It seems like yesterday I was taking my first steps as an adult learner in the BSc (Hons) Paramedic Practice programme at Edge Hill University (Springett et al, 2019). Now finishing up my final year (having taken a year out), once all assessments were complete, I had the opportunity to undertake an elective placement.
Choosing a placement
An elective placement is normally an experiential placement within a specialist area the student is interested in. When the time came for us to choose our elective placements, I decided to research paramedics in urgent care and how this service fits within the wider ambulance service model of care delivery. In keeping with the NHS long term plan (2019) and NHS recovery plan (2023), supporting more patients to remain at home and avoiding unnecessary hospital admissions is what I wanted to focus on.
Edge Hill has strong partnerships internationally, with the option to apply for one of many opportunities abroad. However, I wanted to experience an advanced paramedic practitioner urgent care (APP-UC) as my elective placement. Everywhere I looked, it all circled back to the APP-UC at the London Ambulance Service.
Initially, I found the contact for the programme lead and sent an email to introduce myself, explaining the elective, and my interest in urgent care and the LAS APP-UC programme. It was a little nerve-wracking, as Edge Hill did not have an associated link with the LAS and I had to make initial enquiries. However, my enquiry was warmly received and I was invited to meet the clinical practice development management for the programme, Georgette Eaton, who is also an editorial board member on the Journal of Paramedic Practice.
It was planned and agreed that the 2-week elective placement was to be split between the various areas operated by the APP-UC within three shifts on one of the solo response cars, one shift in a primary care practice, one shift in an urgent care centre and two in the emergency operations centre EOC). Since the placement was in London, I was required to relocate for the duration of the placement.
First steps: week one
On the first morning, I nervously made my way to the allocated ambulance station to meet the APP-UC I would be with that day. This was to be my first taste of the LAS, and it was nerve wracking. However, we hit off instantaneously, talked about what the average day for an APP-UC would look like, what to expect—and to expect the unexpected. We also discussed training and what is needed to become an APP-UC. We completed vehicle checks, I was shown the layout and the equipment of the car, where to find it and what we would take into each call/incident.
Then came the familiar sound of the radio and a call came through. The first patient of the day was a lady suffering with torticollis. Following a musculo-skeletal assessment of the head and neck, and an in-depth assessment, it was decided that the patient was well enough to remain at home, following a call to the patient's GP and a prescription for further pain killers. General worsening advice was given and we were off again.
We attended three other patients. One was a gentleman with a chest infection, and another with tonsilitis. These two patients received a thorough examination, which then led to the need for antibiotics, a phone call to each of the patient's GPs, and prescriptions were arranged and sent to the pharmacy for them to collect. Other APP-UC clinicians in the programme can prescribe medicines, but the person I was with had not completed the course yet. Again, robust worsening and sepsis advice were provided to both patients before our departure.
The final patient of the day was a lady who had received a palliative diagnosis only a few weeks earlier. This patient was being looked after at home, but the family was now unsure about what was happening. As my mentor explained to the family what was happening, I observed the caring and compassion with which this was done. We arranged for the local palliative care team to become involved in the patient's care, all while discussions with the patient's GP were taking place on how to make her comfortable. We spent a considerable amount of time with this patient and her family, arranging onward referrals to palliative care nurses, the patient's GP and the local hospice.
I was assured that the range of calls that were received made up a typical day. We then bode farewell at the end of the day, and I found that my head was spinning. I had witnessed everything we had been taught in university modules in action, making the correlation between the classroom and practice setting so much more real.
The following day, I attended a GP practice with another clinician. We saw 15 patients all before lunch. This included a variety of patient presentations, from children with chest infections and tonsillitis, to adults with acute flair ups of chronic conditions. These patients were either seen face-to-face or via telephone triage. It was brilliant to see the APP-UC switch between face-to-face and telephone consultation, still assessing the full age demographic seen out on the ambulances.
Wednesday brought about an afternoon in the EOC, witnessing the APP-UC clinicians review the call list and dispatch their colleagues on the cars. From here, I witnessed the the use of the GoodSam application, which is used by the LAS clinicians in the EOC to call back patients. It also has the ability video-call patients so that the clinician can assess a patient digitally before an attending clinician arrives. The clinician in EOC sends a text message to the patient's smartphone device, which the recipient accepts; it then opens the camera and allows for video calling. Calls using this technology included dislocated patellas and wounds requiring suturing.
On the Thursday, I attended a day in an urgent care centre. The day involved caring for a variety of patient presentations including minor injury management of soft tissue and musculoskeletal injuries. One was a teenager who had returned from a skiing trip with severe knee pain, along with two teenage boys who attended due to sustaining ankle injuries from football and rugby games earlier in the week. Another lady had injured her knee running that morning. Each of these four patients received a thorough musculoskeletal examination, presenting positive results for Ottawa Ankle rules, as well as on cruciate ligament tests. Every assessment that was undertaken further linked the modules I was undertaking in university to what it would be like practising as a qualified paramedic. I also witnessed an eye assessment of a metal worker who had a burr of metal in their eye, observing a slit lamp and eye examination, highlighting a graze on the cornea.
