Volume 7 Issue 8

The search and rescue helicopter paramedic: an emerging role

Tactical development of the SAR paramedicThe SAR paramedic role is at an exciting stage in its development. Not only is it transitioning from a predominantly military-provided service to a civilian contracted one, but also SAR paramedics are now transitioning from being trained to being educated.The current SAR paramedic training provider has embraced the aspirations of the Paramedic Evidenced-based Education Project (Lovegrove, 2013) and the College of Paramedics (CoP) (CoP, 2014b) by educating SAR paramedics to academic level 5 in England, Wales and Northern Ireland. This has equipped and empowered them to utilise professionally desirable graduate attributes to enhance their role (Kilner, 2004). This is not only achieved at the coal-face but also indirectly, by giving them the tools to drive their profession at a strategic level. This article will begin by critiquing the tactical effects on SAR paramedic practice of the transition from the Institute of Health Care Development's (IHCD) Business and Technology Education Council (BTEC) level 4 training syllabus, to a higher education model.Traditionally, SAR paramedic training followed that of the ambulance services' IHCD BTEC level 4 programme. This method of training has attracted criticism in the past by many authors who considered it as surface learning. They suggested it focuses primarily on the performing of clinical skills as a reaction to recognised signs and symptoms, but encompasses little underpinning knowledge (Kilner, 2004). It is described as a rote method of training that fosters learning through the memorisation of mnemonics and protocol-driven practice (Ryan and Halliwell, 2012). Focusing on the ‘doing’ rather than the ‘thinking’ (Wood, 2012), it fails to promote true learning, preventing practitioners from knowing the ‘hows’ and ‘whys’ of their practice so that informed decisions can be made (Ryan and Halliwell, 2012). By offering little scope to challenge practice, or explore the reason for adopting a particular skill, knowledge is created without a depth of understanding (Emms and Armitage, 2010).As the demand on the ambulance service changed, this method of training became insufficient to meet the requirements of the role. 80% of the IHCD curriculum had focused entirely on life-saving protocols and promoted a ‘treat and transport’ model. But the majority of the patients now encountered on the street didn't fall into this category (South and Wenman, 2012). The Department of Health (DH) found that despite 999 calls increasing by around 6–7% each year, only 10% of them had a life-threatening emergency (DH, 2005). This resulted in around half of 999 patients being transported to, and then discharged from, the emergency departments, without significant treatment or referral (DH, 2009). It appears that many patients could have been more appropriately cared for at home or by other urgent care services (DH, 2009). It was evident that the current curriculum had unsuccessfully attempted to define the paramedic role, rather than the requirements of the role defining the curriculum (Kilner, 2004).The Association of Ambulance Chief Executives (AACE) (2011) recommended that paramedics needed greater underpinning knowledge and skill to more effectively address the remaining 90% of patients they encountered. Paramedics needed to be developed to offer a greater range of unscheduled, urgent care with an aim to facilitate patients remaining at home or exploring other more proportionate, appropriate care pathways (AACE, 2011; NHS England, 2013). The greater autonomy, professional knowledge and the higher level interventions required to make this possible were gained through higher education programmes (AACE, 2011; Lovegrove, 2013). This additional education better equips paramedics to manage complex, minor or undifferentiated presentations more effectively, thus minimising the requirement for transportation to hospital (Catterall, 2012). The overall aim of this strategy is that patients would receive the ‘right care, at the right time and in the right place’ (NHS England, 2014).While the ambulance paramedic is predominantly dealing with an ageing population requiring urgent (not emergency) care (NHS England, 2013), the SAR paramedic is faced with a different demographic of patient altogether. The majority of casualties necessitating the deployment of a SAR helicopter are usually those in austere, inaccessible locations presenting with emergency injuries or illnesses (Dykes et al, 2009). Most of them are relatively young, healthy adult males either at sea or participating in adventurous activities overland (Dykes et al, 2009). This results in around 80% of casualties being victims of traumatic injury (Howes et al, 2011). By predominantly focusing on treating life-threatening conditions followed by transportation, the IHCD training model seems already appropriate for the SAR paramedic's caseload. However, the SAR paramedic's practice is still enhanced by higher education, particularly when faced with emergency or critical casualties in the challenging SAR environment.The pre-hospital arena is austere and often unforgiving: ‘Practising in this chaotic environment necessitates elements of speed, versatility, improvisation, physical and emotional control and interpersonal finesse…’ (Nelson, 1997: 168). This is certainly true of the SAR environment. The SAR paramedic often works alone, faced with severely injured or ill casualties, in difficult environments and sometimes within weather or fuel restrictions (BBC News, 2015). The consequences of missing a rescue window could be of significant detriment to overall casualty care. They may now face a difficult ground-based, technical rope rescue lasting several hours. For casualties at sea this could mean a long sail into the nearest port. The setting in which they practice often limits the SAR paramedic to fitting in medical procedures (BBC News, 2015). This results in their overall ability to manage the emergency scene (rather than focus exclusively on clinical interventions) being one of their most highly prized attributes (Campeau, 2008). To achieve the best overall outcome, it is necessary to resist focusing entirely on the clinical needs of the patient and take a more holistic approach to the management of the mission's aviation, rescue and clinical requirements. It is here that the tactical benefits of the higher-educated SAR paramedic gives them the edge over their IHCD-trained colleagues.This new higher-educated generation of SAR paramedic not only has the ability to recall and implement guidelines, but it also possesses greater underpinning knowledge and has the ability to critically analyse those guidelines (CoP, 2014b). Together with the principles of evidence-based practice (EBP) (Jones and Jones, 2009), they use these attributes to specifically tailor their care to the unique, challenging, sometimes extraordinary circumstances of the SAR environment. Rather than blindly following a strict A to E protocol they are able to provide more realistic, proportionate and achievable care, and still meet the all-important rescue window. This concept is advocated in pre-hospital care by the National Association of Emergency Medical Technicians (NAEMT):‘Guidelines for patient care must be flexible… they [guidelines] are not the definitive be-all- and-end-all steps that cannot be violated by thoughtful, insightful analysis of the situation and application of appropriate steps to assure the best possible patient care in each unique situation’(NAEMT, 2011: 38–39).

