I used to look out into a spacious waiting room with an enclosed Chihuly art piece tucked in the corner. At times it was bursting with ill children waiting to be seen, all under my supervision. I would run through my head, recalibrating who was sickest, who was in need of analgesia, or who needed a new set of vital signs. I had the independence to administer medication without a second check since it was all computerized. My old world, one which is fading now. The current waiting room, or closet thing to it here, is a skinny white tent with a queue of patients waiting to be seen. At times the line extends into the parking lot.
I have learned (or learnt) to be a nurse in a new capacity. Fellow international nurses say you take a step down from the autonomy you held back home, but I think of it more as a side step. I am no longer wearing a stethoscope every day, nor do I know the results of all my patients, but in exchange I get to talk to them and learn their stories. By taking that side step I am able to look around and observe the difference in health care
Is care better?
In the Emergency Department (A&E) care is more efficient. Is efficiency better? The fact is eighty percent of patients get their disposition in less than four hours. Almost every patient with an acute complaint (ESI 3 or higher) will get an IV (cannula), labs (bloods) including a venous blood gas, EKG (ECG), and a COVID swab on arrival. An hour later with lab results in hand (the doctor’s not mine) you know whether the chest pain needs a cardiology consult, additional work up and admission.
Most patients admission is to the Emergency Medical Assessment Unit EMAU. This is where further evaluation is completed. Such as CT scans, heart rate control, or potassium replacement. EMAU provides care up to a progressive care unit (PCU) level. If the work up extends past a 24 hour period the patient will then move to a specialized ward. General practitioner (GP aka PCP) also directly admit to EMAU bypassing the A&E all together.
A typical patient in our A&E is a little old man curled with age and his tweed cap faithfully at his side. The one in my head arrived via ambulance with “long lie” due to being “off legs.” In other words he was found on the floor after an extended period of time by his carer. due to leg weakness. He took the time to read my name badge and it struck a chord in me. Reminding me of the value of being called by your name. He received the work up previously mentioned but even with his complex history everything came back normal. In these situations we arrange an In Reach evaluation.
The In Reach Team
In Reach is team at the hospital that evaluates the patient and their needs to be able to stay at home. The assessment includes checking mobility, family support, and overall safety of living conditions. The team provides the patient with appropriate assistive devices, arranges for district nurse visits or meals on wheels.
No More Pelvic Exams
Diagnostic studies must be justified. Even a head computed tomography (CT) scan must be accompanied by altered level of conscience or blunt head trauma with persistent vomiting. Elevated inflammatory markers is the only way to land an abdominal ultrasound. And even at that, it will be scheduled for the following morning, not in the A&E. If you suspect acute appendicitis the patient goes directly to the operating room/theatres.
A young female with upper abdominal pain will get the work up mentioned and sent home to follow up with their GP. More weight is placed on the physical assessment versus jumping to a CT scan. Children that present with abdominal pain first get an assessment, then urine analysis, possibly blood work but an ultrasound will only be done if deemed necessary after blood results. We are more likely to schedule it as an outpatient or to monitor the child overnight. I am torn to which is better, at times things are missed when you skip the scan or an ultrasound but then again you do not always need it. Things here are not better or worse, just different.
A female with lower abdominal pain or a pregnancy complaint will get stabilized then sent to the OBGYN ward in a neighbouring building. A young pregnant woman with heavy bleeding presented via triage the other day. After I obtained her vital signs I paged (bleeped) the GYN doctor and sent her directly to the OBGYN ward. Pelvic exams are not done in the A&E! At first sending a patient to another building just because they required pelvic exam seemed foreign. Now, it just is.
What about Sexually Transmitted Diseases?
No emergency treatment required therefore patients get directed to a specialized clinic. The sexual health clinic offers contraception, free condoms, testing for sexually transmitted infections including HIV.
Stroke Team
The hospital, and most hospitals in the NHS, have a dedicated stroke team. The team consists of a doctor and health practitioner. The health practitioners are trained in National Institutes of Health Stroke Scale (NIHSS) assessment. The NIHSS is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. In addition to placing IVs, determining if the patient will require thrombolytic intervention (“the clot buster drug”) and transport the patient to CT. The doctor does the formal admission and will be present if thrombolytics are administered. A stroke patient will get their evaluation by the stroke team and admitted within a couple of hours. The A&E nurse will assist with paper work, medication administration, but no need to transport the patient for CT or do the NIHSS assessment.
Minor Complaints
When I started, I was blown away when an Emergency Nurse Practitioner (ENP) guided a smartly dressed woman directly into one of their exam rooms. The chief complaint was a foreign object in her ear. Turns out it was a piece of her hearing aid. I never really saw the patient, only glance at her in passing, she bypassed triage. The ENP took the chart, took the foreign object out, did one quick set of vital signs and discharge her. The staff nurses do not get congested with these patients. Other patients that will get seen by the ENP directly are limb injuries such as a sprained ankle or a simple laceration.
Minor complaints (ESI 4/5) get seen by ENPs, a different scope of practice than back home. For example, an ENP in England would not just evaluate a simple urinary tract infection. But being previous A&E nurses, they do everything from start to finish. The triage, wound care, x-ray ordering and reading, plastering (applying a cast) all without any help from an ER tech or another nurse. ENPs are very independent and hold their own.
Seeing things from a different side
Learning to see things under a different light reminded me of Begonia, a stern retired teacher we stayed with during our travels in Spain. She could not brush off her years of teaching and was always sharing her wisdom. During our final night, I was complaining about the world’s agonies and she grabbed my hand and held it up. She was looking at the back side with the cracks on my skin and I was looking at my palm. Then she said “we are both looking at your hand, right? But we are looking at two very different things because of where we sit.”
When I arrived I saw thing from the American view, now I see them from the other side.
A Sundry of Difference
-We do not administer narcotics instead we give paracetamol IV. I have given morphine less than a dozen times in the last year.
-Patient to nurse ratios are 5:1, pediatrics 8:1, and ICU level patients 3:2
-A medical cold blue is an incoming sick patient not a cardiac or respiratory arrest. Those area announced as a cardiac/respiratory arrest.
-No ambulance phone just a screen, we only get a phone call if the patient requires a resuscitation bed.
How has all this changed me as a nurse?
I have had to recalibrate how I see myself and emergency care. It is no longer about trying to find the mystery diagnosis or a reason for admission. It is now about figuring out if the patient needs immediate treatment or what support they may need from the community to lead a healthy life at home.
Back home I am just another nurse, but here due to the vast difference in training I am a source of knowledge. I have learned to carry that knowledge carefully and use it as a mean to elevate those around me. A personal goal is to teach the newly arrived foreign nurses of the intrinsic difference in England. I have learned to Trust myself a little more and not be afraid to have voice, embracing my American heritage. I now introduce myself as the American nurse working for the NHS.
