A courageous action is one where there is a morally worthy goal, associated with real or perceived danger, and which involves acceptance of the inherent risks and benefits of any act (or omission) (Konkin et al, 2020).
Clinical courage is the term used to describe the practice of medicine—or paramedicine—outside one's usual scope of practice, or relevant clinical guidelines, to provide essential medical care (Konkin et al, 2020). It has been said that clinical courage is a nebulous entity, which inhabits the grey zone at the fringes of competence (Wootton, 2011). Another expression of the concept could be that it exists where patient needs push us to the edge of our training and experience. This borders on clinical recklessness, where stepping outside of one's competence is unprofessional, risky or indeed harmful, and we must be mindful to not venture too far into the grey areas that we find ourselves in this position.
A real-world example of clinical courage may be the experienced paramedic who is presented with an acute palliative emergency, requiring sedation or analgesia during a terminal event, such as a catastrophic bleed. While they may be familiar with the drugs and pathophysiology, management of palliative emergencies may not be part of their established scope of practice; yet for the patient in front of them, it may be vital to control their symptom burden. Similar, but more nuanced, discussions relating to clinical courage and stepping to the edge of one's competencies can be seen in debates around international medical electives (Gilbert et al, 2013), where the concept intersects with global health ethics and cultural relativism. Furthermore, the concept of clinical courage accepts that evidence-based medicine may lack direct relevance to the variable and inherently imprecise nature of prehospital care, where linear protocols and guidelines may not be wholly suitable (Bledsoe, 2015). In such cases, clinicians may need to do the best they can for their patient, while practising outside guidelines.
In paramedic practice, clinical courage probably occurs frequently, at the roadside, in the sixth-storey apartment or on a remote hillside; however, for the most part, it happens in silence. It is likely significantly underreported, as clinicians may avoid documenting how they stepped outside of guidelines. This likely occurs for many reasons, but I suspect fear of disciplinary action or other sanctioning is a central factor. As the paramedic profession moves forward, there will be a time when we need to acknowledge clinical courage, and face it head-on. This requires a fair amount of fortitude, as one's actions will undoubtably be scrutinised and questioned—and rightly so. It also requires a strong foundation of knowledge to facilitate clinical problem solving and innovation, while maintaining patient safety. In addition, it requires the support of our professional community, and an acknowledgment that the challenges of prehospital care are not easily predicted within written protocols or guidelines. Our profession is full of grey areas and challenging decisions. We have already made huge advances in paramedic education, and bringing clinical courage into the light may be the next step as paramedics continue to expand their autonomy.