News reports are full of ambulances queuing outside hospitals, full of patients with nowhere to put them.
I wish I could say this is the exception; propaganda, fake news – alas, this is the new normal.
Whatever the local press tells us, this is not a local issue but a national one.
Every emergency department and ambulance trust in the UK will be experiencing significant delays in handing over patients at hospital and will have full ED waiting rooms.
So, what is the problem? Is it the GPs’ fault for ‘not seeing patients?’ Is it stupid people who don’t need A&E clogging up the triage system?
Is it 111 and its computerised triage system sending everyone an ambulance? Is it the lazy nurses and doctors who seem to be laughing and joking, on their ‘phones, instead of seeing patients?
Is it the ambulance crews just taking everyone to a hospital? Is it the Government and its poor management of the NHS?
The truth is far more complex than that, and depending upon whom you ask, there are myriad reasons for the status quo.
GPs ARE seeing patients and have been through the pandemic.
There are not enough of them, and GP practices are being given ridiculous targets to meet with limited resources.
They are being penalised for missing deadlines or treatment bundles that a bureaucrat has deemed vital in primary care; invariably, someone who doesn’t work in the system and has no real idea of what they ask.
There is a considerable retention crisis in GP land, exacerbated by the awful treatment of doctors in training, who have it harder than generations before them.
Who would have expected doctors to use food banks as they cannot afford to eat and train?
As for people clogging up A&E, it is fair to say that the sorts of people who would attend when they could self-manage or find a minor injuries unit/pharmacy, etc. are always going to do this.
The difference now, in my opinion, is a lack of patience with GP telephone lines.
Many pre-hospital patients say ringing a surgery is a ‘waste of time’ and ‘you can’t get through.’
The reality is that it is not a waste of time, and people can eventually get through; they simply lack the resilience to keep trying.
If ambulance crews do not have ‘back door’ numbers for surgeries, they too must call in the same way as the general public.
We manage to get through – every time.
Why have we as a species become so fixated on the immediacy of action? People seem steadfastly resistant to waiting these days.
111. Wow! Where to start?
Frontline ambulance has no love for the 111 system. It is essentially a computer algorithm operated by non-clinical staff.
If a person says they have pain in their chest because they were hit with a cricket ball or they have been coughing/vomiting too hard, anecdotally, it is the commonly accepted belief that the computer will determine an MI (heart attack) and dispatch a Category 2 ambulance (potentially seriously unwell patient groups).
The patient may have only wanted to speak to a doctor or pharmacist for a prescription but was sent an ambulance.
Incidentally, people can refuse an ambulance but sometimes a clinician will decide that a crew needs ‘eyes on’ a patient for a welfare check.
If a parent declines an ambulance for a child, it has been known that threats have been made to put a safeguarding referral into social services to protect the child from perceived harm when all the parent wants to do is seek medication or advice.
Whilst 111 does not necessarily account for more patients at hospital, it does remove the capacity for ambulances to be available, thus removing the ability to cohort patients being held by crews who have not had a meal break or who are running beyond their 12hr shift time.
Inside ED, staff of all grades are working flat out to triage, test and treat a range of patients promptly.
They also need to refer patients to specialities such as orthopaedics or gastroenterology.
These things take time: the receiving speciality does not have an empty ward with clinicians just waiting to hear from ED so they can jump on the next job – they are also overwhelmed, with little or no bed capacity for new patients.
Sending people home, whether from ED or a ward, seems more complicated than diagnosing the patient’s problem.
There is such a lack of social care provision that it is often unsafe or unethical to send a patient home at any given time.
Strangely, I have also witnessed firsthand – patients (who typically live alone) refusing to leave ED because it’s 3 a.m and they want to wait for a lift from family at a more reasonable hour.
I don’t recall the A&E signage resembling AirBnB.
As for staff on phones or sitting at computers, documentation comes in many forms and on many platforms.
In the pre-hospital environment, I am often on my phone as it has various medical apps, calculators, aide-memoirs, etc.
All are useful in diagnosing and treating patients.
