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Contemplating life.

Collaboration & Specialisation

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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.

Bern Baby Bern

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Up next on the second day of the meet up was a guided tour of the Paramedic Service in the Swiss City of Bern, curiously named the “Sanitätspolizei”, literally “medical police”. I guess that gives a whole new meaning to the term “Cardiac Arrest”…

In reality though, the terminology can be explained historically – over a century ago, it was realised that a dedicated corps was needed to help people with medical problems in the community (well, get them to hospital). This group was recruited from the police force, and the police moniker stuck, although they have nothing to do with the police at all.

044When the service was being set up early last century, a specialised water rescue group was also needed. So the Sanitätspolizei got lumped with that too, and has proudly kept it to this day and age. Every ambulance is fitted to tow one of the many boats that can be found at their HQ.

 

The 6 day rota that staff work seemed interesting; day shifts on day 1 & 2, moving on to a night shift from the evening of day 3, finishing on the morning of day 4, and having day 5 & 6 off.

Far more interesting (read: different, strange) was the way vehicles are staffed. To understand this, I will list the “clinical points” that are given to staff of varying clinical grades:

  1. Student Paramedic, year 2
  2. Student Paramedic, year 3
  3. Qualified Paramedic
  4. Experienced Qualified Paramedic
  5. Experienced Qualified Paramedic with ICU/Anaesthesiology nursing qualifications, OR Junior Emergency Doctor
  6. Experienced Emergency Doctor

There are a pool of staff floating around the station (the only station in Bern) at any given time. Staff are not assigned to a specific vehicle during shift, or have a certain partner. When an emergency call comes in, the calltaker/dispatcher (same person) triages the call. Depending on the nature of the call, a varying amount of “clinical points” are needed to appropriately staff the vehicle. A patient transfer job (all done by these guys and girls) can be handled by a single qualified person, only three points are needed (there will always be a fully qualified Paramedic on every vehicle). If a call is deemed low to medium priority and needs (minimum of) six clinical points, it could be two qualified paramedics, or an experienced qualified paramedic with a year three student. Cardiac arrest calls have the highest point count at 9, and one of the staff have to have at least 4 points to their name. For calls like this, they try to put three staff on a vehicle.

To get the resource running, the dispatcher broadcasts the names of the staff that they want to respond, they go down to the garage, get a “job fax” (a printout stating the nature of the call). Staff then grab a vehicle, tell control what vehicle they are on, the call details are sent to that vehicle (including sat nav), and away they go. After a call is finished, the vehicle is returned to base, the crew restock and clean it, as it unlikely that they will use it themselves in that configuration again.

Confused much? So were we.

IMG_8208Emergency! Jackets and boots are not allowed past the garage, so staff leaver them here, ready for their next call

A few numbers before I leave you with a selection of vehicle pictures:

The Sanitätspolizei Bern

  • have 150 staff
    • 15 of those are office based. They are all qualified paramedics, and can respond to calls if need be (non-clinical work such as accountancy and HR are dealt with by the city of Bern, and are located elsewhere, separate from the service).
  • receive 186 000 calls for help annually (510 calls a day)
  • dispatch 39 000 calls annually
  • do both primary (75%) and secondary (25%) calls.
    • On average, once a week the water rescue team are dispatched. Approximately half of the staff are water rescue trained, both above the water (boats) and below (rescue divers).
    • 2% of secondary calls are made up of transporting corpses to the mortuary. These transports are done with neutral coloured vans with undercover lights and sirens if needed – an example given where expedited removal is needed is to clear the high speed rail lines after people have been hit by a train.
  • have a company policy that staff must use the sliding pole to reach the garage when called out. It is seen as too dangerous to use the stairs. This caused amusement amongst some of us, as in Germany many services have banned the use of sliding poles as it is seen as safer to use the stairs.

And now, finally, the moment you’ve been waiting for. Colorful cars!

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The group around a Mercedes Sprinter 315, coachwork by the German company Ambulanzmobile, type “Delfis”. This is the main type of emergency ambulance in use in Bern.

 

036Mainly used for nonemergency calls is the smaller VW T5, coachwork again from Ambulanzmobile, type “Hornis”. Can be used for emergencies as well, has all the same kit, just less room.

 

049The so called “Hochlang” (literally: talllong, because it is tall and long) built on a Mercedes E Class chassis is a dying breed – as they age, they will not be replaced by newer versions. They are primarily used for long distance transfers – colleagues who have used them love the smooth ride, but this comes at the expense of far less room compared to other types of vehicles.

