Florian Breitenbach

Rettungsdienst und mehr

“Pre Hospital” versus “Out of Hospital”

Or: are name changes really that important?

The professional body representing paramedics in Australasia,¬†Paramedics Australasia, support a name change from paramedics working in a ‘pre hospital’ environment to an ‘out of hospital’ environment.

Big deal, I hear you. Doesn’t roll off the tongue as nicely, I hear you whinge. Can’t find it referenced anywhere else, I hear you mutter.

Here’s the thing: If we are pre hospital providers, we limit ourselves to going to people that are in the pre hospital stage of illness or disability – you call, we haul. Now, in most western countries the hospital system is chronically congested and overloaded. Pre hospital providers just add to that. Never mind that hospital treatment is the most expensive treatment (Google to find some proof) – pre hospital providers can only convey and treat patients before taking them to hospital.

Enter the out of hospital provider. Out of hospital includes pre hospital Рbut it gives us far more options, but more importantly a clearer, unobstructed view. This patient might not be suitable for the emergency department Рhow about in home treatment? In most cases this translates to happy patient, happy relatives, happy bean counters. A little more  education, backed with a few more guidelines and referral services, this would work out just fine.

Or does work out fine. Emergency Care Practitioners have been around for a while now, tried and tested so to say. Programmes and their implementation are popping up all over the country (especially in the UK, Canada, Australia and New Zealand that I am aware of).

One point that was made in regards to a Paramedic Out of Hospital Practitioner is “makes me think of community nursing – medical emergencies probably require hospitalisation”. Yes, true medical emergencies generally require hospitalisation – but people calling 000/999/911 don’t know what a medical emergency is – patients define their own emergencies (and pt II).

What does that leave us with? Two things, in my eyes:

  1. If patients define their own emergencies, we should give them a single emergency number to contact. Oh, we already have! Brilliant. “But people abuse the system” I hear you mutter under your breath. Well, if the response from a three digit emergency call is going to be an emergency ambulance, yes, that is inappropriate. Inappropriate from an ambulance service point of view. Some calls for help – give them help they need – GP referral, an ECP, a lift off the ground, transport to hospital. They give you details, you give them an adequate response
  2. Community Nursing vs Community Paramedicine. Nursing vs Paramedicine? How about Nursing and Paramedicine. At the last Paramedics Australasia conference, Dr Cindy Hein (from Flinders University, and South Australian Ambulance Service) who explained how South Australia set up their ECP programme. There was a void, and someone needed to fill it. The nursing profession couldn’t or didn’t want to fill it, so the ambulance service stepped in. At the end of the day, we both look after patients. The nursing profession has the advantage of having that long term patient care view, especially good for low acuity patients. Then again, the ambulance service has all the hardware and networks in place – response cars, radio networks, call centres. Plus we can do a quick fix in emergency situations, we just need to adjust to long term patient care. How? Easy, employ nurses alongside paramedics as ECPs, and eventually their experience will rub off in to the team.

Here’s my ideal (possibly already implemented somewhere): 000/999/911 is for all health issues that people need help with. Which it already is, let’s just make it official. From there, trained staff triage and send an adequate response: Poisons info, ECP, BLS, ALS, cement mixer etc. The term “frontline ambulance” is occasionally thrown around…how about “frontline healthcare” instead? Any issues, call us, we’ll sort you out initially, and if required we can refer you to an appropriate long term care provider – be that as an inpatient or outpatient.

It will do our profession a whole heap of good – more treatment and management options, more career opportunities, an additional ‘long term care’ outlook for patient.

And finally a sense of belonging and a firm place in healthcare: on the frontline, no matter what.


JB says:

I like it.

Right up to the point where the 60yo chest pain is waiting on hold to 000 because all the operators are busy consoling other non-emergency callers about their sniffles. Or the structured call-taking process wastes valuable time because it has to be able to deal with telling people what to do if they “found an interesting lump” on their chest just as much as what to do if there’s cardiac pain there.

000 (/112/911/999 depending on your geographical preference) is an EMERGENCY number, and should be used for such situations (yes, I know as much as everyone that it gets abused), and should be set up to get a rapid response (if deemed necessary), rather than bogged down with stuff needed to suit mum when she calls about her kids head lice. Healthdirect, Poisons info centre, etc are good resources and people should be educated about them.

That said, a lot of this is implementation.

A system like Ambulance Vic’s referral service, and better integration of services like healthdirect and poisons info centre would be a great idea. So when our 60yo calls up healthdirect for his chest pain because he “doesn’t want to bother anyone”, let them send the call straight to ambulance dispatch. And when someone calls 000 for head lice, let them put the caller through to one of the “experts” who can dispatch a fact sheet to their email rather than two paramedics and a big white truck.

But don’t encourage people to call 000 for crap.

As far as frontline medicine, I like it. But I signed on to this job to do emergency medicine. I’m honestly not that interested in being dispatched to change someone’s wound dressings at home that need changing every day. I’m glad that it can be done in the community rather than taking up a hospital bed, but I don’t want to be the “out-of-hospital care” guy doing it. When he initially falls off the roof onto the pile of steel offcuts though, I’m your man.

That said, I’m more than happy to be the guy who goes to a patient (assuming it gets this far and hasn’t been caught by the call centre, but I understand the need for cautious triaging over the phone) and says “you don’t need hospital, let’s make a call and see if you can get in to your GP tomorrow”. So if that’s what we’re talking about, I’m all for it.

And all the effort I’m putting into writing this post should really be going into my health ethics assignment…

Anonymous says:

More generally, the recent G5 meeting of international paramedics leaders has suggested that the most appropriate term to use might be to grasp the bullet and explain the variety of work as simply “paramedic services” Simple enough isn’t it – define the work you do in terms of your profession rather than the other way around. Medical practitioners do medical work,
Nurses nurse, dentists do dental work and so on. Paramedics provide paramedic services services within the more general field of paramedicine.

flobach says:

@JB: Fair Point, but you are pointing out staffing issues as well – a whole other kettle of fish. Sniffles need to be triaged too – if Sniffles decides to call, we have to deal with it. Teaching people is again, a different kettle of fish.

I know you signed up for emergency medicine. Wound dressing change is not emergency medicine per se – more and different qualifications needed, nobody says you have to head down that pathway.

@Anonymous: Its all what you are used to. Up to us to make sure the future generation gets used to calling us Paramedics, not Ambulance Drivers.

Interesting times ahead…

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