Posted by: medicblog999 | February 27, 2010

Do you treat or do you care?

caring

Do you treat your patients or do you care for them?

Have a little think for a moment then read on and see if you still think the same way by the end of the post.

Here’s a little bit of a back story as to what got me thinking about it….

I was working with a new member of staff a little while ago. We were sent to an elderly male who had fallen outside of a bar after he had been spending the evening with some of his friends. He was intoxicated but not drunk as such, and he was my favourite type of drunk….The happy singing drunk.

Anyway, he had a small laceration to the back of his head which had stopped bleeding and probably only needed a little bit of glue to close it up. He also had a small haematoma surrounding the wound. There was no known loss of consciousness, although there was no witness to the fall. He had no neck or back pain and appeared alert and orientated. All of his primary observations were well within normal limits.

It all pointed to a simple mechanical fall after tripping on a lose pavement stone resulting in a minor head injury.

With these sorts of cases it is up to me to decide if it is suitable for my colleague, an ECSW (Emergency Care Support Worker) to go in the back with the patient to the hospital. When this happens and an ECSW ‘observes’ the patient on the way to the hospital, I am still totally responsible, clinically for the patient, even though I am in the front and driving the vehicle.

[An ECSW is trained to be able to assist the paramedic in his/her interventions and care. They can complete all clinical measurements that the paramedic can, and they have a basic understanding of A+P and various clinical and trauma conditions. They are trained to ‘observe’ suitable patients in the back of the ambulance on the way to A&E after the paramedic has completed a full assessment – Maybe this is the same sort of thing as an EMT-B?}

It goes without saying, that there has to be an element of trust between the paramedic and the ECSW for this to work. As the senior clinician, I need to know that if there is any  change in the condition of the patient, then the ECSW in the back will inform me immediately so that I can decide whether I need to swap into the back and take over care of the patient.

But, there always has to be a first time to start to develop the trust, and this was that moment.

Once I had completed my assessment and decided that the patient was suitable for an ECSW to care for them en route to A&E, we set off up to the hospital.

On the way, I kept looking into the rear view mirror so I could see the patient and my colleague. It was all very quiet back there. I could hear no chit chat and no questioning for demographic and personal details. As I looked back, I could see the patient asleep in the chair.

I started to get a little nervous…

“Julie……Can you please check that Bobby is just sleeping and not actually suffering from a decreased level of consciousness?”

A quick shout over to him saw him wake up and acknowledge Julie, he then stated that he was just tired and then shuffled in his seat and closed his eyes again.

“He is okay, just a bit tired!”

I decided to keep driving but keep a very close eye on the rear view mirror. I know that the chances of anything bad happening to Bobby were very small, but I just wasn’t happy.

A few minutes later, I still don’t hear any conversation, so I look back and see Julie, writing on the patient report form, but not looking up and checking on Bobby.

Something is nagging away at me so I pull over and ask Julie to finish the drive to hospital. I get the expected dirty look, but now is not the time to discuss why I have pulled her out of the back.

The rest of the journey goes without a hitch. I engage Bobby in a conversation about his time in the Air force in the 1950s (always good for checking someone’s level of consciousness) and I hand him over to the hospital team where he gets cleaned up and sent off home in a taxi with a head injury card.

All well and good, yes?

No, not really, and here is my point.

In these days of ‘respond not convey’. If you are taking a patient to hospital, it is because you have a legitimate concern about them. If there was absolutely nothing wrong with them, then they wouldn’t be going to hospital would they?

Therefore, if you have a patient in the back of the ambulance, they need constant re-assessment. They are in your care and they are your responsibility. You don’t have to take constant blood pressures and ECGs for the vast majority of patients. It doesn’t mean that you have to be actively assessing them throughout the journey, but it does mean that you at least need to engage in some form of regular conversation or interaction with them.

‘Treating’ your patient is performing the interventions that are required by your protocols and guidelines in specific response to a clinical presentation. ‘Caring’ for your patients is to provide much more than an intervention. It is to show concern, empathy, understanding, and interest in them and their lives.

If you care for your patient then in return they feel cared for. They feel as though you actually want to be there and you want to be looking after them. They don’t feel as though they are troubling you and they open up far more than what they would if you are just treating them.

Virtually anyone can treat a patient…Give someone a list of signs and symptoms, then give them the interventions that are required to treat those signs and symptoms and the vast majority of people could do that adequately.

You can’t teach someone to be truly caring, it has to come from within, and if you find yourself in any of the health professions, I would assume that you are one of those people.

However, there are some of us out there who are not carers, and sometimes it is blatantly obvious to see.

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Responses

  1. Well Triple 9, after reading your post and what it means to care vs treat. I can say honestly that I care for my patients. A very common scenario with a hard hitting point. A ECSW does sound very similar to a EMTB. One difference is that the EMTB is usually the driver.

