Paramedic practice in the UK is heavily based on robust and practical clinical guidelines and algorithms. These guidance documents may evolve from local or regionally-derived protocols to systematic national clinical practice guidelines based on current best evidence. Guidelines such as the UK Ambulance Services Clinical Practice Guidelines (Association of Ambulance Service Chief Executives, 2016) are universally adopted as the gold standard of practice. Although such guidelines are based on the premise of evidence-based practice (Joint Royal Colleges Ambulance Liaison Committee and Association of Ambulance Service Chief Executives, 2014), clinical medicine is full of gaps in evidence, not least in the pre-hospital environment where time pressures, clinical urgency, logistics, and complexity may hinder thorough scientific enquiry.
As a profession, paramedics are no longer the ‘ambulance drivers’ of the past; a new cadre of university-educated professional paramedics are now arriving for work with a more sound academic grounding than their generational predecessors. Furthermore, their pre-hospital physician colleagues are fully accredited pre-hospital emergency medicine (PHEM) practitioners with comprehensive PHEM training and on-going requirement for clinical excellence and revalidation. The direction of travel in the pre-hospital environment is one of improvement, optimisation, and professional development of paramedics and physicians alike. This should be integrated into care within seamless clinical pathways reaching into hospital practice and with patient-centred outcomes.
Scientific insight
As a natural consequence of increased demand for clinical excellence and improved outcomes for patients, there is a related increase in demand for sound academic foundations for pre-hospital treatment. While current guidelines are based on best available evidence, there is a desire to fill gaps in knowledge through further investigation including during clinical trials.
Paramedics should be encouraged to engage with the concept of evidence-based practice, and challenge the available evidence base in terms of its quality, source and level. Rather than continuing to blindly use protocols based on limited evidence, the entire pre-hospital community ought to design ways to put these protocols under increased scrutiny and determine the gaps requiring further investigation.
Recent trials in the pre-hospital environment such as PARAMEDIC (Perkins et al, 2015), PARAMEDIC2 (Warwick Clinical Trials Unit, 2015), Airways-2 (Clinical Trials and Evaluation Unit Bristol, 2014) and Golden Hour (National Institute for Health Research Surgical Reconstruction and Microbiological Research Centre, 2014) have done precisely that: they have aimed to establish a better evidence-base where one was lacking. The new generation of paramedics ought to say: ‘Show me the evidence!’ when following common procedures based on expert opinion rather than science.
Culture change
It is counter-culture for paramedics to question practice, and one could even argue that it is very much the norm to do the exact opposite. However, rather than being passengers in the evolution of pre-hospital medicine towards higher scientific and evidence-based standards, paramedics should be at the forefront—the ‘front line’—of innovation and advancement in their field. They should be drivers of change and leaders of pre-hospital research. Pre-hospital practitioners may be described as early adopters, and it is perhaps within this context that paramedics will emerge as pioneers of the future of pre-hospital research. We predict that the culture-change in the paramedic profession will be one where evidence is not only expected but demanded, and where it is standard practice to challenge the evidence base.
‘ Paramedics should be encouraged to engage with the concept of evidence-based practice, and challenge the available evidence base in terms of its quality, source and level ’
The future
It is an exciting time for the paramedic profession, a time where paramedics have the chance to shape the profession for themselves and for the patients that they treat.
With the profession's regulatory body, The Health and Care Professions Council, currently debating the threshold level of education for entry to the register as a paramedic (Health and Care Professions Council Education and Training Committee, 2015), the progression towards a more highly educated pre-hospital practitioner is upon us. This evolution must not stop with education alone. Modern paramedics must have ongoing, career-spanning active involvement in the development of evidence for pre-hospital practice, in particular with engagement in randomised controlled trials and high quality studies. The ‘gold standard’ in modern pre-hospital practice must be that which is evidence based and built on a foundation of scientific enquiry, and paramedics must continually ask their colleagues: ‘show me the evidence!’