Thursday, 13 February 2014

Hot Potato

"31 year old female, 37/40 pregnant, loose stool, NHS111"

WHAT?! A loose stool. Why in God's name is a bum-wee worthy on an ambulance?! On top of that, how, in a huge busy city, am I the nearest ambulance to this?! It was 9 miles away, which if my maths is correct (∏ x r2? Right?!) then I was the only available ambulance in an area of almost 255 square miles. That means, based on the cities population, I was the only ambulance covering the needs of 3,449,880 people, at that particular snapshot in time, isn! Thinking twice about calling an ambulance now?! Good! Anyway, the powers that be over at NHS111 deemed it appropriate to use the only resource available covering the equivalent of the entire population of Berlin, for a woman with the runs! I can't for the life of me understand while people have to wait for ambulances from time to time......

So, after an indignant statistic filled rant, similar to the one above we pulled up at the house. Within two seconds of knocking, the door swung opened and out came our patient, wrapped up warm, all ready for a night at the hospital. Clearly, hospital was where she wanted to be! Formalities and introductions out of the way we headed into the warmth of the ambulance where she appeared most put out by my request for her to remove her layers so we could do her blood pressure. 

"Can't it wait until we get to hospital?"

"You might not be going to hospital, I haven't assessed you yet."

"What do you mean?"

"I'll assess you, if you need to go to hospital, we'll take you, if you don't, we won't."

*shocked face*

I decided to follow the 'lets start where it all begun approach'. After various questions I established that she had had an 8 hour history of the shits and her abdomen felt warmer than normal. Once I was happy that that was all that was wrong with her, I had to ask the question that was burning on my mind.

"Why do you think you need to go to hospital?"

"111 told me I had to go."

What transpired ran deeper than that, and goes a long way to explain why the ambulance service is under such strain. It also explained why we were the only available ambulance in such a large area! 

At lunch time the patient's symptoms begun. Personally, a loose stool wouldn't give me any cause for concern or invoke a need to seek medically attention or advice but she did the right thing, she called her maternity unit. They didn't answer so she left a message. Two hours later, she rung again. Like before there was no answer so another message was left. Maternity units are notoriously hard to get in contact with. Obviously they are busy departments but the amount of expectant mothers who then call an ambulance because there was no answer is quite astonishing. 

Anyway, after two failed attempts she called her GP. The GP had no appointments that day. She was told to go to hospital if it was an emergency or call back in an hour to speak to a GP. It wasn't an emergency so she phoned back an hour later to talk to one of the doctors. She got the answer machine as the surgery was now closed! 

Annoyed at the lack of help and advise available to her, she phoned the number she had for the out-of-hours GP service. This service no longer existed and the message she got told her to hang up and dial 111. So she did. The friendly voice at 111 asked her lots of questions and after the thorough 'clinical assessment' it was determined that she needed an ambulance. She told them she didn't want an ambulance. She didn't want to go to hospital. She was told she had to go to hospital and an ambulance was on its way. So she got ready and waited by the door. 

So, after being ignored and passed around like a hot potato all afternoon and evening, here we were! I phoned the maternity unit and got through to the delivery suite. A rather angry sounding midwife started lecturing me about how the patient didn't need an ambulance and didn't need to go to hospital. She then gave the patient the same ticking off, told her call her GP and ended the conversation. Midwives fill me with such joy.....perhaps she should have answered the phone hours ago and saved all this nonsense now!

I told the patient to go back indoors, relax and try to sleep. I said I would phone the GP and get them to phone her within an hour. Off she went, appearing slightly confused that the ambulance wasn't driving her to hospital like she had been told! I phoned NHS111 and referred the patient back to them to get the duty OOH GP to phone her. Annoyingly the GP decided to phone me instead so I decided to take my phone to the patient to get a conclusion to this ridiculous episode of passing the buck! The GP told the patient to take some over-the-counter remedies and to call back the next day if she had any further concerns. Wouldn't it have saved a lot of time and money if they had all just told her that 8 hours ago?! Why does everyone need an ambulance to facilitate common sense?! 