Delving in: week 2
The second week of placement included two car shifts and further experience within the EOC.
The first car shift included very much the same types of patient presentations as in the first shift; chest infections, a dislocated patella and soft tissue injuries required intervention. I observed the use of point-of-care blood testing, reducing the need for the patient's being admitted to hospital for blood tests. We attended a further palliative care patient who had a urine infection; we dipped her urine, identifying protein, blood and leucocytes in the sample. From this, a prescription was arranged through her GP and left at home with her family. We also attended a patient who reported feeling weak and lethargic, with a history of anaemia. Upon completing a full patient assessment, including an electrocardiogram (ECG), it was discovered that the patient was having a myocardial infarction. He was displaying none of the normal signs or symptoms of an ST segment elevation myocardial infarction (STEMI) and had no relevant or significant cardiac history. He was taken to the nearest primary percutaneous coronary intervention receiving hospital by an ambulance crew.
For another call, we attended to a patient in a high-rise office in central London, for a gentleman who had a seizure earlier in the day. He was initially recovering well, still in a very postictal state but was able to hold light conversation. However, company policy was to call an ambulance as the company first aider was not sure what to do next. We therefore attended, and I observed a full cranial nerve assessment along with an advanced patient assessment. The patient was recovering well and talking to us about going home and resting, when he went into another seizure, followed by two more seizures. Both myself and the APP-UC paramedic travelled to hospital with this patient, so I was present throughout the full patient journey.
This second time around in EOC, I spent some time with the clinicians in the clinical hub (CHUB). Clinicians working here call patients back and further assess their need for an ambulance. During my time in CHUB, I listened in to a range of category 2, 3 and 4 calls. One call that stood out to me was from a parent who was concerned that their young child had consumed seven multivitamin chewy tablets. Toxbase (database of UK national poisons information service, providing details on advice, features and management of toxic consumption) was checked to ensure the toxicity of the multivitamins in a young child.
There was also a call for a concerned spouse; a husband rang 999 for his wife, who presents as having a possible urine infection. The clinician triaged the call and appropriately re-directed the call to the patient's GP. Following this, there was a call for a lady receiving palliative care; the patient's family was unsure if she was struggling to breathe. The family was called back by the paramedic in the CHUB, and post assessment, it was deemed appropriate to pass the case to the local district nurses. However, upon speaking to them, they were unable to attend and the call was then passed to the APP-UC in EOC for one of the APP-UC on the road to attend. This showed me how cohesive the LAS is when triaging and allocating calls—ultimately trying all sources of intervention before dispatching ambulances where it is clinically appropriate.
Reflecting on the experience
I also had chance to speak to other clinicians in EOC. We discussed being a newly qualified paramedic and the opportunities available to paramedics within the LAS. I spoke to the APP-critical care, as well as some of the other dispatchers about their roles in EOC.
My time with the LAS has benefited me in many ways. As a 3rd year paramedic student, I am normally attending most incidents and take an active part in patient consultations, decision-making, care plan discussions and treatment, ensuring the patient is involved throughout.
To be involved, but in a different contextual setting, has been beneficial as I have had the opportunity to observe incidents like the status epilepticus patient and witness how the APP-UC programme serves to better provide for the patient. Observing the pathways available to LAS clinicians when attending to a palliative care patient has been inspiring. I had ample opportunity to talk to different clinicians, to gain advice and insight into their perspective on the incidents we attended. Being an observer meant I could be on the periphery of the incident, having situational awareness but be involved where appropriate.
It has been a positive experience to see the knowledge and skills I have been learning in university to then be applied to clinical settings in practice, from full cranial nerve assessments to assessing cruciate ligaments in the knee and implementing the Ottawa ankle rules. I have noticed that I have used some of the techniques I observed and applied them to my own patient assessments. I have been more contextually aware of the importance of a structured patient assessment, allowing me to feel more confident in my approach to assessment. This opportunity has taught me that the knowledge and skills I have achieved previously and skills that I am learning are all transferable and adaptable when I am on placement and beyond.
Looking ahead
I valued my time with the different clinicians by asking for advice and getting their opinions on what to do next. As a student about to qualify as a paramedic, there are many opportunities and employability options.
Overall, the experience has been excellent. The APP-UC programme is a scheme, which aims to lessen the burden on many areas of the NHS, from the 999 calls diverted from unnecessary hospital admissions, to having paramedics in GP and urgent care settings to see acute illnesses and injuries, thus increasing primary care capacity From my very limited exposure to the programme, I believe it would be beneficial to expand the presence of the APP-UC to other trusts.
On a more personal level, by the time I had finished the 2-week elective placement, I had decided that as a newly qualified paramedic, there are a lot of employment paths available within the paramedic profession and within the LAS—and this is where I would like my future career to be!