The first question facing the industrial paramedic—and indeed within this discussion article—is: what is so specific about the skill-set you may have identified?
Clinically, the industrial paramedic must be able to expedite safe extrication of the patient, but clearly this necessitates an advanced level of trauma skills, with practised rapid diagnosis and treatment (industrial paramedics work to PHTLS (Pre-hospital Trauma Life Support) ‘Platinum 10’ standards), although much of the work undertaken actually falls into the category of minor injuries and illnesses.
This, arguably, requires a broader skill-set than some, or all, of our colleagues in other fields of rescue/paramedicine.
The UK Health and Safety Executive (HSE) reports the following industrial injuries in the UK; (based on last available data 2014):
‘155 workers killed annually—equating to three per week’
‘22 500 workers seriously injured per annum—one every 22 minutes’
‘79 000 workers unavailable to work for between 3 and 7 days’
‘16 000 people leave the workforce annually never to return due to harm at work’
‘Overall, the cost to UK society and industry is £14 billion per annum.’
It is arguable that much of this burden of cost is shared between productive industry and the NHS. Furthermore, the HSE risk management guidelines state that facilities are required to ‘mitigate the risk they have created’ and therefore may not entirely rely upon the statutory services. The importance of the industrial paramedic may be described in the following paragraphs and associated arguments.
We argue that the industrial paramedic has five unique responsibilities, skills and identifiers, as discussed in the following sections:
Economic
This is the cost (as described above) to the industrial economy, the broader economy and the NHS. We believe this case has been made using HSE statistics and requires no further discussion.
Efficiency
To improve industrial practice with the input of medical and health and safety professions. Furthermore, to improve that same review by the medical/rescue data achieved from active response, be it minor injury or major emergency.
Health and safety is an integral part of this—industrial paramedics must have an IOSH (Institute of Occupational Safety and Health) accreditation, in order to effectively mitigate risk, produce rescue plans and work effectively with our health and safety colleagues.
Coalition
Working with local NHS public health professionals to report and treat outbreaks of viral or bacterial illness; for example, an influenza outbreak on an industrial site may burden not only the client in days of work lost, but the local NHS (in particular many of the workers may be resident in another NHS Trust, therefore relocating costs locally and unexpectedly).
On many sites, the paramedic team are responsible for annual influenza inoculation as part of a proactive policy to reduce non-incident related lost time.
Often the industrial environment poses serious and aggressive environmental and bacterial risks—workers may need to descend into deep underground chambers containing, for example, decomposing shellfish, diesel fuel and human waste. In each case, the industrial paramedic must, besides recording the industry standard gas tests, advise the workers and managers of appropriate precautions and subsequent ‘markers’ for eye and respiratory infections (this may coincide with annual influenza and often be confused with the same, therefore workers are sent home with advice cards and the telephone number of the attending industrial paramedic for the guidance of local emergency department (ED) teams).
In addition to trauma response, health screening (for suitability for a given task, such as confined space working or driving heavy machinery) provides a necessary risk management tool with the additional benefit of often discovering issues which may be reported to the worker's own GP for further investigation.
The minor injuries role in the industrial sector is an often overlooked but equally essential one, with the prevention of LTIs (lost time incidents) and further pressure on local walk-in centres and EDs, especially given that a major ‘outage’ in the sector may involve around 400 staff on average (often many more).
Treatment and advice on site saves time and money and improves patient outcomes, particularly as travel times to local NHS facilities are often long, and shift workers may present at busy times, or otherwise ignore injuries if no on-site treatment was available.
Cooperation
The 8-minute response target for NHS ‘Red Calls’ for the most serious medical or trauma response is always difficult and under review.
In particular, within the industrial sector, and power generation in particular, it is highly unlikely that most NHS Trusts can achieve this target, given the often remote locations of the facilities outside urban conurbations.
Even if an advanced paramedic crew arrives on scene, the difficulties and hazards of the rescue environment and their lack of task-specific equipment, may of course render them useless.
