for them.
When the bells ring tonight for the 30 year old male with chest pain at the police station, will you groan and start the assessment looking to exclude him from transport or will you assess him and help him make a good decision regarding his complaint?
I hope he's OK.
Comments
This also means I shudder at the attitude and arrogance displayed towards patients by these crews as they struggle to find the line between professional diplomacy and just plain crass aggression, dressed up in their minds to be "assertion".
The other notable feature of leaving patients home is the background thought of "what would the coroner say"- something that ultimately finds experienced paramedics playing it safe and just transporting all the young and elderly patients as a CARE (cover a**, retain employment) approach to patient management.
I enjoy the reality of knowing that despite being on opposite sides of the world, we have the same problems!