A day in the life of a paramedic advanced clinical practitioner in primary care

7.30 am: Arrive at practice

Arrive early to have time to prepare the consultation room, re-stock equipment and stationary, and review the appointments for the morning clinic.

8 am: Physician associate student arrives

PAs are a new role designed to complement the multidisciplinary team. PA students do not have a clinical background and are not registered health professionals. However, they do have a science undergraduate degree and typically study for a postgraduate diploma. They are intended to support doctors in the diagnosis and management of patients, rather than work as autonomous practitioners (BMA 2017). PA students have a range of placements in primary and secondary care. My practice hosts two PA students each semester, and I help to mentor one, as I have previously completed a Higher Education Level 3 qualification in mentorship. The student observes one of my practice days each week for the 6-week duration of their placement. Time is factored into my work plan in order to accommodate learning time and to prevent delays for patients—these slots are primarily used for case reviews.

8 am: Start face-to-face clinic (memory problems)

A 78-year-old man attended with his wife—both were worried that his memory was deteriorating. His wife reported a 6-month history of him forgetting conversations and stated that he occasionally became disorientated. The patient described feeling ‘fuzzy-headed’ at times, but had no history of headaches, collapses, falls or trauma. He had a history of hypertension, carpal tunnel syndrome, hyperlipidaemia and spinal stenosis.

A comprehensive history is the first and most essential step of the diagnostic work-up for memory loss (BMJ 2017). The rate of clinical progression of memory loss is a helpful clue to understanding the underlying aetiology. Acute symptoms (within minutes to hours) are suggestive of ischaemic stroke, haemorrhagic stroke, seizures, migraine or transient global amnesia. Paramedics are trained and experienced in dealing with acute stroke and seizure presentations. Subacute symptoms (days to months) typically occur in infectious and inflammatory conditions, such as encephalopathy and Wernicke-Korsakoff's syndrome. Chronic symptoms, typically lasting for longer than 2 years, are suggestive of a neurodegenerative process or vascular dementia (BMJ 2017).

The second part of the work-up is the neurological examination. The patient was orientated to time, place and self; Glasglow Coma Scale was GCS15; and both cranial nerve and motor examinations found nothing abnormal. The patient's cognitive function was assessed using the General Practitioner assessment of Cognition (GPCOG) screening tool, which is used in primary care to assess for cognitive impairment (Brodaty et al. 2004). He was found to have significant impairment; he had difficulty recalling the name and address element of the test, and had poor recall of recent events. The patient was advised of the outcome of the tests and the need to refer him to the memory assessment team.

Metabolic dysfunction may lead to cognitive decline—this is particularly the case for older patients who become more susceptible to the adverse effects of medications as a result of decreased renal and liver function (BMJ 2017). Older patients are at higher risk for infections, such as urinary tract infections (UTIs), which can cause sudden cognitive decline. Urinalysis was performed immediately to rule out UTI, and bloods (FBC, U&E, LFT, TFT and vitamin B12) were taken immediately in support of the referral process.

8.40 am: 20 minutes late for next patient (UTI)

A 63-year-old woman presented reporting a 5-day history of aching in her groin and burning during and post-urination. She had experienced an episode of suspected gastroenteritis 1 week prior, which she had self-managed. She had no recent history of fever, and no previous history of urine infections or kidney problems. Clinical observations and abdominal examination were unremarkable.

Urinalysis was positive for nitrites, leucocytes and blood. This result has a 92% positive predictive value for a UTI (Mambatta et al. 2015). Local guidance indicates empirical treatment with antibiotics for women with mild symptoms and positive dipstick results; in this case, a 3-day course of nitrofurantoin 100 mg modified-release twice a day (bd) (Salford CCG 2015a). I presented my findings and proposed a management plan to my GP mentor, who agreed and signed the prescription I had pre-prepared in his name for the short course of antibiotics.

Local and national guidance are consistent for the treatment of suspected uncomplicated UTI (NICE 2015a). National guidance advises against sending urine samples for microscopy and culture for women with suspected uncomplicated UTI, because by the time results are available, the symptoms will typically be resolved (SIGN 2012).