  2. Mark, I'm not going to lie to you there are times where I fall into the category of “treat”. I think you were to take an anonymous poll of all EMS providers you'd find (at least in the US) that we've all been there. No matter how well intentioned I may be there are circumstances where I'll treat them but the empathy and compassion kind of flew out the window. I'll give you a scenario that's all too common (at least round here): we get called out by the local PD for a “psych eval” on a local roadway (usually around bar closing time). When we get there, the patient has no injury, no medical history, no allergies/meds (you get the picture)…but they sure have a strong scent of alcohol on them and is being more than a little abusive. They admit to “two beers” (never more never less) and the PD pulled them over, noticed the “signs and wanted them evaluated”. Translation: PD doesn't want all the hassle of taking this person in, booking them, having them create a fuss in their nice holding cell and all that stuff. So they call us and the “patient” (or client) knows the game and says “I need to go to rehab, I need help” (translation “this way I won't get arrested). Those my friend, those get “treated” but “care” not so much. Oh they get reassessed, the get evaluated, the fight the BP cuff, the blood glucose measurement and all that good stuff. They do ask standard questions though: “how much will this cost, will you tell my mother/wife/sibling/boss, when do you think I'll get out of the ER etc.” Sorry man but the compassion is REALLY REALLY hard to find for those. Of course you have some options I don't. You can tell them to, politely and professionally, to pound sand.

  3. Talking to your patient and finding out about them is one of the best parts of the job! Chatting, showing a genuine interest in what they have to say ( war vets are my fave) and establishing a rapport is part of the job. I'm not saying I do that with every patient. I don't. Especially if they are abusive towards my crewmate and I or if you've tried your best and you get one syllable answers – these patients get the treatment not the extras or caring as you call it.I have often cringed with embarassment at the silence in the back of the amb as I'm driving to hospital. Caring is part of patient treatment. It's just that some are more caring than others. For me? One of the best bits about the job we do… SLM

  4. As a CFR I don't get to ride with the patient very often, unless I'm spending a shift on an ambulance as an observer. However, being quite voluble by nature (my Mrs says I never stop talking!) I talk to my patient before the ambulance crew arrives, provided I have done all the things that need doing quickly. “Unconscious” patients can often hear you.I will also talk to the rellies/carers once the ambulance has gone, if they seem to need it. Recently I've been to a 99-yo patient in a residential home who had DIB and “turning blue”. I treated for the SpO2 of 73-82% (poor perfusion was probably the reason for the variability). The crew, who were just behind me, did an ECG and diagnosed an MI. Shortly afterwards they left with the patient and her daughter.I went back to collect my kit and one of the carers in the home asked me what were the patient's chances. This is about the first time I've ever been glad not to have higher level training. I could honestly say “I dunno”. The patient was old and had an MI. However, she was generally pretty healthy (only one medication) and was bearing up well.It was obvious, though, that the staff thought a lot of our patient. I spent 15 minutes with them talking about the patient and their role. They cared; it's only right that I had a bit of care for them too – and I didn't have to rush off.

  5. Great post as usual, sir. Your post really strikes a chord with me because I, like most people in our blogosphere community, care for my patients greatly. I'm glad that someone acknowledges the difference.

  6. Funny story on caring. I had just gotten my patient into the back of the ambulance, gotten him assessed and given my report to the hospital that we were incoming. After gleaning his history and determining my patient was very stable, I paused to fill in some of my report as the back of my glove was getting full and I had completely spaced on the notepad I had in my pocket. Now let me pause here. Normally when I ride, there is more than me in the back of the ambulance, giving care and treatment, which typically does let me write the essential parts of my report down, this time it was just me. Maybe a minute into this adventure, the absolute silence in the ambulance struck me and I immediately felt guilty. Needless to say, I promptly got back to talking to my patient, even learning a few things about diabetes drugs in the process!

  7. Drunk + unwitnessed head injury will automatically buy you a board and collar anywhere I've been. And possibly a trip to the trauma center, and depending who the triage nurse is, a trauma room. Even in jurisdictions of the US that allow EMS to choose NOT to spineboard someone, ETOH onboard removes that option. I'm sure he was fine. Its just that even in the more progressive areas of the US, he still doesn't meet “walk to the truck and sit in the seat” criteria. (And I'm *positive* that there's places out there, somewhere, that would've flown him.)

  8. I think you did a good job when you pulled the ECSW from the back with the patient. You gave her a shot and she didn't pass that test. She could of been talking to the patient and keeping him alert. I am trained to treat every patient as if it was my mother, father, brother, son, or any of my family members. I think of my patient as a family member and treat them like i would one of my family members. And i wish more Paramedics was like that because i would be ticked off if i knew one of my family members wasn't treated with the proper care from the paramedics that don't care. I wish sometimes they had video camera's in the back of the ambulances to see how some patients get treated. I bet we would be shocked by some of the things we would see… No matter what type of call it is, whether or not the patient needed to dial 911 they did and we respond to do our job. And i do mine 110%. I just started reading your blogs today, they are very good and i'm going to start reading them more often, keep them coming!!

  9. I think you did a good job when you pulled the ECSW from the back with the patient. You gave her a shot and she didn't pass that test. She could of been talking to the patient and keeping him alert. I am trained to treat every patient as if it was my mother, father, brother, son, or any of my family members. I think of my patient as a family member and treat them like i would one of my family members. And i wish more Paramedics was like that because i would be ticked off if i knew one of my family members wasn't treated with the proper care from the paramedics that don't care. I wish sometimes they had video camera's in the back of the ambulances to see how some patients get treated. I bet we would be shocked by some of the things we would see… No matter what type of call it is, whether or not the patient needed to dial 911 they did and we respond to do our job. And i do mine 110%. I just started reading your blogs today, they are very good and i'm going to start reading them more often, keep them coming!!


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