On 22 May 2017, at approximately 10:30 pm, a bomb was detonated in the Manchester Arena, tragically killing 22 people and injuring many more. The North West Ambulance Service (NWAS) responded to the atrocity through activation of their major incident plan. Over 60 ambulances and response vehicles were dispatched to the incident alongside specialist resources including the Hazardous Area Response Team (HART), the NWAS clinical leadership team, and medical responders from the British Association for Immediate Care (BASICS), and Medical Emergency Response Incident Team (MERIT). Working alongside partner agencies and using a predetermined NHS mass casualty distribution plan, NWAS transported over 60 patients to numerous hospitals across the Greater Manchester area.
Out on placement
Edge Hill University currently runs a 2-year diploma programme for Paramedic Practice evolving into a 3-year BSc (Hons) starting from September 2018. At any one time, the department will have a cohort of students in university studying and another learning through clinical practice placements. These placements are either with NWAS or on a range of multi-professional bespoke placements facilitated across the entirety of the North West region. Throughout their 2 years of study, students are expected to work closely with their paramedic mentors, developing the necessary skills and confidence required to progress into independent (although still supervised) practitioners during their final year.
On Monday 22 May, 62 first-year student paramedics had just commenced a week of clinical placements with NWAS. The students, aged 18 years to their mid-50s from a variety of backgrounds and experiences, only joined the university in September 2016. Being in their eighth month of study when the tragedy struck, their experience of paramedic practice was somewhat limited. Working alongside their paramedic mentors, some students were deployed to the incident.
As news of the attack began to break across the world, academic staff in the Paramedic Department of Edge Hill University were aware that students may be involved in the immediate response to the arena attack. On the morning of 23 May it was confirmed that eight of the first-year student paramedics had been involved in the immediate response to Manchester Arena. It became clear that a number of other students were also on duty and were indirectly involved in supporting the response by continuing their placements with their mentors and responding to regular calls from the community. It was apparent that all students involved would require support and the following is an account of the actions of Edge Hill University Paramedic Department and the NWAS in the aftermath of the incident in order to support the students.
Support in the aftermath
At 7 am on Tuesday 23 May, the University programme management and delivery team consulted via telephone as to what approach would best suit the unprecedented situation. Concerns regarding students' safety were paramount and the situation both at the arena and elsewhere was still unclear. The very real concern of further attack was confirmed later that day when the national threat level was raised to critical.
Alongside concerns for their physical wellbeing, there was also a strong feeling among the faculty that the students needed time to reflect on the events of the previous night. Some of the students had worked more than 18 hours on shift in support of the response, and it was felt that they were unlikely to have slept well the following morning. There was a clear concern for their psychological wellbeing and it was important that they were given time to process the events of the previous night.
Thoughts also turned to colleagues in NWAS who would undoubtedly be affected by the incident, and would also need time to reflect and deal with their own emotions without the additional pressures of having to mentor a student. The departmental team was aware that NWAS managers were working tirelessly to support their staff and did not want to add pressure to mentors to stay in work simply because they had a student to mentor.
For these reasons, the department made the decision to immediately withdraw not just those students who were directly involved in the response, but all students on placement. This ensured that those directly involved in the response did not feel segregated from the rest of their cohort, and allowed NWAS time to manage their recovery. It also allowed space for their paramedic mentors to reflect and process the events.
Following this, other universities in the North West region, in conjunction with NWAS, withdrew their own students from clinical practice in the Greater Manchester area.
Immediately after the team was made aware that students were involved, the personal tutors made telephone calls to each of the affected students. Contact was made to establish a welfare link and to advise that there was support available to them through university support services. The calls were made at approximately 9:30 am on 23 May, and every student highlighted that their mentor, senior paramedic or advanced paramedic, and the practice education facilitator had already been on the phone to them that morning to see how they were.
The students discussed how supported they felt but it also became apparent that they were all dealing with the previous night's events very differently. The team talked to them all and told them how very proud they were of their actions and professionalism that night, and the importance of seeking appropriate support should they need it.
