Use and abuse of ambulance services

As a GP I was privileged to be allowed join the National Ambulance Service (NAS) earlier this year as part of the plan to manage the current Covid-19 pandemic. Doctors were asked to become involved in the triage of non-serious and non-life-threatening conditions and minor illness or injury calls at the NAS.

It appears that there is a huge variation countrywide in GP involvement in the pre-hospital care of those with non-serious, non-life-threatening and minor illness or injury – also known as alpha and omega calls.

When I started working at the NAS, one aspect that surprised me was the nature of low-acuity calls. These included calling an ambulance to help an overweight person off the floor and an elderly lady in a self-contained unit within a nursing home (who had specifically said that she did not want to go to hospital) looking for help to get off the floor.

How the ambulance has adapted to increasing demands on the emergency services is impressive. There have been several innovative recent additions to ambulance crews. These have been outlined in articles in previous issues of Forum and include community paramedics, advanced paramedics in a rapid response vehicle and a medical registrar from an emergency department.

My real-life experience of a doctor with the NAS was varied. I started my shift at 4pm on a Wednesday.

A child with abdominal pain

The first alpha call concerned a 10-year-old boy who had developed abdominal pain. He had developed this two days earlier, having had diarrhoea the previous day. His dad phoned his GP on for an appointment. He was offered one two days later. Dad was a bit worried so he decided to phone for an ambulance.

It should be borne in mind that the estimated cost of an ambulance journey is €1,500, plus the expense the hospital would incur, which is estimated to be another €3,000. The call-taker at the ambulance centre took the call and advised Dad that a doctor would ring him back. I rang Dad and advised him that the ambulance was not immediately available in his area. I got the history of the abdominal pain and suggested that I would telephone his GP. He gave me the number. I got to speak to the receptionist and I told her that the child’s father had requested an ambulance for his son with abdominal pain. It was now 4.30pm and I asked if I could speak with one of the GPs, but she told me they were all busy.

The receptionist suggested that the patient contact the local on-call service. This service started at 6pm. I suggested to the receptionist that perhaps she ring them directly as the practice would be more familiar with the service.

She suggested that she would discuss the case with one of the doctors in the practice who would be in contact with the child’s father.

I waited until 5pm to ring the father back. When I spoke to him he told me his GP’s receptionist had phoned him and offered an appointment for his child the following day.

Finger injury in an 11-year-old girl

The next omega call was from the parents of an 11-year-old girl who had fallen off a gate and cut her finger. It was bleeding profusely. I got some brief information from the call-taker. 

When I phoned, the father answered. Dad told me that the child was not as upset now but that the cut was probably the length of half her finger. It obviously needed suturing. It was now 4.30pm on a Friday evening and I knew from my experience of working at the ambulance service to date that I would find it difficult to get her GP by telephone. I advised Dad that there was no ambulance immediately available in their area.

The father then volunteered to bring his daughter to the local hospital, which is probably only a 10-15 minute drive away from them. I suspect that if a GP was available, they may well have been able to suture and ‘glue’ the skin, which would have saved hospital resources.

Knee problem in a 74-year-old woman

Next up was a 74-year-old woman who had a knee problem and had phoned the ambulance. I spoke initially to her husband and then to the patient herself.

She gave a classic history of a twisting of the knee as she stood up. She was getting a friend a cup of tea and walking across the floor when “the knee seemed to give way”. She said that there was no direct trauma to the knee and I assessed that she had no bony injury and that a standard visit to an emergency department would suffice. 

I suggested that the local private hospital might be appropriate and she was delighted with the suggestion. I rang the hospital and the nurse manager answered the phone in the emergency department. I gave him the history and he said that it would not be possible to do an MRI scan at this time of the evening – 4.45pm.

The nurse suggested that the patient could attend the emergency department in the morning. She was happy with that plan. I advised them that if anything changed over the next few hours to ring us back and we could bring her to hospital.

Yet again, no ambulance was needed. Did they need GP advice? Could this work be done by GPs in their own practice rather than GPs in the NAS? 

In two of the cases I dealt with, as outlined above, the patients did not contact their own GP, but instead called immediately for an ambulance. In the third case, the patient’s father had eventually contacted the family’s GP about the abdominal pain.

Is the ambulance the default method of hospital transport for ill people?

This question struck me as I took another call recently. I received a request for an ambulance for a young woman who complained of anorexia and dizziness. Her GP was still at the scene. On contacting the GP directly by phone, I asked if the patient or her parents could self-transport. The GP on the scene asked the parents, and they agreed to do so. I wondered why the patient was not asked to self-transport before an emergency ambulance was ordered.

Exploring this hypothesis further, the doctors who work in the Tallaght NAS reviewed low acuity calls received in May 2020. They found that of the 1,099 calls they triaged, only 27% (294 callers) had contacted their GP or out-of-hours service. Of those who contacted their GP, 71 (6.5%) had been examined by the GP.

In order to rule out the Covid-19 influence, we repeated this review in June. Doctors at the NAS triaged 962 calls in June who had non-serious, non-life-threatening, minor illnesses or injury. Interestingly enough, only 5.9% of patients had seen their GP prior to requesting an ambulance. 

Conclusion

Our initial results show that the ambulance is often the default point of contact when an emergency of varying seriousness takes place. We noted this initially during the Covid-19 outbreak but even more so when the first surge of Covid-19 had passed. 

We believe that a campaign to advise the public about the proper use of the emergency ambulance service is needed so that the ambulances can be available to those with life threatening illness in a timely manner.

We should encourage patients:

• Where it is safe to do so, to make their own way to hospital
• Not to use the ambulance as a method of ‘skipping the queue’ in the emergency department – patients will be triaged anyway and returned to the waiting room if it is deemed appropriate
• Discourage patients from using the ambulance as a ‘taxi service’
• Have a care plan for all nursing home patients, which includes patients who wish to be transferred to an acute hospital in the event of an illness, eg. pneumonia. 

Special thanks to Dr Leanne Hanrahan, Aoife Canavan and James McEvilly for their input.