Ambulance clinicians are generally
unable to revisit patients to review their progress.
We reflect that GPs can arrange
another appointment, or consider district nurses’ assurance when they will next
attend a patient’s home.
Emergency Department staff rely
on seeing a patient over several hours to develop a sensible management plan,
and for admitted patients there is relative certainty they will remain in a
safe place until treatment, delivered by colleagues they know and trust, has
concluded. Where there is an ongoing issue after inpatient care, a service user
can easily be booked in for a clinic appointment.
In contrast, the ambulance
services have a propensity to assess, diagnose, treat and refer within just one
episode. There is little chance a service user will see the same ambulance
clinician again, even if they call appropriately recall 999, and so lack an
opportunity to develop a professional rapport based on multiple contacts.
While the ability to see a
patient repeatedly and predictably confers significant advantages and might be
a very pleasant way to practice, there too are potential advantages for the
ambulance clinician in the implicit understanding they are unlikely to see that
patient again.
Where circumstances are medically
or socially complex, or potentially distressing but unexplored themes such as
end of life care or psychosomatic symptoms are emerging, a non-ambulance practitioner
expecting a medium or long-term partnership with the patient, family and carers
might need extreme tact and diplomacy to maintain good communication channels. It
is potentially difficult to talk about a patient’s expected death if you know
you’re likely to see them many more times before it happens. It is hard to know
if frank conversations will be taken badly, hurt feelings and erode the trust
you have developed, maybe over decades of friendship with the patient’s family.
Ambulance professionals, as
autonomous clinicians with substantial executive power within a context of very
discrete episodes of patient contact, are in a valuable position to initiate
and navigate difficult conversations, and do something useful with the results.
-“I don’t think you are coping”
to the exhausted husband of someone living with dementia, but too proud to ask
for help
-“Sometimes the mind causes
genuinely distressing symptoms that we can’t easily explain. Could anything
within the family be upsetting them?” to the quarrelling parents of an
adolescent having inconsistent symptoms.
-“If you carry on living like
this you’re at serious risk of dying” to the drug user whose lifestyle has
spiralled out of control
-“It looks like someone did this
to you; would you like to talk to the someone who can help?” to the patient with
the bruised face after what may be a domestic assault
-“When your heart failure gets
worse and treatment isn’t allowing you to enjoy life any more, have you thought
about where you would want to be cared for and ultimately die?” to the frail
patient with bilateral rales and a poor quality of life
-“What will you be happy with in
a year?” where a patient’s family need help imagining what bereavement might be
like
A person might feel able to say
things to the kindly but fairly anonymous ambulance crew they have felt unable
to say to close family members who want to talk about “hope” or “battling”
disease. If their specialist has spent years talking about cures, interventions
and “next steps”, a patient might worry about hurting their doctor’s feelings
to ask whether more chemotherapy is really going to be worth it to prolong
their life a little more.
Sometimes a patient will see your
intuitive and sensitive questions and observations as a light being thrown upon
their crippling darkness and embrace your help. Other times the conversation
might be fraught and confront service users’ painful inner feelings as waves of
emotional turmoil are offloaded. Rarely, the patient’s trust in you might be irreparably
damaged and they may disengage from further discussion, but they will still
have cordial feelings towards their day-to-day health professionals who have
not confronted them in the same way. Perhaps they will later reopen the
conversation with other professionals, but on their own terms.
Saying things people don’t want
to hear can sometimes be the right thing to do and be hugely productive to
ongoing care, but someone needs to say it to find out.
Without nastiness, prejudice or
unprofessional behaviour, there are times and places ambulance professionals
have the almost unique opportunity to risk `burning bridges` on patient’s own
territory. With consent, you can act on your findings or pass them onto someone
else who can help. The patient’s reassurance they are unlikely to ever meet you
again keeps a reassuring exit point to agonising conversation and objective
discussion.
In a year’s time and when the
dust has settled, perhaps they will be thankful you said it.
Matt Green, @MLG1611
February 2017
February 2017
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