Tom Cheke is this year's winner of the Carol Furber Award for his reflectice account of a Category C, 30 minute diabetic problem.
The prime purpose of the award is to encourage members of the College of Paramedics to make case study presentations. This will promote reflection on professional practice and enable the results and experience to be presented to the wider profession and other health care practitioners. Case studies of a high standard may also raise research questions.
Using communication to generate new pathways
This reflective account will be structured using Gibbs’ (1988) model of reflection. Pseudonyms will be used to maintain patient and employee confidentiality (HCPC, 2007).
Description
I was working as a student with a paramedic (P1) and an emergency care support worker (E1) on an ambulance. We were sent to a Category C, 30 minute diabetic problem. On arrival we were met by ‘June’, a patient with dementia being cared for in a nursing home. June suffered from dementia and was a type 1 diabetic, managing with insulin injections three times daily. Today June had a blood glucose reading of 24.2 mmol/L and nurses were concerned; they had spoken with June's GP who wanted her taken to A&E for management. It came to light that June had only been discharged from a two night stay in hospital in the early hours of the morning, for complications with her diabetes. She had had her insulin regime changed and there seemed to be some confusion from the nursing staff as to what the new regime was.
After assessing the patient, P1 suggested we try and speak to the diabetes clinic at the local hospital to discuss the most relevant care pathway for June, and whether we could avoid another hospital admission. On speaking with the diabetic on-call doctor we managed to clarify the regime and the doctor suggested an intermediate plan for today to restore her blood glucose level within the nursing home environment. The doctor was happy that any ketones could be managed under the intermediate regime, as her blood results from the previous day looked favourable. The doctor was happy for the nursing home staff to liaise with the hospital throughout the day to manage June's condition and provided a direct dial number for the clinic.
The nursing home staff were happy to deal with the intermediate regime and P1 spoke with June's GP to inform him of the plan of action; he agreed and said he would arrange for a visit within the next two days to discuss with the home and clinic the management plan for June.
Feelings
I believe this was a really well managed job that was purely about good communication between the professionals involved in June's care. This allowed her to be treated in the community in an environment that she was comfortable in, and avoiding an unnecessary hospital admission. This job demonstrated to me that if you act in a professional manner and intelligently question other healthcare professionals, a referral pathway specific for June and her current condition could be established.
Analysis
The key to this whole exchange was P1’s excellent communication skills across a multitude of different levels. Initially he used a mix of professional clinical language with the nursing staff and simple terminology with June due to her dementia. Ellis (2003) talks of the different paralinguistic features of vocabulary and P1 was able to change not only the terminology he was using but the different features of how he spoke the words, alternating correctly between different communication receiver groups. Blaber (2008) explains that ambulance clinicians are required to use professionallevel vocabulary with colleagues, yet be able to translate that to meet the needs of the patient and relatives. This is a key component of a paramedic's skillset.
Another key aspect of communication, the non-verbal features, were apparent during P1’s face-to-face interaction with June and the nursing home staff; he maintained eye contact with the subject of his conversation as well as maintaining an open and approachable posture. Ellis (2003) goes on to state that in a similar way to paralinguistic features, non-verbal communication can replace, supplement or contradict the meaning of the verbal message. Whilst these features may not be apparent when making telephone calls to other healthcare professionals, they are intrinsically linked at some level (Bledsoe et al, 2007).
It is these key competent communication skills that facilitated the care pathway for June. P1’s open and approachable style combined with the technical professional knowledge, encouraged other healthcare professionals to trust in his management plan for June.
Evaluation
This job was well handled by the crew, who recognised the ability to liaise directly with an established specialist care team. It was a niche referral pathway that did rely on several other factors, like the recent discharge. However, because of the open and honest communication between members of the MDT, an A&E admission could be avoided, allowing for community-based care to be instigated. This was an appropriate pathway for this patient and key at a time when A&E is under pressure from unnecessary usage. Constructing individual care plans and alternate pathways for patients is likely to be a key element of future paramedic practice with the increasing demands upon the urgent and emergency healthcare.
Conclusions
This job was a great example of how thinking outside of the box and utilising effective communication strategies can build links that weren't previously available to benefit patients. This was a pathway that was very specific to June and may not work for other patients, but by liaising well with the correct department, who were well aware of June's condition and her specific management, we were able to avoid an unnecessary hospital admission.