Blue lights and sirens; A Paramedic's perspective of caring for older people
Duncan Robertson is a Consultant Paramedic with the North West Ambulance Service. He has an interest in falls and frailty and a research interest in the lived experience of frailty in the 999 population. He tweets @NWAMB_Duncan
If, like me, you spent your formative years watching Saturday night television on the BBC, you may have a particular view of the ambulance service. Through popular dramas and fly on the wall documentaries more people than ever have an insight into the work of the Paramedic. We deal in saving lives; we come to you when you have had a road traffic collision, a stroke or a heart attack, we perform heroic resuscitation, we treat stabbings, shootings, assaults and intoxicated revellers on weekend nights. We use blue lights and sirens, arrive by ambulance, response car, motorcycle, bicycle or helicopter and we must see some sights...or so we are told!
Much of this is true, but represents a skewed view of our everyday. In fact, the types of incidents that capture the public imagination represent about ten percent of our workload. An average shift, if there is such a thing, is perhaps not as adrenaline fuelled but no less remarkable for the care that is provided.
In the last financial year (2015/16), the Trust I work for received 1.15 million 999 calls. We also dealt with approximately 2 million 111 calls (my trust is responsible for running this service too), and nearly 2 million planned journeys through our Patient Transport Service. As a service, we speak to or see a massive number of patients each year; some are having a crisis, others need advice and many are transported every day to appointments that they may otherwise be unable to get to. All on the NHS and all free at the point of contact.
What is becoming clearer is that, like much of the NHS, the patients who need us are getting progressively older, which is a success and should be celebrated as such, but brings a new challenge. Of the 1.15 m 999 calls, there were nearly five hundred thousand patients aged over 65 years old from which the top three reasons for calling 999 were calls by a fellow health care professional, following a fall, or from breathing difficulties.
With increased age, comes complexity, individuality and the need to make different decisions. You see, we don’t just take people to hospital. For our patients aged over 65, up to 35% did not travel to the Emergency Department and there is scope to make this figure higher. In fact, since the 2013 Review into Urgent and Emergency Care we know that as one of the front doors to care, Paramedics are well placed to provide safer care closer to home. We also know that for older patients, hospital can be a dangerous place, so if a different decision can be made closer to the point of crisis, we can be part of a safer system of care that acts to prevent future harm. Therein lies our next professional challenge.
Our paramedics are more educated than they have been at any point in the past, but the motivation for joining the service and the education received is biased towards the types of jobs outlined in the opening paragraph. Rightly, we are expected to have expertise in resuscitation, yet most Paramedics will only see one or two each per year. The majority of the workload is represented by providing care for older people, and our expertise, and expectations, need to shift towards these goals. In short, we need to up our game to provide evidence-based care for older people that takes their needs and wishes into account.
How do we do this? There are pockets of excellence which are well placed to be up-scaled and replicated; but we Paramedics need to be braver and collaborate more. Collaboration should lead to integration with services that provide clinical expertise outside of our traditional scope of practice. Where gaps in the curriculum exist, they should be addressed and education should reflect the expectations for care that our patients have. Opportunities for Paramedics to rotate through placements can build new knowledge such as frailty assessment and delirium screening. Bringing other healthcare professionals into our world so they might understand our challenges can lead to the development of care plans and, importantly, crisis plans. As a 24 hour service, our strength is that we can be there when the system, whether perceived or for real, fails to provide the right care at the right time, but we cannot practice in isolation.
While we look to change systems and become more integrated with other healthcare professionals, we must always have in the middle of our thoughts, our patients. Not only must we think of them we have to hear them, and on a personal level we have to work harder to actually listen. We are their advocates, and with advocacy comes responsibility to provide not only the best care today but better care in the future.