The UK power generation ‘cluster’ in Kent (UK), for example, deserves discussion. Distance to the nearest UK major trauma unit = 1 hour 12 minutes to St George's Hospital (major trauma centre) or 44.3 miles (by road). Distance to the nearest ED = 26 minutes each way, or 14.3 miles, minus traffic (using commercially available maps and online services to determine this response—again by road). Distance to HEMS helipad = 81 m by road if weather against flying—estimated at 1 hour 18 minutes. Flying (McDonnel MD Explorer at max speed of 161 mph according to manufacturer) would still take perhaps 30 minutes to receive critical care assistance and rapid retrieval of the patient (if available). Average response for local 999 ambulance Trust (South East Coast Ambulance NHS Foundation Trust) for the reporting period 2013/2014 was 73.9% for RED 1 calls, against national target of 75% (South East Coast Ambulance Service NHS Foundation Trust, 2014).
An examination of the journey times and distances within the Isle of Grain cluster, suggest there would be difficulty responding within the guidance times for either individual, or perhaps mass casualty incidents.
Capability
Whether in power generation, water utilities, nuclear plants, port facilities or the myriad of other industrial sites the modern economy relies upon, the industrial paramedic must have an advanced rescue skills portfolio.
HART teams and fire and rescue services may not have the operational or specific specialities in order to deal with some industrial emergencies.
A working knowledge of the industry (e.g. power generation, underground work, or utilities) is certainly desirable, and moreover, knowledge of the individual site and the high-risk work to be undertaken is absolutely essential.
Local HART and fire and rescue teams may or may not have trained on their local high-risk industrial sites, but are highly unlikely to have trained for the site and industry specific-risks. For example, power generation sites use hydrogen gas to cool the generators, and large quantities of hydrochloric and sulphuric acids in water treatment. Each of these substances present a high risk over and above the activities taking place at a given time in the operation and maintenance schedules.
The industrial paramedic will not only be COSHH (control of substances hazardous to health) accredited, but must be aware of (and document) the location of COSHH substances on site, delivery dates and times, current storage status and quantities, and the movement of temporary risk items (e.g. welding gases during maintenance work).
Before high-risk activities take place, a rigorous risk assessment takes place, involving on-site management, health and safety, but usually led by the industrial paramedic team. Rescue plans must be submitted, tested and agreed by all concerned before permits to work are issued.
In many cases, gas tests must be undertaken by the paramedic team, often using breathing apparatus—a skill common to HART and fire crews, but rare elsewhere. Thereafter the task must be closely monitored. For example, in situations involving a metal confined space, things to consider include the number of workers inside, how much carbon dioxide is being produced, external and internal temperatures, continual gas monitoring, emergency back-up lighting and emergency breathing sets for each worker. Additionally, the following questions should be asked: how long can the workers be in the space without a break? Have suitable hydration facilities been put in place? Have the workers been health screened for confined spaces?
The next step is detailed practice and critique of emergency extraction and follow-on medical care for one or more workers in the event of an incident. Equipment (and medical kit) must be tested and placed as near as possible.
Questions such as the type of stretcher (often a ‘troll’ or ‘paraguard’) for appropriate access must be discussed and tested (local HART or fire rescue may not carry this equipment or have trained on site).
As we have seen from the distances, the time to assess the emergency, response times and the local expertise needed—in the event of a time-critical access and medical response—much or all of the ‘golden hour’ has already been expended.
Confined spaces are defined in the regulations as:
‘A confined space is a place which is substantially enclosed (though not always entirely), and where serious injury can occur from hazardous substances or conditions within the space or nearby (e.g. lack of oxygen)’ (HSE, 2016a).
Work at height is also clearly defined in the regulations:
‘Work at height means work in any place where, if there were no precautions in place, a person could fall a distance liable to cause personal injury’ (HSE, 2016b).
