by Thijs Gras
Yes, it is very tempting, but no, I will not mention IT. Last month we had a German nurse riding along for two weeks. He wanted to orientate himself on Dutch prehospital care and the hospital he was working in gave him the opportunity.
He was a nice, care-dedicated person and it turned out to be a very rich and interesting experience for both parties. Though the problems are the same (a heart attack, stroke or broken hip is the same everywhere), the solutions and given care turned out to be quite different, especially in the battlefield – sorry – I mean the prehospital phase.
Only in a setting like this, differences come clearly to the surface.
In the Netherlands we work with a team of a specialised nurse and a well-trained driver. The two of them can handle most cases. In case of unstable vital signs a second ambulance crew is called in. For severe traumas or child resuscitation one of the four mobile medical teams gives assistance. In Germany ambulances are staffed with lesser-qualified personnel (with a maximum of three-year training), who can do a lot less compared to the Dutch nurses. For assistance a so-called ‘Notarzt’ (emergency doctor) can be called in who comes by car or helicopter. Almost any doctor can become a Notarzt so there is a wide quality- range. He or she is necessary for severe pain cases, difficulty breathing, heart attacks, alterations of consciousness, etc.
One of the things that struck our colleague was that our care is patient-orientated and we look at what is suitable, desirable or necessary under the specific circumstances. We stopped in front of a general practitioner’s house to pick up someone with chest pain. He was surprised to see us go inside with no case or scope and instructed the patient to walk with us to the ambulance. There we made a 12-lead ECG, showing no real problems, gave an IV-access and off we went to a non-intervention hospital: efficient in time and resources. Our German colleague became really uneasy when we went up with no equipment to a woman in labour, third floor, first baby, too long in labour, who had to go to the hospital. She came down by herself with the help of the midwife. We put her on the stretcher and drove her to the hospital. He indicated that in Germany an emergency doctor would have been called and that they would have gone upstairs with practically all their portable equipment (scope, case, birth case, oxygen, respirator, etc). He shook his head: “You were right again, Thijs. This is far more efficient.”
Next case: a woman suffering from pseudo neurological epileptic syndrome. She had another attack, did not react to pain and could not be left home amidst her family. Though not much was to be expected from the hospital (during my conversation with the A&E staff to see what they had done last time, I learned that they only observed her and discharged her when everything was over), we had to bring her there. I decided not to give her an IV, since there was no use for it. Our German colleague indicated that in this case an emergency doctor would have been called, she would probably receive two IV-accesses and because of her alternated consciousness level, she would have been intubated. I consider this useless medical consumption, exposing the woman to unnecessary, even dangerous iatrogenic risks.
Then we were called to an old man who was nursed at home by his loving family. He suffered from lung cancer and there was not much time left for him. The family had called us because of his difficulty breathing and they did not want him to suffer. When we arrived it was soon clear that the best approach for this man was to leave him at home. We gave him a nebulizer and I decided to insert an IV to give him diuretics since he clearly had water in his lungs. Then we learned that next-day euthanasia would be performed by their very involved family doctor. Speaking to her we fine-tuned the treatment and she was glad the IV was all ready for tomorrow. The family was glad we left him at home as was the patient himself, in this case the most important person to please. In Germany he would have been brought to the hospital since they look primarily to the medical problem.
The last experience I would like to share is a call to a carwash where a 35-year-young man suffered from a circulatory arrest. In good cooperation with police and fire service, together with a second ambulance crew, we managed to achieve ROSC after six shocks. The man was too reactive to intubate, but with balloon insufflation we were able to re-oxygenate his brain. In the hospital the doctors could already talk with him. Next day we went by to shake his hand and receive his warm thanks and those of his mother and sister who were in the hospital visiting him. This outcome was quite rare in Germany, also because BLS by bystanders and AED’s are not so common.
t has been a very interesting experience for both sides. Our German colleague was impressed and I was a little proud of what we have achieved over the years. Amidst a lot of criticism you do not always count your blessings. And did I mention IT? I did once, but I think I will get away with it…