The days that followed
On Wednesday 24 May, tutors rang the students again to check up on them and see how they were, following some sleep and time to reflect.
On Thursday 25 May, the students were invited to come and talk to the university counselling team. This was approached as a group exercise, with the counsellors also being available should students wish to see them on a one-to-one basis.
On the same day, the area consultant paramedic, practice education facilitator and a Trauma Risk Management (TRIM) team from NWAS came into the university and spoke with the students. University tutors were available all day and sat and chatted with the students.
This day seemed to have a positive feeling about it. The students were very quiet, and seemed to be obviously still processing what they had seen and dealt with that night. Informal conversation allowed the students to openly discuss what had happened to them as individuals, and how they had dealt with it. There was a lot of support for each other as a group on that day.
On 5 June, the area consultant paramedic from NWAS visited the entire cohort and spoke to them about the process of ‘what happens next’ regarding a major incident of this magnitude. He explained about the processes that NWAS has in place to deal with such an incident and how well they worked on the night. He also talked about the future and how the investigations and inquests may proceed and the possible time frame for all of this to occur.
The students had all attended a ‘hot’ debrief delivered by NWAS in the early hours of Tuesday 23 May immediately following the incident. They were further invited to another service debrief, and also to an NWAS group reflection day, both arranged by NWAS to support their staff. The students were part of the NWAS response and therefore remained part of the aftercare provided to NWAS staff.
The decision explained
The faculty felt the decision to cease placements was correct, but there were a couple of unintended consequences experienced that are worth some consideration for any future occurrences of this magnitude. Some of the students who were directly involved in treating patients both inside and outside the arena that night, naturally wanted to visit their station and talk to their ambulance colleagues as a form of reflection and catharsis.
The faculty recognised this need once highlighted, and respected the feelings of the students who felt they needed to discuss the response with people who were there and who they felt understood. This is natural and necessary following such a traumatic and highly emotive event, and so the students were advised that they could attend their ambulance station. However, they were not to go out and attend incidents.
The decision to withdraw students from practice was also questioned by some paramedic mentors; they were unsure why students had been withdrawn, and felt it was important that they could support them and reflect on the incident as a crew/team.
After the university tutors provided an explanation, many of the mentors appreciated the rationale for the decision, which ultimately received the full NWAS support. However, some mentors still considered the decision to be unnecessary.
A further repercussion of this decision was that the students who were not on shift that night and not directly affected, became frustrated wanting to be out on placement to help and support their NWAS colleagues who were still dealing with the aftermath of the event. They were already feeling part of the ambulance ‘family’ and wanted to offer their support. The tutors needed to explain their reasoning behind the temporary suspension of practice.
A further reflection on the incident identified that while the students undertake education and training on major and mass casualty incidents as part of the programme, the reality of students being directly involved and responding to such an incident had not been fully considered previously. Policies and procedures needed to be reviewed from a university and NWAS perspective for reference, in the case such an event were to occur again.
Time for reflection
Two months on since the dreadful events of 22 May, and all students continue to study on the programme. They continue to receive support from personal tutors, the wider university team and NWAS. They remain able to access university counselling services should they need to.
The students' response is that they have felt very supported by the university and NWAS. The academic team is immensely proud of how they have dealt with this incident, both on the night and in the weeks and months that have followed.
An incident of this nature, even for the most experienced paramedic, is difficult to process. The high-profile nature of this event means that the students are experiencing almost daily reminders of this terrible incident—from media and social networks, and the subsequent inquest process (to which they might be called), to the worker-bee bumper stickers and tattoos that can be seen across the city of Manchester as a symbol of love and defiance.
Looking forward
It remains to be seen how this will affect the students in the future; however, both the university and the ambulance service will be keeping a watchful eye over them and wish them every success with their chosen career. As a department, the team will continue to develop the support procedures, and also add emphasis to resilience training and wellbeing during the students' education.
Our thoughts, and those of our students, remain also with the victims and their families who will forever be remembered.