No wonder the NHS is in a bloody mess. Not only can people not cope with minor ailments and treat themselves at home, but every part of the NHS is determined to pass the buck and hope the ambulance service will pick up the pieces!


20 comments:

  1. Sounds about right....
    We've just cleared for an end stage COPD pt who called 111 for right sided flank pain to ask if he could take 2 of his 30/500 Co Co codamol to keep him going until his surgery opened......due to his "breathing difficulties" we were sent. Needless to say we called his GP for him and got an appointment through the receptionist!

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  2. 111 gets some real bad press for no other reason than 'it is fecking rubbish!'
    Why do they insist on employing people that have been refused jobs at McDonalds? People that have just started college courses so that they can claim some form of benefits! These people are going to end up having a member of the ambulance service killed due to responding as a Cat 'A' to someone with PILES!

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  3. Reminds me of the past,when I used to work nights as a Radiographer, and heard of a crew cursing black and bull the guy who dialled 999, for a bad wound.
    When they got there they found his paper cut had nearly stopped bleeding...
    Makes you wonder if the human race is actually trying to die out due to stupidity...

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  4. I am a GP and I work both in- and out-of-hours. I must say that I totally agree with most of what you say. It is really frustrating for patients not being able to get sensible advice quickly, and often they become so exasperated that they default to the ambulance service or A&E. I think the main issue is that we need to have significantly more GP's (the RCGP estimate this number to be around 10,000) in order to meet the needs of the ever-expanding, increasingly frail, increasingly housebound population. I think that being more accessible and working on a shift basis including weekends and evenings is a good thing. The problem is that I already work from 8am-7pm Mon-Fri then do a couple of 7pm-midnight OOH shifts also - I can't physically (and safely) do any more. I'd love to work on a shift-based system working alongside other doctors to provide more accessibility, but to do that we'd need significantly more staff. I work in a progressive practice that has tried to address some of these issues with having nurse practitioners seeing patients in addition to practice nurses and now also a trainee paramedic practitioner (who is excellent), and for our patient list of around 14,000 patients, we offer over 1,000 appointments per week, including until 8pm three times a week. But it's still not enough. The demand is ever-growing, and - as you quite correctly state - people present requesting assistance for a very minor symptom within hours of its onset requesting advice and (usually) a cure. Often at such an early, undifferentiated stage there is absolutely nothing I can do apart from offer the advice that any sensible parent could give of take some analgesia and fluids and waiting to see what happens. Unfortunately, all too often, these kinds of appointments get in the way of the main workload of general practice which is looking after people with chronic illnesses, children, the frail and elderly, practicing preventative medicine to stop them getting ill in the first place. I really do admire paramedics and A&E staff, especially after having worked as an A&E doctor in the past, and I would like to see GP's working in A&E departments more often. I have always thought a great idea would be to physically locate out-of-hours GP's centres within A&E departments, so incorrectly diverted attendances could be redirected by the triage nurse at the front door and seen by a GP instead. Similarly, in an out of hours setting patients can sometimes actually be very unwell when assessed and require admission to hospital - if the GP only had to walk across to the major's desk and liaise with the staff there, this would decrease the burden on the ambulance service and provide a much better handover for improved patient care. But all of this sounds like a utopia doesn't it? Meanwhile, we'll keep battling on with the daily frustrations of our jobs and occasionally come across patients - the meek old lady who didn't want to waste our time but she's just had a devastating stroke - who make it all worthwhile.

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  5. I have for some time thought that NHS should actually stand for 'No Help Service' as that is usually what you get when trying to obtain any kind of help or information - especially over the phone. It's even worse if you or a relative need any kind of mental health input; where I live it seems to be non-existent.
    About the only part of the NHS that appears to this layman to function with any kind of efficiency is the Ambulance Service, something for which I have had reason to be grateful on more than one occasion. Respect to all who 'wear the green', keep up the good work - and keep up this blog, Ellie, its brilliant!