9 am: patient did-not-attend/back on schedule (mole)

A 31-year-old woman attended surgery concerned about a small mole over her right eyebrow. The mole had been the same size and colour for many years. However, over the course of the previous 6 months, it had grown from 2 to 6 mm in diameter. The increasing size had resulted in a lesion with different-coloured pigmentation and irregular borders. The lesion did not itch, bleed, ooze or discharge. There was no local inflammation or changes in sensation. National guidelines for the recognition and referral of suspected cancer include a weighted 7-point checklist (NICE 2015b). This patient's presentation included three major features, each scoring 2 points, raising suspicion of melanoma, and requiring a referral on the 2-week wait pathway to the dermatology specialist. The patient was counselled on the reasons for the referral, and explicitly advised of the possibility of cancer.

9.40 am: review electrocardiogram (ECG)

The health-care assistant (HCA) is part of the nursing team and undertakes a range of activities including phlebotomy, ECGs and spirometry. ECGs need to be reviewed by an appropriate clinician. Performing and interpreting ECGs is part of the training and scope of practice for paramedics, so I am able to continue to review them as part of the extended scope of practice of my new role. In this case, the patient had normal sinus rhythm.

10 am: sore throat, cough and fever

A 23-year-old female patient presented with a 5-day history of sore throat, a non-productive cough, runny nose with clear mucous, and mild fever for the first 2 days which was successfully managed with paracetamol. She reported no haemoptysis, no shortness of breath and no wheeze.

Patients with cough frequently present to clinicians working in both primary and secondary care. It is the commonest initial presentation in primary care. Acute cough is usually caused by a viral upper respiratory tract infection (URTI) and, while it may be initially disruptive, it is usually self-limiting and rarely needs significant medical intervention (Morice et al. 2006). However, assessment needs to be systematic and thorough in order to rule out any chronic history or presence of red flags, or identify signs that the infection may be bacterial (BMJ 2016). The CENTOR clinical prediction score tool should be used to assist the decision regarding whether to prescribe an antibiotic (NICE 2015c).

Clinical observations found nothing abnormal. On examination, the patient had no lymphadenopathy; tympanic membranes were healthy; tonsillar nodes were red, but no exudate was present. Breathing was equal, symmetrical and there were no added sounds such as crackles or wheeze. No red flags were found. The patient was discharged with self-care advice including symptomatic relief, rest, fluids and prevention of transmission to others. She was also advised to return to clinic should her symptoms worsen or fail to improve.

10.20 am: discharge from ear

The next patient was a 47-year-old male complaining of a 2-week history of left-sided otalgia, orange discharge and reduced hearing on the left side. He experienced a mild fever for the first 3–4 days. On examination, he had no lymphadenopathy and no mastoid tenderness. Nothing abnormal was detected with the right ear canal or tympanic membrane. However, the left tympanic membrane was bulging, opaque and vascular, with dark-coloured effusion clearly visible in the inferior aspect of the ear canal. There were no physical signs consistent with mastoiditis or cholesteatoma.

National guidance advises that adults with acute otitis media should manage their fever and pain with paracetamol or non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (NICE 2015d). NICE (2015d) also advises against treatment with antibiotics; however, local guidance recommends antibiotics for patients with otorrhoea of more than 3 days duration (Salford CCG 2015a). The patient had a known penicillin allergy, so treatment with erythromycin was indicated at 500 mg four times a day (QDS) for 5 days.

10.30 am: query from HCA

The HCA had been requested to take bloods from a patient, but the request had been created by a locum GP who was unfamiliar with the practice systems, and so wasn't set-up with the details of the specific tests needed. The patient had been assessed the day before with palpitations. I advised that the appropriate laboratory tests would be full blood count (FBC), as anaemia can cause a sinus tachycardia); thyroid stimulating hormone (TSH), to evaluate sinus tachycardia or atrial fibrillation; and urea and electrolyte (U&E) profiles, to check for abnormalities such as hypokalaemia.

