Menu

flobach.com

Contemplating life.

Collaboration & Specialisation

ambulance-157036_640

 

I recently attended the Blue Light Collaboration Conference in London representing the College of Paramedics. I was initially a little sceptical, as I don’t have much to do directly with collaboration between services apart from direct contact with them as an on road paramedic, but then I thought this may be a good opportunity to meet new people, see different perspectives and get some other thoughts.

And it delivered. There were many delegates from various UK Fire & Rescue Services, plus a few paramedic, police and government representatives. Due to this, the main `topic was the collaboration between paramedic and fire services – co responding, emergency response, joint response…different names for basically the same thing: Fire & Rescue Services with their decreasing workload assisting Paramedic Services with their increasing workload.

There are a couple of different models how this works, but the most advanced and integrated (or overlapping?) model comes from Lincolnshire, in the East Midlands of England. There, East Midlands Ambulance Service (EMAS) and Lincolnshire Fire & Rescue Services (LFRS) have been working together in an official capacity since 1998, and their current setup is a natural progression of pure first responder type scheme: In a UK first, Fire & Rescue are actually manning three ambulances.

In my opinion, the pros outweigh the cons: The Fire & Rescue Service have capacity to spare. Their workload has gone down significantly over the past decades, but the public still deserve a good level of fire protection. In between fire and rescue calls, there is only so much training one can do – why not utilise their time for medical transport? Ideally, fire cover should not suffer from this model, but have a thought and compare: the risk of morbidity and mortality of medical origin (mainly cardiac) outweighs the morbidity and mortality of a fiery origin by quite a high factor. Both Paramedic and Fire & Rescue Services have one single task when broken down to the bare essentials: to serve & protect the public. Why not collaborate in order to maximise our efforts and outcomes?

This direction also got me thinking one step further: What if Ambulance Services (you may have noticed I have been avoiding that term) focus on their core strength of providing healthcare to the public, and “outsource” the transport side of operations to other services or suppliers?

A true Paramedic Service would take requests for help from the public, and point them in the right direction. If they can be helped at the point of their initial query and be referred on to more appropriate services (e.g. home care, GP, pharmacy), that works in favour of the public (accessing the appropriate care as timely as possible), and in favour of the service (only sending paramedic resources to the patient when appropriate). If a Paramedic is required at the scene of an incident, they can decide if transport is necessary. All this is already happening in some services around the world, but lets take it one step further: The Paramedic on scene then needs transport capacity, as they respond in mobile rapid response units (fancy speak for cars or minivans). Enter Fire & Rescue Service: they provide the transport capabilities, with basic life support dual trained fire fighters. Should the patient be stable and only need transport, they they can be transported. Should they need ongoing paramedic intervention and/or monitoring, the paramedic can hop in the back of the fire ambulance, and paramedic care can be given en route until handover at hospital.

Currently, there are only three Fire & Rescue (F&R) Ambulances in Lincolnshire supporting the Ambulance Service in a transport capacity. But if F&R took charge of the entire transport side of things, Ambulance Services could turn in to dedicated Paramedic Services, and focus on delivering high quality paramedic care to the community, without the overhead and distraction of not only fleet maintenance but number of other areas. F&R Service would be able to use their resources more effectively, and not have to close fire stations, thus keeping up fire cover for the public.

The above lines are only a thought experiment taking the Lincolnshire model one step further, but it is an option to be considered. The people behind the pilot programme in Lincolnshire are due to publish some numbers based on their facts and figures over the past month (the preliminary data, I’ve been told, is promising). It will have to be properly evaluated and adapted to local needs, but  I believe this could be quite an exciting game changer. I will be watching these developments carefully and with a lot of interest.

366 days

366 days – a short film about a young paramedic in Austria.

These 12 minutes really brought back some memories, feeling and thoughts not only from when I started, but also where I am now. A very touching insight in to life as a Paramedic.

366 Days from Die Trickfilmer on Vimeo.

Follow your dreams…and your patient

“Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.”

