Response to ‘Paramedic treatment—wherever that may be?’

Dear Editor,

I am writing in response to James Price's article: ‘Paramedic treatment—wherever that may be?’ This is a clear and comprehensive description of the HART concept and capabilities; however, I think that some of the challenges that have evolved alongside this new way of working warrant further discussion. I will be talking from experience but will try and give a balanced account of my personal perception and experiences of HART.

Firstly, I would like to agree with the theory that the sooner a clinician is with a patient performing clinical interventions, the greater the chance of survival. However, on balance I would have to question: with regards to hot zone working, how can a clinician deliver degree or even regular paramedic care in a chemical environment wearing a gas tight suit and carrying heavy breathing apparatus? The suit includes thick, sometimes loose rubber gloves and provides limited vision through the visor. I realise that you have the EZ-IO drill which will help you gain access instead of trying to cannulate, but to crack ampoules, draw up drugs, prime a 3-way tap and secure an ET-tube would be extremely difficult and inherently dangerous, e.g. when dealing with sharps that could breach the suit. I would argue that delivering paramedic care in the hot zone is inappropriate and very difficult. I believe that patients should receive only basic intervention such as treatment for major haemorrhage, basic airway management and possibly auto-jet intra-muscular pain relief or antidote before moving to the warm zone. I think it is important to remember that the patient is still in the hot zone and the temptation may be to stay and play and struggle through interventions when instead, you should really be thinking about getting the patient to a respirable atmosphere, and quickly. I think we need to maintain an awareness of the bigger picture and make sure that we can safely add to a situation in order to benefit patients. We need to ensure that what we do not become task focused in the hot zone and delay a patient's journey to their detriment.

I have questioned the need for paramedics working in the hot zone of CBRN environments but on the other side of the argument I think that there are areas such as safe working at height (SWaH), whereby paramedics can do a great deal to help patients. I would like to use the example of a call I attended in 2011 when a man who was working in a roof space fell and fractured his femur on exposed floor beams at the base of the roof. HART facilitated the safe delivery of a paramedic who, wearing the correct PPE, secured themselves onto high beams and attended to the patient, giving them pain relief, applied a traction device to the fractured femur and then packaged them in conjunction with a fire service rope rescue team who then safely delivered the patient to ground level. Without HART, there are two ways that this call would have been dealt with: a paramedic crew would have climbed into the roof space, risking both themselves but also risking the patient. The patient had already fallen on the partially constructed floor so if a paramedic was to climb and stand on this possibly weakened structure, this would have created the possibility of a collapse of the whole floor. Alternatively, fire-fighters alone would have packaged the patient and lowered him down safely but at the expense of the extreme pain and further injury that the unmanaged fracture would have caused. There is no doubt that HART was needed and added a massive benefit to this patient.

So if HART can add more in certain incidents than others I would also have to question if you could afford to try and stay current and competent in all areas? HART personnel are expected to be at an acceptable standard as a paramedic, in a ballistics setting, in CR1, wearing breathing apparatus in a gas tight suit, in a PRPS suit, working at height and working in and around water. I anticipate that the counter argument will be that there is a dedicated training week every seven weeks but in response to that I would have to say that some people spend their entire careers training for just one of these areas. With clinicians possessing relatively new skills and with low levels of exposure in real incidents, I wonder to what level of competence and safety HART is working at?

The example I have to re-iterate this point is that after working for the East of England Ambulance Service HART, I undertook a tour with the Royal Air Force as a reservist medic and I thought what better preparation could I have had than working in HART. I thought that with all the advanced training I had had I would quickly be able to adapt to the high tempo work anticipated when working in a war zone because this is the sort of worst case scenario that HART is designed for after all isn't it?

I was wrong!

I hadn't realised how much I had de-skilled by hours spent on standby in HART. Even the basic fundamentals of paramedic practice had gone rusty. I hadn't been on a conventional ambulance for months, if not years, and big gaps in my knowledge had appeared whilst confidence had disappeared.

I didn't have much choice but to relearn the skills and quickly, but I will never forget the first call where this became apparent. I remember being handed a small child in the middle of a hot pick-up who received a significant head injury after getting injured from an indirect fire strike, and my first thoughts were: ‘I don't know where to start.’ This should have been automatic, but I stalled.