Are coaching and mentoring skills crucial for ambulance service managers? A personal reflection

The purposes of coaching and mentoringIn the 1960s, the use of the term ‘coaching’ by some experts was different to the perception we have today. Use of the term was perhaps more aligned to my own interpretation, which is, intuitively, to lead and persuade staff to adopt a previously agreed solution to a problem. So the need to understand the wider purposes of coaching is essential to both the coach and the coached.Predictable though it is, it seems to be universally accepted that to maintain high standards, great sportsmen need great coaches. Why? Not because they lack the necessary mastery of the game, but because to maintain such high standards is reliant on the ability of a coach to manage the potential. The Inner Game of Tennis (Gallwey, 1974) similarly proposes a philosophy that performance = potential - interference. So perhaps, as coaches, it is our job to interfere in a positive way to ensure that existing potential is released. While I feel that release of potential is a key skill in the coach, I also find that the self-awareness of the individual being coached is often far removed from reality. This works both ways of course and it can be genuinely as frustrating and challenging to manage the expectations of those who do not possess the necessary raw materials, than it is to encourage confidence and self-awareness in individuals who are oblivious to the extent of their talent.There is also a need to foster a wider range of skills in individuals who may not possess natural ability but who nevertheless, are required to perform at a high standard within the complex environment of healthcare clinical operations or management. These individuals may not naturally aspire to ‘greatness’, so to coach in such a way could be counterproductive in raising expectations above the capabilities of the individual. I have personal experience in choosing to develop a highly competent clinician into a challenging role, when, ultimately, the person in question was not naturally aspirational. If the talent lacks ambition, do we then relent and concede that we will be forced into coaching the unexceptional? I expect that the talent pool is deep and crying out for development.Does mentoring really need definition? Attempting to define the concept of mentoring surely detracts from an inherent ability to simply act as a role model without conscious thought. While I feel that coaching can be defined in its context and purpose, mentoring seems open to interpretation by those who consciously engage in it.Formal mentoring arrangements can fulfil many purposes. For example, provision of mentorship throughout an induction process can help to develop a more collegiate and reassuring approach to supportive mechanisms which can then propagate throughout an organisation culture. So in this context, it is important that the purpose is clearly defined before the period of mentoring commences. Peterson (2007) highlighted this as a concern within the teaching profession, as mentors seemed to transcend the concept of support, and simultaneously assumed the wider remit of new teacher certification.‘Attempting to define the concept of mentoring surely detracts from an inherent ability to simply act as a role model without conscious thought’In addition to offering support in a new post, a mentor can assist someone who has added a new aspect to their existing role. This can be achieved, not by directing or acting in an advisory capacity, but by listening and then empowering the mentee and enabling them to find their own way through the complexities of any particular situation. This encourages reflective practice on the part of the mentee, which coupled with access to knowledge, can allow the mentee to develop their own skills, strategies and capabilities. While the importance of developing good mentoring skills within the clinical leadership structure of an organisation should not be underestimated, these leaders must also be empowered in such a way that encourages innovation and not convention to the norm. I have been lucky enough to develop extremely beneficial relationships with my ‘mentors’ and cannot think of anything more valuable than the benefit, exposure to the wider system has afforded me.