Ernest Codman 1914

 

Let me adapt that to our profession, one hundred years later:

“Every Paramedic Service should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future. This information should be shared openly with staff for education purposes and to allow a greater interprofessional understanding of each role involved in patient care”

Florian Breitenbach 2014 (Thanks @MDuschl)

Keeping it real

Paramedic

In the EMJ Podcast from April 23, 2013 “The Wells scores for VTE” (iTunes link), a notion that is briefly mentioned and discussed is the move away from the “rule in/rule out” strategy for (possible) disease management in emergency medicine, instead employing clinical probability, the burden of disease and considering false negatives and false positives.

And how does this tie in to the world of Paramedicine? Let me demonstrate.

I’m sure most of us have responded to calls where patients have punched their minor ailments in to a computer, and the wonderful world wide web has diagnosed them with cancer, the black death, and being pregnant with triplets.

In a sense, paramedics often do similar things. We are quick to turn up to patient, assess them, expect the worst, then make them expect the worst, and transport them to hospital. Just in case. To be sure, to be sure.

The only thing that is sure is that it is clogging up the hospitals.

Instead of ruling a specific disease in “because we can”, how about emphasising clinical probability and disease severity, and weighing them up against each other? We need more training and education focussing on minor injuries and diseases, allowing us to recognise issues, and deal with them appropriately. More diagnostic kit is becoming increasingly mobile, with blood analysis now not only for glucose levels, but for white blood cell count, and more. A framework of robust clinical decision making guidelines for the well educated paramedic, together with optional online (phone/video) consulting for a second opinion and appropriate referral pathways is the way of the future.

The “You call, we hall, that’s all” paradigm is outdated.

Paramedics are specialists in unscheduled and emergency healthcare. Care right at your doorstep. An you won’t necessarily even have to cross it.

Minimum skill levels on emergency ambulances

If you phone for emergency medical assistance, you would think and hope that there is some sort of minimum set who will actually respond to your call for help.

Call in Germany, and you will be guaranteed that the arriving ambulance is staffed with at least one Rettungsassistent (see paragraph 25 of the Durchführungsverordnung HRDG vom 3. Januar 2011, this is for the state of Hesse).

Call in England, and…well…you might get a Paramedic, or a Technician, or both, or an Emergency Care Support Worker, all three, a mix…it’s up to the individual service. All I could find was the Health and Social Act (Regulation 22), which merely states:

In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.

 

To me, that reads a little like “if you can get by, then you’ll be alright”.

It’s high time for some research to be done in to this (I’ve just started), to ensure that skill levels when staffing frontline ambulances are evidence based, that they are cost effective, that they can deliver the care when and where they are needed. In other words: When a patients needs help, they get the help they need.

Thought I’d share a poster I recently created for uni about the possibility of merging Fire/Rescue Services with Paramedic Services in England. Acknowledgements and thanks to TJ for helping me craft the idea.

Constructive criticism welcome.

The Urge to Merge

Overtime

Work Life Balance. Source

#Paramedics: How much overtime/additional shifts do you do monthly, and why? For the money, for the fun, nothing better to do? #flobachpoll

 

The other day I was having a chat with a colleague about overtime shifts. We agreed that overtime is an easy way to earn some money on the side when saving up for something, and it’s something we generally enjoy doing. They added that because their partner works Monday to Friday 9-5, boredom can kick in easily, so rather than stay at home one may as well do an additional shift.
The discussion moved on to burnout, and how overtime may contribute to this. I thought I’d put this out to the greater twitter community via the above tweet, and got some interesting answers back. The general gist was that people do overtime for all three reasons, with an (somewhat unsurprising) emphasis on being underpaid and overworked in this profession.
Here are some of the highlights:

 

Work/life balance has been reported to be an important, if not the top priority amongst Gen Y employees – but we’d all like a little more money than we currently have. Is our race to own more burning us out – are we living over our means? Are paramedics underpaid, or is everybody else overpaid? Would the profession benefit from increased pay and/or other measures to reinstate a better work/life balance?

As always, I’d welcome your thoughts in the comments or on twitter.

An Insomniac’s Guide to…Professionalism

Yesterday, I went to the theatre.

Today, I did some study.