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  6. As a Paramedic of 32 years and now a clinical supervisor at 111 I can sympathise will each and every point made here. The maternity unit is too busy and under staffed, the GP has too many patients needing his time, 111 can only act on the symptoms a patient tells them and the OOH service is inundated with the overflow. In an ideal world patients would only need 2 numbers to remember. 999 and 111 and every call to either service would connect a patient with an experienced clinician who could probe the patients symptoms to arrive at the correct disposition. But as we all know this is not a perfect word so the best we can hope for is a safe disposition. This situation may have been frustrating but at least it was safe. I'm sure all involved will learn from the story and all involved will continue to evolve their practice. One day there will be a limitless budget and everything will run as it should. I will have a Ferrari and a villa in Jamaica and the author of this blog will finish every shift on time. Until then keep smiling !! Paul

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  10. Typical of todays mentality in I suspect many spheres of life "Not my problem" syndrome. If I don't answer the phone it's someone else's problem, I'll pass it down the line & unfortunately the Ambulance Service is bottom on the totem pole! WHAT HAPPENED TO COMMON SENSE IN THE PUBLIC & THE N.H.S

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  11. I agree. I work for a NHS Trust in mental health. although slightly diffrent from acute trsust the same pass the buck cultre exsists between inpatient and outpatient service and this im afriad also adds to the over streched ambulance services and police. I think it is hight time people remember their own judgement and codes of practice be reponcable for your own paitent and actions (by the way as a lowly HCA I am) and stop passing patient around and just give them the care and advice they need early. who know this ight mean it frees up money in the NHS to fix things like our pay fixes for example.

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  12. Any reason why HART are mentioned in same way as Racists and homophobes...?

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  13. I feel your pain. As an ecp I get a large proportion of 111 referrals which thankfully I can "hold off at the pass".
    GPs need to reclaim ownership of their patients needs at a local level before things will change for the better. Sadly I think this is a long way off.
    Great blog! Thank you.

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  14. Ambulance teams are the true hero's it's just a shame the NHS didn't have enough to cope with the demand!! Perhaps they should start billing for self inflicted uses of this wonderful service and free time for the emergencies

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  15. I can understand your frustrations however being dismissed with bad diarrhoea at 32/40 weeks by my GP (actually called a time waster) led to my son being born AT HOME following a prolapsed cord. I had told out of hours service how ill I was but they told me to see how I was in a couple of days. My son went on to develop a number of problems including life threatening infection followed by a number of surgeries. If I had been encouraged to go to hospital instead of being resolutely told NOT to go - you're only 32 weeks pregnant you can't be in labour- perhaps he wouldn't have suffered so badly?

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  16. I feel someone at sometime should have the authority to tell people to strap a pair on and that your not getting an ambulance for that.

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  17. people don't want to take responsibility for themselves or their family. I work in an area where children wait for 2 hours with their parent with a grazed knee when all is needed is a clean at home and a parent saying 'there there there'.

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  18. And they get it wrong the other way too. I am now sitting on a Surgical Assessment Unit with my son with a query testicular torsion. He does have a car so at 3am I had to take him to hospital because his polyuria, 7/10 pain, 5x vomiting and diaphoresis didn't warrant an ambulance!!! As a Paramedic myself I am so annoyed with this when we go to all the aforementioned 'red' calls!

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  19. ex leading ambulance Technician15 February 2014 at 11:54

    Regretfully there willl always be the exception, as in your case but im afraid generally most 999 like that are a pile of poor and only need a small amount of common sense.

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  20. When they built the new hospital in Durham they put an OOH GP unit on site, about 50 metres from the door into A&E. Brilliant you would think wouldn't you? But, despite being told repeatedly, they had forgotten to link the main hospital with the satellite bits using a covered corridor. Someone was seen at OOH and was to be taken to the A&E bit - an ambulance had to be called to do the transfer the porters said they couldn't as the patient was in a wheelchair. Oh yes - and every such transfer was billed to the satellite units at about £100 a time because that was "hotel services" in this PFI facility where it was not built but also run by PFI...

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