I am calling for a reconsideration of safety-nets.
I am not planning
On a change of career
To tight-rope walker
Not my thing
(Although, being a doctor or nurse is daily walking a tightrope, especially during these times of austerity when we are encouraged to do more with less.)
Safety-nets are core to the life of doctors, nurses, therapists, and paramedics working outside of hospital. Less so for those on wards.
When you are a doctor on a ward-round, you don’t tell every patient, ‘If you are feeling unwell again, call me.’ As, there is an assumption, if you are well, especially in 2022, you won’t be in hospital, and second, if you are unwell and become more unwell, don’t consider calling the doctor – that is the nurse’s role. The nurse can call the doctor, not the patient; that is the hierarchy in a hospital, no matter how flawed or flattened. And, finally, the assumption, if you become more unwell, we, the hospital staff, that is, the nurses and nurse support workers, will detect your deterioration. You don’t have to do anything, as our measurements, our hourly pulse, blood pressure and other checks will detect any concerns. You, the patient, can lie-back, become passive; if old, allow the hospitalisation/institutionalisation/deconditioning to do its thing. (Heck, in hospital, as part of your shift to passivity, we will bring your food and drink, we will wash, dress, feed, and toilet you, all for free.)
Outside of hospital, in the community, which is, Primary Care – your GP as well as all the interconnected services that maintain health and wellbeing beyond the hospital walls, district nurses, specialist nursing and therapy teams who visit you at home, in your own bed when you can’t leave the house, have a different agenda.
First, I guess, because you are ‘at home’ there is an assumption, that no matter your level of disability, there is some ab-ility, some things you can do for yourself, and there is the matter of autonomy. As you are not a hospital patient, you, yourself retain some responsibility for doing what the doctor or nurse says or asks, such as, ‘call me if the pain returns.’ This, indeed, otherwise called a safety net, is how care outside hospital operates. It is useful for those occasions when a doctor hasn’t a clue what is wrong, ‘I am sure it is nothing serious, call me if it gets any worse or doesn’t go away,’ or, if the patient plan is uncertain, ‘Take these antibiotics, if you don’t see an improvement in 24 hours, call me.’ Kind of thing. (Acknowledging the difficulty inherent in ‘getting through’ to some doctors in 2022.)*
At another level there are the first or emergency responders, or those from secondary (specialist care) who might see you in your home. Like me. Although, I don’t want to give myself as an example as I am not an extensive safety-netter.
Imagine you are old, you fall, bang your head.
An ambulance is called.
The paramedic checks you over, no obvious damage, no bleeding, loss of consciousness, weakness down one side.
‘You seem OK, if you start vomiting, your headache gets worse or doesn’t go away, you become confused (etc), call 999.’
This is the safety-catchphrase.
For staff visiting care home residents, ‘If Nora becomes more unwell, ring 999.’
This is the problem.
For a variety of reasons. Principally it conveys a lack of confidence to the patient and/or their carer, as in, ‘I think this is the problem, although, I might be wrong, in which case, call someone else.’ It is a form of delegation of responsibility, such as, ‘If things deteriorate, it’s not my fault, it’s yours, call an ambulance if you are worried.’
And, it is a hand-over to discontinuity.
This is a reference to continuity of care.
This is the essence of primary care.
The relationship developed between a patient and their primary care doctor or nurse over time.
The same man or woman who knew you when you were a child, who is supporting you with your parent’s decline.
The doctor who knows where you live, who knows your family, your story.
The knowledge inherent in this continuity, remembering, for example, that you don’t like needles or work nights and need an early appointment or don’t always answer the phone on the first call, are elements of personhood, the acknowledgement of the complexity of another, that is as important as knowing the guideline for management of condition x or y.
This continuity is an infinity that relates to human connections and relationships that cannot be replicated by the episodic nature of emergency responders.
When you are ropey, calling 999 will get you a response that sees you as a citizen, a human with a unique anatomy and physiology, yet with parameters that are measured against the average:
‘Your blood pressure is 85/50, we need to take you to hospital.’
It is protocol and algorithm.
It doesn’t know that your blood pressure is always low and even when you say, ‘My blood pressure is always low,’ you aren’t believed or trusted (what do patients know?!), the paramedic finds another reason to follow the protocol, ‘Yes, that may be the case, however you have just fallen, we should get you checked-out,’ and so it goes.
So, it goes with a transfer to hospital, the waiting, the doctor, or nurse who says, ‘85/50, we had better take some blood and give you a drip; hold-on whilst we arrange an x-ray, ECG and scan of your heart. Sorry, you said your blood pressure is always low. Let’s see, shall we.’
Continuity of care versus emergency response.
They are difficult to reconcile.
And this is what is relinquished with the safety-net.
The safety-net functions 24/7 – that is its magic. If at three in the morning you experience further chest pain or breathlessness and don’t call an ambulance, that is on you, the doctor you saw earlier is absolved. Without that catchphrase, you can blame someone else, although, if the chest pain heralds a cardiac arrest and you die, no one will know.
It is tricky.
What I am asking is that people think when they safety-net.
They consider the implications.
Of the message conveyed.
Most patients want their clinician to have a degree of confidence (not cockiness or arrogance).
Part of the therapeutic interaction is reassurance, is taking the burden of worry from the patient and placing it on your shoulders.
And this, is how it should be.
If you don’t agree, or even if you do, if you are in doubt, call an ambulance. I am sure the crew will be pleased to see you.
Take care readers.
Wish me well with my three-degree swim.
*Yes, the Tory government over the past 12 years has supported the progressive destruction of the NHS/Primary Care, selling large chunks to the private sector, avoiding the relevance of continuity of care (imagine, an effective, efficient health service (like we had) isn’t a great money-spinner, one that lacks efficiency, that arranges tests, investigations and treatments that are not necessary, is a fantastic way to boost your income or profit) – see USA healthcare (or think of your vet).