The connection? I read an article about “Becoming professional in the 21st century|. It is written that:

“Health care professionals of the 21st century cannot afford to be technically competent only; they need to be competent in social and communicative aspects of practice”.

This was said in a context of mainly communicating with the patient, but I would take it one step further: it is important for the profession; I would go as far as saying vital for an emerging profession (such as paramedicine) that members of the profession communicate and promote themselves as professionals to the public. Making a good impression (through proper treatment) on each individual patient is important, but equally important is to reach out to our “potential” clients. The public must know we take pride in our profession, study hard, work hard, can deal with a variety of situations and are becoming an integral part of healthcare, rather than just a transport adjunct to the hospital.

So, Yesterday? Yesterday, I went to the theatre to see a (possibly the worlds first) play based on a paramedic blog – namely InsomniacMedic himself. I can really recommend going if you are anywhere near London in the next few days. There are still tickets available…just go. After the play there was a Q&A session, so I asked the cast what knowledge they had of “our world” prior to having a role in this play, and then how playing a role had changed their perceptions. The answers were interesting: Most hadn’t had any contact with the ambulance service at all before and regarded the big yellow vans as part of the city landscape. One actor that had been a patient fairly recently stated that after a few panicked minutes, the attending crew managed to calm her down, make her comfortable and take her in to hospital for further treatment; she was impressed with the ‘ambulance drivers’ (followed by a palpable wince amongst the paramedics in the audience).

Only after they had been accepted for the role in the play did they start doing their research, and realise the world we work in. The lead actor said he started turning around, watching after ambulances passing him on the street. If he saw the paramedics attending the job near him, he would observe their actions from a distance (what he stated as “feeling weird, a little voyeuristic, kind of wrong but highly interesting”). Playing the roles of the different paramedics, the cast could immerse themselves in to the lives of paramedics, both professionally and personally; only then (and with the great help of the blog authors former student who was in charge of clinical oversight of the play) did they realise what our world is made up of.

I found this rather interesting, and it highlighted a point that many of us like to forget: the great majority of the public don’t know or sometimes even care about us – until they need us. If we want to improve our standing within the population, we need to have a stronger presence within the mind of the population. And that must come from each and every one of us, reaching out not only to those that are in need of our assistance, but to those who may need our assistance in the future. Everyone.

Hello, my name is

Hello, my name is anonymous

 

It is early in the morning, the break of dawn. A small army of heavily armed specialist police officers congregate behind a wall, around the corner of a house where a wanted suspect with a violent history is suspected. Police intelligence states he may very likely be armed. Last tactical plans are run through again, all members take their positions: Snipers are in place on the rooftop, a group of officers provide firearm cover behind trees in the front yard. The crashing of the battering ram against the front door pierces the silence, breaking it down on second impact.

The armed officers storm the building, guns drawn, making their presence very clear:

ARMED POLICE CARS! WE ARE ARMED POLICE CARS! SHOW YOURSELF! HANDS ABOVE YOUR HEAD!

Unfortunately, the suspect sustained a fatal gun shot wound from the police after laughing so hard he could not comply with the above shouted instructions.

– ~ –

Similar scenario, but instead of a violent criminal, inside the house is someone with a medical emergency who requested the attendance of health care professionals. Instead of a battering ram, a gloved finger gently pushes the doorbell…*ding dong*. Nothing can be heard from inside.

Ambulance! Hello!? Can you hear us? Ambulance! Hello!

No laughter this time.

So why is it acceptable that us paramedics are identified by our primary mode of transport? You may know I follow the International Paramedic naming convention, I even wrote more about it last year.

Now, having been in the UK and getting to know the system more, some difficulties arise. Not only is it very common for people within our profession to refer to themselves as “ambulance person” doing “ambulance work” – local legalities leave them little else to say it seems. The title “Paramedic” is protected in the UK – if you are not HCPC registered, yet still call yourself a paramedic, you are breaking the law. Plain and simple, great for the public, great for the profession (our Australian colleagues look over here with envious eyes), but it leaves us lingering with the question: “What do we call those who work alongside paramedics, but aren’t paramedics?”