This is a really honest account of some of the difficulties I faced in HART. I didn't like that moment where I felt completely overwhelmed so I have since left HART so that I could concentrate on my core skills alone. I thought the HART concept was utterly amazing when it came about and I was very excited to be part of it. I have since realised that I can never be good at everything so in taking a step back I hope to be good at something.

It would be a brave person to say that we don't need HART and I would disagree with them strongly. I think that one of the biggest challenges facing HART is the plethora of skills required by an individual clinician, a low level of exposure and the consequent degradation of skills. In order for HART to be successful, I believe that staff need to have rotation and regular exposure to frontline operations. A consideration needs to be given to reducing the HART skill set so that staff can better focus and develop effectively instead of spreading themselves so thinly that their development is stunted and safety is threatened. HART needs to have strong leadership, with good discipline and crucially, have the ability to evolve with the risk/benefit ratio at the forefront of the planners’ mind.

Dear Sally,

Firstly, I would like to thank you for your reply to my article ‘Paramedic treatment—wherever that may be’. The HART programme, along with the paramedic skill set, will constantly evolve due to open and honest discussion and evidence-based practice.

Secondly, we have only completed the roll out of HART within England in the last 12 months, but with over 20 000 calls attended there is a growing bank of evidence for what works, or does not as the case may be.

Thirdly, HART is no different to any large scale programme in that what we thought would work and benefits patients does not and vice versa; for example, our DEFRA 3 capability has been one of our most widely used skills in allowing the paramedic to work with other agencies to obtain access to those communities cut off due to flood water and deliver care to those patients who are experiencing an exacerbation of underlying conditions such as asthma or bronchitis.

Fourthly, HART was introduced to deal with large scale mass casualty incidents such as 7/7, incidents which due to effective policing, have not been repeated. We have introduced a capability not a work stream and as such the calls received by the ambulance service can be dealt with more effectively, benefiting both the patient but also removing the moral pressure on a responding crew to put themselves at risk to get access to a patient.

To take your points in turn, the CBRN scenario, as with the article as a whole, was painted in a simplistic way; however, my Trust operates a policy of drawing drugs such as morphine in the outer cordon that can be then given to patients within the inner cordon reducing sharps issues. Also, the CBRN issue does need to be demystified as our perceptions of terrorist capability and indeed the extent of damage a chemical can cause have only recently been looked at from a more scientific standpoint. This can be seen in the EU funded Orchids Project, which states the use of dry decontamination as opposed to wet, is more realistic of what can be expected in a CBRN scenario, and this will be further reinforced through the IOR and SOR training that is being delivered to UK emergency services from this year.

The SWaH example is a good one and demonstrates the value of adding a paramedic to a team that is entering a risk area to recover a patient and how the patient outcome will be improved. This is not dissimilar to the use of HART in the current flooding situations we are seeing across the UK as detailed above.

The next few points are not unusual or unheard of given the different workloads and expectations of HART. I would like to challenge a few points and maybe be slightly contentious in that what we think a paramedic should be delivering from a clinical point of view and what patients we are sent to are not one of the same. We live in a safe society and most RTCs—as an example—do not involve serious trauma due to the capability of the modern car. Indeed, some figures suggest trauma is only a very, very small part of our work. Then one could argue that there is skill decay irrespective. In fact, the paramedic of 15 years ago is very different to the one we see today and given the recent report: Transforming urgent and emergency care services in England, that says we could leave 50% of our patients at home would mean 50% of calls are not life threatening. That is not to say these patients do not require care, but that we have a higher level of skills today that can prevent an unnecessary visit to A&E but also our skill base has broadened to deal with the wider scope of patients we now encounter. So, with that in mind, many readers of this magazine would be significantly challenged when handed a baby who has been injured following an indirect fire strike and your honesty in including the story and the difficulties you faced are to be commended and will help further the debate. HART are no different and are indeed an integral part of the ambulance service and will see the ups and downs of the least and most serious types of calls.

The final point with regards to skills mean that we are cost effective. Not something we would always like to discuss openly and will always be a challenge given the current financial backdrop all services are operating against and will always be an issue for highly trained teams such as HART.

Thanks again for your contacting and your points will help to further the debate and ensure through evidence based practice that our patients receive the care they need—wherever they may be.

Regards,

James Price HART CBRN NILO Manager