10.40 am: shoulder pain

A 44-year-old male presented with a 2-month history of right shoulder pain. Pain was provoked on specific movements such as putting his shirt on or reaching up into cupboards, and he had noticed his shoulder ‘clicking’ on occasion. He had no history of trauma, falls or accidents, and experienced no changes in sensation or distal paresthesia.

On examination, it was observed that the right shoulder was lower than the left; specifically, the acromion process was higher than the root of the spine of the scapula. There was no pseudo or true winging. Measurement from the spinous processes to the medial border of the scapula was greater than four fingers, suggesting a protracted shoulder girdle. He experienced a painful abduction arc at 10˚, and active flexion was limited to 90˚. Passive movement of flexion and abduction was greater than both active movements.

The working diagnosis was an impingement of the supraspinatus. The patient elected to continue to manage his pain with cocodamol as he had a history of gastritis, which was likely to be exacerbated with NSAID use. I referred him to the specialist musculoskeletal (MSK) team for assessment and treatment, as per national guidance for rotator cuff disorders (NICE 2015e).

11.10 am: clinical meeting

All clinical staff in the practice attend the weekly clinical meeting to discuss cases of interest or concern. Every clinician's contribution is valued and I was made to feel that I am an equal member of the team from day one, even as a practitioner in training.

This forum is also used to identify patients that have recently been diagnosed with cancer or a terminal illness, as well as patients recently discharged from hospital that might need additional support in the community. Finally, any adult or child patient of concern that may need safeguarding referrals is also discussed.

12.10 pm: telephone advice

This part of the day is used to contact patients that have requested telephone contact. Most calls are follow-up enquiries regarding blood or imaging test results, or essentially administrative in nature such as requests for sick notes or repeat prescriptions. These are checked and put into the electronic approval queue for my GP colleagues, as paramedics or advanced practitioners cannot currently sign sick notes or prescriptions.

1pm: administration (blood results, DocMan and referrals)

The final task of the morning session is to review results that have arrived electronically for blood tests and action them accordingly. Examples include starting treatment for patients found to have vitamin D deficiency or anaemia. Similarly, electronic communications in DocMan [document management system] are reviewed—these may include letters from secondary care that indicate outcomes from assessment or request changes to treatments. Finally, any time left over is used to complete any outstanding referrals paperwork—and grab a bite to eat!

1.50 pm: distressed patient presents at reception

A 32-year-old female presented at the reception desk, crying and distressed, asking to see a doctor. The patient had become more distraught when advised that there were no free appointments left that day. My GP colleagues were already seeing patients, so reception staff asked if I could help in any way. Reception colleagues are reliable gatekeepers and would only make such a request if they felt there was a genuine and unexpected need. I accompanied the patient to the consultation room to help and find out more.

She had recently been discharged from hospital after a 10-day admission for a sudden subarachnoid haemorrhage. She had aftercare arranged with the hospital and had been advised not to get distressed or do vigorous exercise while in recovery. After discharge, she had discovered that during her hospital stay, her 14-year-old daughter had alleged to have been sexually assaulted by a friend of her father. The father had already alerted the police, who had informed social services and the safeguarding team.

The patient was distressed as the alleged assailant lived nearby and the family had to walk past his house every time they went out. The local housing team was already aware of the circumstances surrounding a request for rehousing, but were asking for documentation to confirm the recent hospital admission. With the patient's consent, a brief letter outlining the circumstances was drafted and sent to the housing team.

As a result of the distress the patient had demonstrated in practice, a rapid assessment was carried out to ensure that she was pain-free, had no photophobia, no altered vision, no tremor or convulsions, and that fundoscopy was normal. The patient was also given safety-net advice and a patient information leaflet on subarachnoid haemorrhage. Despite the aim of this day-in-the-life article to provide insight into a ‘typical’ day, this case demonstrates that there is no such thing as a typical day in primary care—there is a constant need to re-prioritise our workload based on changing circumstances.

2.20 pm: patient advice call

The patient who had booked into the 2.20 pm slot hadn't arrived. As I had one outstanding patient advice call to make, I decided to make contact with the patient requesting advice. The patient was prescribed aspirin (as she had suffered a myocardial infarction (MI) 2 years prior), as well as a proton pump inhibitor (PPI) for gastro-oesophageal reflux disease (GORD). She had read an article in a national newspaper stating that taking a PPI in combination with aspirin was dangerous. I admitted to the patient that I hadn't read the article to which she was referring, but neither had I read any recent evidence or research that had reached that conclusion. I reassured the patient that I would check and call her back.