There is only one level of Paramedic registration. A Paramedic here has a multitude of advanced skills and to become one nowadays, it is mandatory to have a degree in Paramedical Science. UK Ambulance services aren’t going to solely employ paramedics, they are teamed up with either (Emergency Medical) Technicians (a dying breed of BLS trained colleagues) or colleagues with very basic medical training (approx. one month),  and a driving licence that are called either Emergency Care Support Workers (ECSWs, Emergency Care Assistants (ECAs), Accident and Emergency Support or something in between. Their (unregulated) job is not officially recognised as that of a clinicians.

From personal experience, the vast majority of them a great people and a real asset to work with, generally eager to learn more with the prospect of becoming a paramedic in the future – but their meagre (official) training keeps them locked in a low rank that we cannot call a paramedic.

So – what to do?

Museum: Anaesthesia Heritage Centre, London

Semester is over. It’s been a particularly hard slog. What better way to sit back on the couch with some chips and an episode of Top Gear? That was last night. Can’t stay indoors all day, especially when its 20 degrees (Celsius, for everyone in the US) and a beautifully sunny day in London! So I continued on my “Museum Mission”, aiming to visit all of London’s Museums of Health & Medicine.

Today, I visited the Association of Anaesthetists of Great Britain and Ireland (AAGBI) – more specifically, the Anaesthesia Heritage Centre. A small museum, nonetheless with some interesting exhibitions and very friendly and helpful staff.

As George Santayana wrote over a hundred years ago:

Those who cannot remember the past are condemned to repeat it.

In other words: learn from the past. And we may as well learn from other peoples pasts while we’re at it. Apart from all the early forms of pain management (and their abuse), airway management and tools, one single thing struck me on this visit: Anaesthesia was initially poorly regarded amongst the medical profession for the first decades since its modern inception in the 1840s. Until 1935, when the Diploma of Anaesthetics was introduced, there was not even a formal way of qualifying as an Anaesthesiologist; indeed, many people who stated they were specialists in the field were ‘optimistic novices’, as Henry Featherstone, the founder of the AAGBI (in 1932) was quoted.

How do you regard the field of Anaesthetics today? Quite a complex and respectable part of medicine, I would hazard a guess.

If modern anaesthesia only began in the 1840s, that makes the entire (sub)profession approximately 170 years old. In the 1930s, when training became formalised and the AAGBI was founded to support its cause and standing, the profession had been around for around 90 years.

Let’s switch over to what this blog is all about: The wonderful world of Paramedicine. Although the concept of out of hospital care dates back to Dominique Jean Larrey in the Napoleonic Wars (around the 19th century), the first modern on road paramedics were trained in the early 1970s. That makes our profession less than 50 years old. And boy, don’t we have similar issues around the world: poorly regarded amongst other health professionals (and governments), and still some ‘optimistic novices’, amongst the unregulated profession. Sure, this was a generalisation, but parts of it are true in very many services – dig deep enough and I’m sure you will find evidence of it near you.

“So what?” I hear you say, “Time will sort it out!”. Well, time and a fair bit of effort – remember to support your profession, and the best way of doing that is by joining your professional body.

I’ll leave you with my favourite display item, a resuscitator from the 1960s. See if you can identify similarities and differences to our commonly used Bag Valve Mask from today!

Untitled

RESUSCITATOR, PORTABLE, MARK I

Instructions for Use.

  1. Lay the patient on his back.
  2. With a finger covered with a handkerchief clear his mouth and throat of mucus and any foreign matter
  3. Kneel or stand behind his head, place the face mask on his face with the lower rim under his chin so that his jaw is lifted up. This is important.
  4. Work the bellows steadily at about 16 strokes a minute. The thrust of the bellows should be upwards on his face so that his jaw is kept up.
  5. Watch the patient’s chest. It should rise with each down stroke of the bellows and fall during each up stroke.
  6. After about every 50 strokes of the bellows, clear the patients mouth and throat of mucus with a finger covered in a handkerchief.
  7. Continue resuscitation until the patient breathes naturally, or for at least 2 hours.