The ‘Home and away’ International pre-hospital care conference, joint–hosted by the British Association for Immediate Care (BASICS) and the Faculty of Pre-hospital care of the Royal College of Surgeons of Edinburgh, took place on the 12–13 October 2012 at the Holiday Inn, Walsall.
Attendees varied from doctors, nurses, paramedics and academics, all of whom shared the common purpose of improving and defining pre-hospital care within the UK, and exploring those lessons learned from events and situations which have tested emergency care across the globe over the past 12 months.
A range of talks and lectures on such topics as Treatment for Afghan civilians by Mr Jeff Evans, The Polar Bear Incident by Dr Chris Press and Time to bypass the resus room? by Mr Tom Konig were delivered over the two day conference, demonstrating the vast spectrum of global pre-hospital care and the myriad of challenges facing practitioners in the field from both a microcosmic and microcosmic perspective
An eloquent breakdown of many of the presentations delivered at the conference is provided at the back of this issue in the form of the College of Paramedics column, and so this article will attempt to give an overview of the conference, as well as a few presentations in particular that the author considers most applicable to the reader and the paramedic profession.
Surf and turf
One of the more curious presentations was delivered by Paul Savage on delivering emergency medicine in hostile or dangerous environments at sea. Titled: Big sick/little sick: good medicine in bad places. The latest RNLI Casualty Care programme, the presentation, along with Adrian Noon's
‘…the ‘sinew and cartilage of the affair’, an element, he said, so commonly underestimated by paramedics on entering the profession…’
PTSD
Perhaps the most interesting and pioneering talks delivered at the conference was given by Ian Truman, Lecturer at the School of Nursing, Midwifery and Physiotherapy at the University of Nottingham. The presentation explored the effects of post–traumatic stress disorder (PTSD), stress and burnout within the medical emergency services personnel. Titled: Post Traumatic Stress Affecting Responders, the presentation explored the long-term difficulties facing paramedics in dealing with traumatic incidents and the results of witnessing them. In what Truman referred to as one of the more ‘touchy feely’ lectures at the conference, he used a great deal of his own experience and memory from his personal paramedic practice to empathise and convey ideas and notions to the audience.
Truman spoke about the impingement upon the first responder's mind of what he called the ‘sinew and cartilage of the affair’, an element, he said, that is commonly underestimated by paramedics entering the profession, or transferring from unrelated fields, as well as those particularly harrowing incidents which can err even the most impervious and experienced practitioners. One case he recalled as particularly striking was an incident in which he attended a roadside accident in which a cyclist had suffered major trauma. Though, Truman explained, it was not the trauma that struck him so poignantly (something he had witnessed and
‘…Emphasising that no person, paramedic or not, can walk away from a severe trauma incident mentally untarnished…’
Continuing to stress the void between practice and reality in paramedic training, Truman noted the stark difference between using a plastic manikin and what he called the ‘real nitty gritty elements of the job’ in the field. As a result, argued Truman, regardless of the quality of the training given and the competence of the prospective paramedic, the experience of dealing with major trauma on a call out can never be replicated as to mitigate the impact of PTSD on the psychology of the paramedic.
‘I can think of two or three people who have left [the profession] completely as a result of seeing a particularly dire, traumatic incident,’ said Truman, adding that many of those who do leave had tried to deal with their issues themselves rather than confide in colleagues or talk to their superiors.
Truman then turned to the audience for reasons of why this may be, and the response given from the floor was intriguing; ‘not wanting to seem incompetent’, ‘not wishing to confide in colleagues as it may seem weak’, ‘wanting to keep a stiff upper lip in front of peers’ and ‘maintaining a macho image’, were offered by the assortment of doctors, nurses and paramedics in attendance.
Many members of the pre-hospital workforce therefore, are quite aware of the reasons behind their lack of willingness to talk about their issues, though few, it seems, are able to overcome this problem.
Truman urged paramedics to be more open about their experiences and share their problems with colleagues, emphasising again that no person, paramedic or not, can walk away from a severe trauma incident mentally untarnished. It seemed quite clear that, for Truman at least, acceptance of this vulnerability by paramedics was a major component in dealing with it.