2.40 pm: emergency shortness-of-breath presentation

A 74-year-old male with a history of chronic obstructive pulmonary disease (COPD) had walked to the practice as he had finished his inhalers and had no rescue pack at home. By the time he reached reception, he had an audible wheeze and had obvious dyspnoea. My GP colleagues were with patients, so reception called me to assist, knowing that as a paramedic, I was comfortable managing such presentations. I attended the patient in a side-room with the emergency response bag and began a rapid assessment, while my reception colleagues rang for an emergency ambulance.

He was alert, tachypnoeic, leaning forward in a tripod position and speaking in short sentences; his observations were GCS15; respiratory rate: 28 breaths per minute; capillary refill: 3 seconds (delayed); heart rate: 77 beats per minute; oxygen saturation: 98% on room air; blood pressure: 118/78 mmHg; and temperature: 36.6 C˚. On auscultation, there was equal air entry, but a diffuse polyphonic inspiratory wheeze was audible as well as bilateral basal crackles. I quickly prepared a salbutamol nebuliser and completed my secondary survey.

After a few minutes, the patient was noticeably more comfortable and speaking in full sentences. He explained that he had had a 2-week history of increasing shortness of breath, which was worse on exertion. He had experienced a 1-week history of productive cough with purulent green sputum, which was worse in the morning. He reported no fever or haemoptysis at any time. My working diagnosis was acute exacerbation of COPD. I did a rapid handover to my ambulance colleagues and left him in their care.

3.10 pm: abdominal pain

My next appointment was for a 32-year-old female who had experienced a 2-week history of constant cramp-like pain around the right umbilicus. The pain appeared to have no pattern in relation to eating or hunger, and she had had no constipation, diarrhoea, melena or haematochezia. She reported no urinary, bowel or menstrual changes.

On examination, the abdomen was soft, but there was obvious discomfort on palpation of the right umbilicus and right iliac fossa. Differential diagnoses included inflammatory bowel disease (IBD), cholelithiasis, UTI, pyelonephritis or ovarian cystadenoma. Urinalysis was performed immediately and the patient was booked to return the day after for bloods (liver function tests) and to bring a stool sample to check for helicobacter pylori and faecal calprotectin. Ultrasound scans of gallbladder and ovaries were also requested.

3.20 pm: blood in stool

A 54-year-old woman attended clinic to report a 12-week history of occasional black stools. She stated that she opened her bowels once daily and had experienced approximately three episodes each week, then would have normal stools on the other days, but noted these were covered in mucous. She was concerned as her father had recently died of bowel cancer. She reported no weight loss, no fevers, no night sweats, no back pain and no urinary dysfunction. She wasn't prescribed iron medications and stated that she didn't take any over-the-counter iron supplements.

On examination, the abdomen was soft and non-tender; there was no organomegaly; and no iliac fossa or rebound pain. A rectal (PR) examination was performed with a female chaperone present. There was no evidence of melena, haematochezia, internal or external haemorrhoids or pelvic tenderness.

National guidelines for the recognition and referral of suspected cancer include a set of criteria for the urgent referral of suspected lower gastrointestinal tract cancers (NICE 2015b). This patient's presentation met the criteria as she was aged over 50 years and had unexplained rectal bleeding. This required a referral on the 2-week wait pathway to the gastroenterology specialist. The patient was counselled on the rationale for the referral and explicitly informed of the possibility of cancer.

