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).