Factors influencing EMS clinicians' speed of recovery between shifts

For many years research has evidenced that people working shifts can experience, among other things, poor sleep quality, occupational fatigue, irritability, and poor recovery between shifts. When focusing on shift work in health care, there are specific concerns about the potential impact of shift work on clinicians, not just in relation to patient safety, but also with reference to the practitioners' own safety. Interestingly, emergency medical services (EMS) staff demonstrate comparatively high rates of injury at work (Patterson et al, 2012). Despite the growing body of evidence of the impact of shift work on health within other professions, there is limited research on the impact of shift work involving EMS clinicians.

Infections of the heart and how they relate to the ambulance service

Background:In the pre-hospital environment, the treatment of acute coronary syndrome (ACS) is at the forefront of most clinicians’ priorities when symptoms include non-traumatic chest pain. As ACS is a leading cause of preventable deaths, less emphasis is placed on other potentially life-changing conditions that are associated with non-traumatic chest pain.Objectives:This article discusses the three main groups of cardiac infections (pericarditis, myocarditis, and endocarditis). It then discusses how they can be identified in the pre-hospital setting and how the ambulance service can contribute to the subsequent diagnosis of patients presenting with these conditions.Discussion:Pericarditis is a relatively common cause of non-traumatic chest pain. It has symptoms that can be found in the pre-hospital environment such as specific ECG changes and symptoms that can be identified during an initial consultation. Myocarditis has a low incidence rate as well as a wide variety of symptoms that can be associated with other common ailments. It is a very hard condition to determine in the pre-hospital environment. Endocarditis in the intravenous drug user population is a significant condition and has a high mortality rate.

A brief guide to borderline personality disorder for pre-hospital clinicians in an emergency setting

Paramedics and ambulance staff are frequently in contact with patients with mental health diagnoses, whether this is the primary reason for contacting the emergency services, e.g. self-harm, crisis or suicide ideation; or, incidental to their primary clinical concern. Patients in mental health crisis can be challenging and demanding. Most paramedics will not have had specific guidance on identifying or understanding the features, aetiology and responses to treatment of patients with a diagnosis of borderline personality disorder. Borderline personality disorder is associated with a high risk of self-harm, risk-taking behaviour and suicide. Building a rapport with patients is often crucial to paramedics achieving optimum patient care. There are features of borderline personality disorder that may make rapport building more complex, and the establishment of trust harder for the clinician to achieve and maintain. There is potential for frustration and a lack of understanding to interfere with patient-centred care. In order to support patients with borderline personality disorder, ambulance staff need to be aware of the particular characteristics of this condition and the current best practice guidance.

Addressing the burnout issue

Last month a special report on the issue of burnout among ambulance staff was published by the Larrey Society (2015), the cross-sector think tank for emergency medical services. Within the report, the society urges all NHS ambulance Trusts, independent companies and voluntary organisations to adopt a 7-point code of practice on work life balance designed to improve the working environment of all employees in the ambulance service. Specifically, the code calls on all Care Quality Commission regulated ambulance providers to:

Continuing Professional Development: Update on the management on sepsis: what a paramedic needs to know

OverviewThis Continuing Professional Development (CPD) module will provide a brief reminder of the definitions of sepsis and septic shock before describing the key diagnostic criteria, outlining risk stratification in the pre-hospital setting, and detailing how these patients can be treated according to current guidelines.Learning OutcomesAfter completing this module you should be able to:Define sepsis and septic shock.Describe the key diagnostic criteria.Appreciate risk stratification for sepsis.Outline a management plan for the septic patient.

Book Review

A Concise Guide to Observational Studies in HealthcareEver since the Bristol Royal Infirmary Inquiry of 2001, the primacy of evidence-based practice in health care has been assured. What is perhaps less well appreciated is how that evidence is collated and interpreted. For many, the spectre of medical research can be daunting and so it falls to books like this to help assuage some of those fears.No previous knowledge of observational studies is required as the author successfully navigates the basic tenets of this subject without leading the reader into a labyrinth of confusion. An honest critique is presented on the relative strengths and weaknesses of observational studies, and the pertinent differences between them and clinical trials (the other mainstay of healthcare research) is distinguished. An excellent account is also given of the elements of a typical process for conducting an observational study, succinctly delineating what can undoubtedly be a complex process.Questionnaire design, data collection, interpreting results and outcome measures are predictably addressed, but the real ‘money shot’ is how the author is able to relate the concept of observational studies to developing medical science and, ultimately, clinical practice. Each chapter is appropriately referenced and specific focus is given to relevant studies which have adopted some of the principles discussed in the text.There will undoubtedly be more in-depth reference material on the market which covers this type of research, so for those with some familiarity with observational studies and medical research in general, this is possibly not for you. Yet, while it is not the most voluminous text, it is certainly one of the more illuminating.Be it medical students or healthcare professionals, whether you are conducting an observational study or simply concerned with interpreting one, you won't go far wrong with this book. A concise but informative guide which I would recommend for those considering observational studies.

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