3.40 pm: infant with eczema/safeguarding referral

A 2-year-old girl was brought in by her mother, who was worried that she might have eczema. She had a 2-day history of a red rash on her head in a band-like pattern across the forehead and around the tops of her ears. The rash was erythematous but with small red, blisters approximately 2 mm in diameter. The rash had appeared within a few hours of playing in the park. I confirmed that the infant had been wearing a hat and enquired whether the mother had changed washing products or used a new brand of sunscreen. The mother advised that she had found the infant's hat in the dog basket prior to leaving the house. I advised that I thought the rash was a contact dermatitis, caused by an irritant or an allergen. I prepared a treatment plan and prescription for my colleague to approve; this included antihistamines, emollient and topical corticosteroid. I also provided self-care advice such as washing the infant's hat, or buying a new one, as well as monitoring future contact with animal hair.

However, while assessing the patient, I noticed a large bruise and haematoma on the right side of the patient's forehead. The mother stated that the infant had had a fall while playing in the home. While the injury was consistent with a fall, it felt prudent to review the patient's notes. I found that in a 2-year period, the patient had attended A&E on 11 separate occasions, with reasons for attendance including three separate head injuries—one burn, one scald and a fractured clavicle.

I had no evidence to confirm the child was being maltreated; the injuries could be the result of an unsuitable environment, poor parental supervision or neglect. However, national guidance advises that burns, scalds and fractures are key criteria for referral of a child to the safeguarding service (NICE 2009; RCPCH 2014). The internal procedure for children's safeguarding was followed, which involves informing the designated safeguarding officer, as well as the advanced paediatric nurse practitioner and the health visiting service.

4 pm: work-related anxiety

The last face-to-face consultation of the day involved a 34-year-old woman. She was a primary school teacher and had recently moved to the area to take up a new position. She reported a 2-month history of feeling unable to relax, waking during the night feeling clammy and anxious. She stated that she enjoyed her job and had a good support network from her colleagues, but felt that her new head teacher was domineering with unreasonable expectations of her. The patient was clear that she didn't feel bullied, but did feel stressed about how to address and manage the high expectations that she felt had been placed upon her. She confirmed that she was getting to sleep without difficulty, had a normal appetite, and had not experienced panic attacks or palpitations.

A mental health assessment was completed; this found that she was dressed appropriately, was calm and engaging, had good eye contact and was able to find the words to express her feelings and situation. She had a clear perception of her mood, good self-awareness and was orientated to time, place and self. She had no thoughts of self-harm or suicidal ideation. A hospital anxiety and depression scale (HADS) assessment was also completed; this is a reliable and well-validated self-rating scale that measures anxiety and depression in both hospital and primary care settings (Snaith 2003). The patient's score confirmed an abnormal/high score for anxiety; this was not a surprise for the patient.

Talking therapies were discussed with the patient as evidence suggests that they work well for anxiety—cognitive behavioural therapy (CBT) in particular (Bandelow et al. 2012). The patient confirmed that she was keen not to take medications for her mood at this stage as she was worried that they might make her feel less alert or affect her sleep or appetite. A treatment plan was agreed with the patient; the first step was to refer her to the primary care mental health triage service, which would be able to put her in touch with a CBT therapist. This plan was consistent with national guidance, which advocates a stepped care model for people with anxiety disorder (NICE 2011).

4.30 pm: home visit—sudden onset leaning and slurred speech

The practice received a call from the sister of a 78-year-old female patient that lived across the road from the surgery. She had found her sister sat in her chair but leaning over to one side, unable to sit up straight or speak clearly. As a paramedic, this immediately raised suspicion of an acute stroke or transient ischaemic attack (TIA), so I advised my reception colleagues to ring for an emergency ambulance. I advised the PA student to finish work for the day and I went to the patient's home with my response bag.

On arrival, I found the patient leaning over onto her left side, seated in a high chair in the sitting room. I completed a rapid assessment; I observed that the woman had a GCS of 12 as she was speaking incomprehensible sounds. She was FAS-test positive as she had a pronounced left-sided facial droop, inability to coordinate the left arm and slurred speech. She was able to confirm with nods and eye movements that she understood my questions and explanations, but was understandably distressed. I called the paramedic emergency control centre to give them an update on the patient's condition. While waiting for the ambulance, I completed a secondary survey, obtained a full set of clinical observations and directed the patient's relative to gather up some personal effects and the patient's medications. The emergency response arrived soon afterwards and the woman was transferred on blue-lights to the acute stroke service at the local emergency department.