Laughing and joking get us through tiring or dark times and should be a firm fixture in the workplace.
Sadly, I agree that (hopefully a minority of) ambulance crews take people to hospital when they could safely be left at home with a modicum of clinical acumen and gumption.
We have access to advanced paramedics, advanced clinical practitioners, doctors and other specialists – if we try hard enough – to support us in our decision-making.
We are unique in that clinicians outside the pre-hospital environment are not generally permitted the degree of autonomy afforded to Paramedics to discharge patients at home or in public.
Some staff are intimidated by some demands of ambulance trusts, perhaps poorly translated by managers, and fall into the trap of, ‘You can’t be sacked for taking them to hospital.’
I find this mentality difficult to understand and almost impossible to tolerate; if we are working in the patient’s best interests, then this must be an intelligent conveyance rather than covering one’s arse.
Yes, the Government(s) bear responsibility for underfunding and mismanaging the NHS but I am not sure where to start with that can of worms, so I shall – in a rather cowardly fashion – leave the lid firmly closed on that one.
What is the impact of these delays?
In short: fed up patients and relatives. Fed up crews. Fed up hospital staff.
A little deeper than that, there is actual harm to be done.
In my experience, I have waited between 15 minutes and 6.5hrs in an ambulance with patients before being allowed entry into A&E.
Colleagues have been as long as 10hrs or more.
What is particularly disturbing is that, recently, a crew took a patient to hospital and waited for over 6hrs.
They were then released by a later crew who took their patient to a different ambulance.
When the original crew returned for shift the next day, they cohorted the same patient from the crew they had left her with the day before.
The patient had yet to enter the emergency department.
Although a rare event, it should be (but clearly is not) a never event.
This ‘new normal’ as I keep hearing things referred to as is such that our mandatory clinical updates now include input on pressure sores and crush syndromes from long lies.
All from being on an ambulance stretcher for so long, trying to access ED.
This is supposed to be for hospital staff and domestic carers dealing with bed-bound patients and not for pre-hospital emergency patients.
Rhabdomyolysis was a reasonably little-known condition among your average ambulance community until a few years ago.
Thanks to hospital delays and delays in ambulances getting to patients in the first place, it is becoming widely known and more understood.
The link below focuses on exercise-induced rhabdo but shows the same issues people suffer from lying in one position for too long. contribution/edge-rhabdomyolysis-signs-symptoms-and-management (credit: blog – EMS World, March 2022, ISSN 51, index 3).
I recently had a patient who was on board for over 3hrs during the early morning hours, and although we ensured she changed position and visited the lavatory, she had declined food and drink.
She had chest pain, and we had enough suspicion of a cardiac event, so we monitored her continually.
As time progressed, her ECG began to show early signs of hyperkalaemia – high potassium.
Untreated, it is potentially life-threatening. We weren’t anywhere near that level, but it was enough to raise an eyebrow and inform the triage nurse.
Various disorders can cause hyperK, but some things can simply exacerbate or encourage it: reduced fluid output, rhabdomyolysis, etc.
For the nerdy types out there, look up the sodium/potassium pump.
Here is a video to start you off:
https://youtu.be/v7Q9BrNfIpQ (credit: Alila Medical Media).
As for the patients’ welfare, imagine having a broken hip and waiting hours on end for a bed.
Imagine a mental health crisis where you are trapped in a small box for hours, unable to access the professionals who can guide you through your problem.
The delay problem is worsened by the fact that patients who are more poorly will inevitably jump the queue, making others wait even longer.
In terms of triage, this is absolutely correct, but it does nothing to sate the desire of the waiting patient for space indoors.
With ambulances stuck at hospital, crews are going to jobs in the community several hours old, with elderly patients still on the floor 11hrs after falling.
This is where serious damage can occur.
Wounds can only be adequately closed within specific timeframes and bones can degrade at the site of injury if not splinted/supported early.
Rhabdomyolysis rears its head – and everybody is different so it will affect different bodies and organ structures more aggressively in some than others.