Clearly, the industrial paramedic must have advanced access skills in confined spaces, as well as when working at height—often referred to as ‘high angle’.
In many cases, the task may demand both disciplines: the confined space may be 25 m or more above ground, creating a dual hazard to be planned for and executed safely in event of an emergency extraction.
Economic, efficiency, cooperation, coalition and capability (EECCC) may therefore be a common identifier and acronym for the competencies of the industrial paramedic.
Legal and ethical challenges
There are a number of ethical dilemmas when working as a healthcare provider in the industrial setting, e.g. drugs (both illicit and prescribed) and alcohol. Consumption of both are either banned or strictly controlled.
Testing for illicit drugs and alcohol is common in the industrial (and offshore) setting; however, this is commonly done by an external agency or contractor as it is felt that testing by the on-site medical team can reduce the workers' confidence and relationship with the industrial paramedic team.
In the case of prescription drugs, the ethical and legal position becomes less clear. The worker may be taking medication that is incompatible with their work—for example, drugs of a soporific effect may preclude working in confined spaces or operating machinery.
Safe practice depends firstly upon the worker honestly approaching the medical team either during routine induction screening or high risk screening (i.e. prior to confined spaces or work at height).
Within the formal health system, service users are protected by the NHS Confidentiality Code of Practice (Department of Health, 2003). As registered professionals, industrial paramedics are bound by the same rules and confines, as discussed in the Caldicott Report (The Caldicott Committee, 1997).
However, these rules must also be balanced against health and safety legislation, individual and collective responsibilities and the risk to the medicated worker and their colleagues.
Conditions are usually acute, but may be chronic and once identified by screening or intervention by the medical team, a dilemma is often presented. Reliance upon the patient's honesty to approach their line manager is the safest step. Often a short period of light duties in a low-risk environment is sufficient to solve the problem.
However, long-term conditions, once identified, also require a risk intervention that the worker (patient) may be unwilling to reveal to their employer for fear of financial losses. In this case a discreet meeting has to take place, always involving the worker/patient themselves and their managers and supervisors.
This is a legal ‘grey area’, but the overriding principle has to always be for ‘the greater good’. This must not only include the safety of the broader workforce, but the worker's own safety and essentially their healthcare outcomes.
Technology
Both medical and physical technology are adjuncts to the skills of the industrial paramedic.
Whether pre-hospital FAST (focused assessment sonography in trauma), ultrasound in the traumatic injury (an increasingly used skill in the pre-hospital and industrial trauma role) and attendant advanced trauma skills, or the use of physical devices such as drones to assess risk or photograph live footage of a major incident, these are all a growing component of the industrial paramedicine ‘toolbox’.
Drones are still in their infancy in the rescue role, but have already been used in the UK industrial rescue sector in order to provide risk assessments and planning, rather than putting a human in place to do the same.
| CCP | Critical care paramedic |
| ECP | Emergency care practitioner |
| PP | Paramedic practitioner (see ECP) |
| ED | paramedic Emergency department paramedic |
| IP | Industrial paramedic |
| HEMS | Helicopter Emergency Medical Service |
| IOSH | Institute of Occupational Safety and Health |
| ED | Emergency Department (A&E) |
| COSHH | Control of Substances Hazardous to Health |
| NHS | National Health Service (UK) |
| EECCC | Economic, efficiency, cooperation, coalition, capability |
| CDC | Centers for Disease Control and Prevention |
From ‘top cover’ to identify workers trapped at high levels, or to identify a spreading fire or chemical spill, they are considerably cheaper and safer than lost life or limb.
Food safety and sanitation may not be one of the more attractive components of the industrial paramedic's role, but remain essential nonetheless.
An influx of 400–600 workers on a site that may normally have 20 people per shift raises interesting challenges, not least regarding food safety and sanitation.
These issues are familiar to many of those working in an offshore and remote area role, but perhaps not in the normal routine and training for the 999 paramedic.
