Pre-Hospital Care-Pathways…



It still amazes me how many calls we get which do not require an ambulance yet the crew will still take the patient to A/E.

Now this can be due to many things:

  • the crew is erring on the side of caution.
  • easy way to get back to station (vehicle needs restocking/cleaning etc.)
  • crew are knackered from job overload and it takes time to arrange other agency response.
  • crew (or member of crew) has been bollocked for previous job where patient complained about been left.
  • easier to shift the responsibility to someone else ie A/E
  • RRV/RFU has told patient that the crew will take them to A/E. (even if patient does not need to go.)

These reasons are of an historical nature. In years gone by we were always expected to convey the casualty to A/E.

If anything went wrong during the pre-hospital phase (bag goes missing/meds get misplaced/patient is sick/relatives go to wrong A/E  /Doctors letter is lost on the ward!) then normally the blame was levelled at the crew (ambulance drivers!).

If for some reason a patient was left at home due to not been ill/injured, and then later does fall or become ill (which was totally unconnected to the original 999 call) then again the crew would cop it!

With the introduction of extended skills with Paramedic training and better education for all Ambulance Service staff, we have a better understanding of things and can make reasoned decisions based on patients presentation, the history, our experience or in easy cases according to a guideline/protocol.

The NHS is battling to balance the books. Measures are being taken to redirect people away from hospitals via other care pathways. For example NHS Direct, General Practioners, Emergency Care Practioners, Social Services, Community Nurses and so forth.

But on the front line we, the ambulance service, are still responding to many jobs where the caller/patient/casualty could be redirected to a more appropriate form of treatment. I, like most of my colleagues up and down the country, have been trained to treat major wounds/massive chest injuries/fractures of long bones/unconscious patients/heart attacks etc. etc. What we need is further training in minor injuries and how to deal with them on scene. This would free up A/E and release crews for the more serious calls.

I feel quite confident in dealing with minor wounds/illnesses and so I will stand a crew down if I can manage on my own (whilst on RRV/RFU). I just wish everyone else was.

I write this post because I am fed up with the different levels of response from crews/RRV/RFUs. We all know that certain people will transport or wait for crew backup regardless of the patients needs. We need to sing from the same hymn sheet. My most recent experience of this was last night….called 999s to an out of town job (14 miles away) to an elderly lady who had fallen in a care home. Blues & Twos go on and off we go in the dark through the late rush hour traffic. On arriving at the scene we are greeted by the sight of the RRV car. (was not aware RRV was attending also). We were met by a member of staff and shown to the lady…who is sat in a wheelchair, nice warm coat on, handbag on her lap, and a nice smile for us. Sat next to her is the RRV paramedic who states that she fell about half an hour ago and is complaining of a slight pain in her side.

I asked if the Doctor has been called…”yes but he said ring 999.” The lady appeared to be quite comfortable and the pain was fairly insignificant. Her breathing was fine and only complained of a twinge when taking a deep breath in. This was a very simple straight forward job which could have been referred back to the GP. Unfortunately the RRV paramedic had stated right from the outset that she would be taken to A/E.

If I had any suspicion of serious underlying injury or illness then I would not have questioned this job….but there are some of us who are confident to make a decision based on assessment/examination/history/experience etc. and some of us who are not!

I have never had any problems in referring to other agencies /care pathways. All it takes is a bit more time and making sure that you are doing the best for the patient. Also the paperwork must be completed and comprehensive in detail.

It is unfortunate that in the past crews have been hauled over the coals by management over petty things involving patients when the crew RRV/RFU have tried to redirect to another agency and something has cropped up. I have personally been bollocked for not taking a patient to hospital (when they did not need to go) because the ladys son was a doctor who was more than 150 miles away and thought she was having a heart attack on the phone!

Turns out she was very anxious and highly strung, a fact borne out when I spoke to the ladys own GP over the phone from her address! He was quite happy for us to leave her at home. (Obviously I had done all the tests as a precaution, monitor, blood pressure, blood sugar etc.) But its easier to bollock us than to say to the son, who was after all a doctor, you are a pillock and should retake your exams! 


3 Responses to Pre-Hospital Care-Pathways…

  1. ecparamedic says:

    Interesting post, if you read my response to you comment on my site there may be a few answers from my perspective.

    I honestly believe that ECPs should be the busiest resources out there and that seeing as the Control triage system doesn’t work with any degree of finesse a clinician should be sent out to ascertain an appropriate route to take. Obviously this is for jobs that aren’t ‘barn door’ life threatening, in which case why not respond the ECP alongside?

    I’ve just come through the complaints proceedure after I left someone at home, the complaint was based upon the opinion of a St John first aider who had had no contact with the patient at all. No harm was caused to the patient (she still didn’t need to go to hospital), in fact I view keeping elderly patients out of hospital as beneficial to their health.

    Instead of the usual Ambulance witch-hunt I was protected by something I do habitually, documetation and lots of it, including my thought process and written advice.

    Sadly I see a lot of PRFs from colleagues that barely identify the patient, let alone record their clinical condition, observations, impressions, provisional and differential diagnosis and treatment plan. Some of the worst I see are from Trainee techs who are supposedly being mentored by experienced staff. Any ambulance chasing solicitor could pick holes in an instant and their asses will be in the sling.

    By all means, leave the patient at home, do the paperwork right and get an ECP to follow them up for you. Job done.


  2. Hey there, i’ve just come to you’re blog through Carmelo’s. Its a good read. I’d be interested to know what you thought of mine if you wouldnt mind taking a look?

  3. Kingmagic says:

    Interesting perspective. You will look back in years to come and realise how things have changed. I tried to leave a comment on your blog but the signing up process defeated me. I have your site in my favourites list and will add it to my blogroll.
    Your question about violence at work was partly answered by ecparamedic. I agree that some people in the job bring it on themselves. I was told many years ago when I first started to speak to people how they speak to you in the first instance. A lot of people think that we will just take it and are surprised when we say “…fine we,ll f*&k off then” after been told to do so.
    I,ve also replied to a post on Diagnosis NFI s blog reference stab proof vests.
    I start weekend nights tonight so I will get plenty of jobs dealing with assaults and get some verbal abuse (at least), so I will probaly do a post on the weekends events.
    Keep up the good work. ….Kingmagic (Purpleplus)

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