The presentation then moved on to explain how the damage of keeping issues ‘bottled up’ will exacerbate them and potentially lead to irreversible mental damage— explaining behavioural patterns that can give away if a colleague may be struggling, and how performance may suffer as a result. Evoking the Yerkes-Dodson law, Truman admitted that an element of ‘productive stress’ was useful in practice, perhaps even necessary to achieve optimal performance, but that in the climate of reduced workforces and shuffling rotas by ambulance trusts to save money, that the level of stress now imposed on paramedics often surpasses this stress level for ‘optimal performance’.
The talk also addressed the (sometimes unhelpful) high level of expectation placed upon paramedics by the public, society and members of the public service sector. ‘There's this idea’, stated Truman, ‘that paramedics can deal with it, that everything will be fine, and that after an incident they will call in to base and say as much, but then,’ he asks, conversing with an imaginary colleague ‘why are you still telling me about this incident four years later?’. Clearly, and despite for the fact that it may part-and-parcel of the British sensibility, Truman stated that maintaining a ‘stiff upper lip’ perspective and dealing with difficult trauma incidents alone is never prudent, and that it can, in some cases, lead to trying to ‘dull’ the problem through less sustainable means.
Finally Truman mentioned the public's duty to reduce stress and burnout, as well as some of the more ‘unnecessary’ and ‘certainly less palatable’ elements of emergency care, most notably (and with rancerous agreement from the audience) the ‘high percentage of calls that don’t need an ambulance at half two in the morning when all it needed was a taxi’.
High speed
After a short break, attendees returned to see further breakout sessions, one of which, Andrew Reed's talk titled New high speed emergency driving legislation, explored the future changes to the training and practice of high speed emergency drivers in the UK, as well as giving some indication as to what these future guidelines might entail.
Reed, Head of Driver Training at the East of England Ambulance Trust pontificated that ‘competence will be key’ when deliberating the future of emergency driving policy.
‘…most notably (and with rancourous agreement from the audience) the ‘high percentage of calls that don’t need an ambulance at half two in the morning…’
Outlining the three key questions that needed answering in any new high speed driving legislation as; ‘what is high speed’, ‘who delivers the training?’ and ‘are training bodies to be accredited by the driving standards agency?’, Reed noted that in the past there has been too much focus put on the credentials and training, rather than the capabilities of emergency vehicle drivers.
‘The paramedic profession is evidently keen to identify itself as a single, unified faction, not only within the NHS, but also in the mind of the public…’
‘The most important factor [we] have got to realise’ he said, ‘is that with new drivers the most important factor [in their accreditation] is their competence’. ‘However, for the moment, he added, ‘we have to look at what is going to define, and what constitutes ‘competence’’.
Past present and future
The first day of the conference was rounded of by a general discussion about the future of pre-hospital care.
Throughout this open debate, attendees proved that not only is pre-hospital care undergoing a significant transformation of identity, but that it is ready to do so with or without the rest of the NHS. As the Health and Social Care Bill ambiguously stumbles and bumbles its way forward, the prehosptial sector, led by the paramedic profession, is evidently keen to identify itself as a single, unified faction, not only within the NHS, but also in the mind of the public and, perhaps most importantly, in the eyes of policy makers.
Clearly, the autonomy of the paramedic profession in the NHS has been growing for many years now, but more than ever, leaders of the pre-hospital sector are aiming to have their voices heard within the Commons and Whitehall as to have more say in the organisation, practice and jurisdiction of their profession. The most striking factor of the entire debate was that, when given an open vote, not one audience member objected to the assimilation of professional leadership in the pre-hospital care sector when suggested by Chairman of BASICS, Richard Steyn. This clear indication that attendees, (many of them BASICS members) raised no objection to their merging with other pre-hospital leadership bodies such as the College of Paramedics, shows great promise for the paramedic profession in particular, (as many would see them as the natural leaders of a united pre-hospital front). However, the motion was stifled slightly when the specifics of any possible action were discussed, losing momentum as few were keen to suggest just who was to lead a transition into a unified pre-hospital care organisation, whatever form it may take. The paramedic profession may still be finding its feet as an autonomous faction of healthcare within the UK, and as a part of the NHS, but it needs to decide whether it is to move forward separately, or as part of a unified pre-hospital front. A decision that will empower the profession in the long–term, but may compromise its agenda in the more immediate future.