A level 2 (UK) Food Safety Certificate is the preferred standard for the industrial paramedic. The influx of a large number of workers doing 24-hour shifts can limit the cleaning time for both cooking facilities and sanitation. Each must be monitored and ‘signed off’ appropriately by the medical team in order to prevent food poisoning, escherichia coli, norovirus or other public health-related outbreaks.
Additionally, the provision of alcohol gel near doorways, ladders and stairwells, and the maintenance of the same can be a powerful preventative tool.
The efficient medical team would treat the enclosed industrial environment in a similar manner to a cruise ship: many people from different parts of the country, or overseas arriving in a self contained habitat, bringing with them potentially inter-exchangeable infection. The US Centers for Disease Control and Prevention (CDC) have written extensively on this subject (CDC, 2016). Although specific to passenger ships, the guidance is equally applicable to industrial practice.
Weather is often an essential factor in the routine paramedic shift; for example, a frosty day may result in more falls, and a hot day in dehydration. In the industrial role, weather is an essential planning and monitoring factor.
Workers in a confined space beginning work in the early morning will feel cold, but in a metal structure, the temperature internally and externally will rise and fall with the sun. This will cause some gases within the structure to rise, and others to fall. This negates initial gas testing and requires ongoing personal monitors and fast evacuation should the safe oxygen levels begin to decline.
Even on a cool winter's day in Northern Europe, those working at height may begin to dehydrate rapidly (the work is often physical, and wind speed can chill the worker but increase skin surface evaporation).
Therefore, the efficient solution is a forecast board so that all those entering the site have a briefing on wind speed averages and maximums; temperature minimums, maximums and averages; hours of sun expected; and humidity.
These forecasts must be included in planning before each shift and those workers at highest risk identified beforehand. Forecasts are exactly that, and the actual values must be monitored constantly throughout the shift, along with the workers themselves.
It has to be reiterated that industrial medicine requires a multitude of skills across a number of specialisations, but in particular, we must identify the industrial sites (at least in the UK) where the presence of the industrial paramedic is most common, and therefore essential.
Power generation, in particular, requires on-site rescue and minor injuries during maintenance ‘outages’ due to the proliferation of high angle and confined space work, and the sheer numbers of workers involved in the operation.
Also within the power sector, transmission line maintenance carries significant risks due to work at height and the obvious remote locations between the generation clusters and the major cities.
Water and waste water plants include by design a number of underground sumps, gas risks and confined spaces, and are particularly high risk.
Underground sewer repairs in major cities present an equally high risk as the workers face gas and aggressive bacterial hazards and may be a significant distance from the nearest ground level access.
Port facilities are also high risk projects due to rising and falling tides, bacterial risks (sewerage outflows, fuel spills, dead shellfish) and also numerous pipelines and moving vessels.
Routine maintenance on dock gates and locks may require paramedics and rescue teams with diving skills and boat skills.
The above is to name but a few of the sub-specialities within the diverse role of the industrial paramedic, each requiring dynamic rescue skills but with a common clinical skill-set, as described.
Conclusions
Although it may be debated that the role of industrial paramedic is simply an amalgam of critical care paramedic, emergency care practitioner/paramedic practitioner and hazardous area response team paramedic, it is our contention that the additional varied and essential skills involved in this role have been successfully argued in the narrative.
As with other specialist grades, the role would be subject to ‘skill fade’ if not in continuous practice and with ongoing continuing professional development. The adjuncts to this grade must be taken into account and understood, such as health and safety, knowledge of industry standards, protocols, guidelines and legislation.
As the statutory services retrench into the traditional 999 role under funding stress, we should expect ever increased participation of specialised grades in industry, though primarily in the private sector in cooperation with local NHS Trust assets and regional fire and rescue services.
It is the conclusion of the authors that industrial paramedicine, with its unique skill-set and specific expertise, deserves recognition and accreditation as a stand-alone pre-hospital speciality, and to be represented as such alongside other grades (in particular offshore paramedics) within the College of Paramedics.