People on anticoagulants can be bleeding internally for longer before help arrives, increasing the risks of strokes, seizures and other problems.
New evidence is beginning to emerge concerning waits at hospital, and I shall be interested to see what comes out of studying wait times at home and in the community.
That’s some scary reading!
We’re probably at the right point to discuss morale.
Hmm… pretty low.
If we can filter out local politics/management in the workplace, idiosyncrasies of one’s employer/trust, and the situation in Westminster at any given time – we can look at how delays affect the individual clinician, regardless of grade.
We drive a long way in the Shires.
On a bad shift, we can do 350 miles in addition to treating patients.
My colleagues in urban areas do fewer miles but see more patients so they have different pressures but no less concerning.
On a recent night shift, we picked up a CAT2 chest pain (possibly serious). A blue light drive.
We were at Gloucester Royal Hospital and we were being sent to the [actual] top of the Long Mynd in Shropshire.
Look it up on Google Maps (other mapping apps are available).
We made it within 100 metres of the property before being diverted to a CAT1 in a local town, where a man was suffering the effects of too many Benzos.
I did point out that we were effectively on top of a mountain, on a mountain track (no tarmac under this bus!), and would be no use for a CAT1 (immediate risk to life) response.
Our control desk informed us that we were the only crew available.
I’m sure by now you can guess where those other pesky ambos were hiding… If it weren’t so serious, it would be funny.
On top of the distances we cover due to poor resourcing, we are now sitting outside hospital for hours.
Ambulances are designed for transport and not comfort.
They are physically horrible to be in for hours on end.
We have risks of musculoskeletal degradation and we cannot ignore the potential for DVT, much like long-haul flights.
We must ensure we move and stretch to look after ourselves – all whilst attending to patients; not all of whom are kind enough to sleep peacefully throughout.
Some can be very demanding and difficult to manage.
Once we eventually enter the department and offload our patients, we are exhausted.
Now we must drive back to the station or off to the next job.
This can be around 90 minutes away as the norm. Is it safe that we drive under such conditions?
Not if you read your Highway Code or our blue light training manuals.
Add to this the statistical likelihood of accidents between 00:00 and 06:00 being higher, we are not in a good place.
Meal breaks are an issue, too.
In my division, we have 30 minutes unpaid in a 12hr shift.
Breaks take place at the station where you begin your shift. The break window opens after four hours and closes after eight hours.
After eight hours, we are paid £10 compensation for a late break. On my last day shift, we started straight away at 06:30, drove an hour (outside of our area) to the patient and took him to (the out of area) hospital.
We waited over three hours with him and then handed him to ambulance crews cohorting indoors (not hospital staff).
We tried to go back to the station but were diverted to another poorly patient who needed to go back to the same hospital we had left.
It was a 40+minute drive to the hospital, where we waited nearly three hours.
We were well outside our break window now.
With 19 ambulances queuing, a friend and colleague from the area offered to cohort our patient, and we gladly accepted.
After the handover, we returned to the station – over an hour away – finishing late without having had a meal break. We were exhausted.
University students come out on the road for practice placement.
They, and we, are experiencing skill fade as we attend fewer jobs due to queuing at hospital.
Some students in hubs with culprit hospitals nearby, who have the longest queues, may only see one patient in a 12hr shift.
Were this the exception, we would not mind. It is now the norm.
It comes to something when we shrug and say, ‘We were only an hour late off shift, so not too bad.’
We are being slowly conditioned to accept this, and it is the acquiescence of staff that I believe the Prime Minister and others are relying on so that they can avoid doing something tangible to assist the NHS.
Many staff are leaving to go to primary care – with office hours, little driving, and no hospital queues.
It’s not just those who’ve been in for years.
I was once a teacher, and retention of newly-qualified teachers was/is a national issue.
We are now seeing this with student/newly qualified Paramedics.
This situation is unsustainable.
Many of us are window-shopping: primary care; university lecturing posts; critical care; in-hospital posts; private healthcare… Is the grass greener on the other side?
I don’t know, but it can’t be any worse than the dystopian wasteland we see on this side every shift.
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