 

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An officers/supervisor car, Mercedes ML.

 

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And they even have a Lambo in the garage!

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Thanks for additional pictures by © Nils Düster and (cc) Martin Greca. To get in touch with them, please contact me via the Contact! page

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

Who you gonna call?

My friend had a heart attack at a party we were at. We were all taken by surprise, and I dialled the paramedics as quickly as I could.

As his wife knelt by his side, she was frantically screaming

“How long is the bloody ambulance going to be!?”

“About twenty feet” is apparently not the answer she was looking for.

 

Moan and groan as much as you like – I had to laugh the first time I read this.

And now, before you strangle me because of my percieved bad sense of humour (you wouldn’t be the first one), hear me out. This has a serious twist to it.

What’s in a name?

A clear misunderstanding – the first person dials for medical assistance in the form of Paramedics, whilst the wife of the victim asks how long the vehicle will be.

Why?

Why is it so engrained in to the public mind that if you need medical assistance, you call for a big box on wheels with flashing lights and some bright paint splashed on the side.

If my house is being burgled, I don’t want a police car, I want police officers. If my garden is burning, I don’t want a fire truck, I want some firefighters. If my toilet is blocked, I don’t want a van with a tap and some tools in the back, I want a plumber. And so forth, I could carry on ad nauseum.

So why the fixation with our transportation device (which is in decline anyway, but Community Paramedicine, Paramedic Practitioners, treat and release is another story). Why the constant referral to our vehicle?

Any Paramedic is most likely to develop and burst an aneurysm very quickly if referred to as an “Ambulance Driver” all to often. We don’t like that. We do more than just drive the ambulance.

But no-one really bats an eyelid if the vehicle is called for assistance, without any proper regard to the professionals that actually staff the vehicle and perform the magic.

If you need medical assistance and call an ambulance, maybe the ambulance will help you get better. But since we don’t have vans that can drive autonomously, thats why we need “Ambulance Drivers’. They just drive the vehicle; they won’t attempt to help or heal you, the vehicle will do that. They just drive the ambulance.

Don’t believe me? Think I’m rabbiting on about nothing? Missing my point?

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At the Emergency Services Show 2012 (I wrote about it here and here) I came across many ambulances of all shapes and sizes. As you can see above, many things marked as an “Ambulance” had arms and legs, a torso, and a head on the top. But no flashing lights. Strange, since the Oxford Dictionary defines an ambulance as:

a vehicle equipped for taking sick or injured people to and from hospital, especially in emergencies

I doubt the bloke in the picture would really want to piggyback a sick or injured person all the way to hospital.

But the misnomers don’t stop there, oh no. What about “Ambulance Service”? Is this the local van dealership providing vehicles?

Here in the UK there is an organisation going by the name of NARU – the National Ambulance Resilience Unit. I suppose the splash very tough paint on the trucks, and maybe equip them with bulletproof tyres.

Then there is the AACE – the Association of Ambulance Chief Executives (also on twitter). When on shift, and I’m the clinically most senior person working, does that make me the Chief Executive on the Ambulance? What about when the ambulance is at the workshop? I take it the AACE are a bunch of people in charge of a lot of vans. Fleet managers I believe is what they call them.

Last but not least, the AACE have an “Ambulance Leadership Forum”. Sounds like an advanced driving course to me – how to lead my ambulance through heavy traffic, and around oddly placed cones on the ground.

I hope I have got my point across what we are not.

So then, if we aren’t a vehicle, what are we? Simple:

We are Paramedics.

We practice Paramedicine.

We study Paramedicine.

We (generally) work for Paramedic Services.

Canadians picked this up quickly (Ottawa Paramedic Services, Peel Regional Paramedic Services, to name a few). No matter what education, you are a Paramedic. Primary Care, Advanced Care, Critical Care…all just subdivisions: They are Paramedics. Some Australian states have picked it up in part (most notably New South Wales and Victoria).

I am aware of some of the legal minefields in different parts of the world (for example, the title “Paramedic” is reserved to those registered as a Paramedic in the UK, and anyone stating they are a paramedic without UK proper registration is committing an offence and can be prosecuted). But I will still refer to you all as Paramedics. You still practice Paramedicine.

Now its time for the rest of the world to wake up, and follow the naming guidelines from International Paramedic (I wrote about it earlier this year):

  • The Paramedic is the professional practitioner
  • Paramedic Service is the provider of emergency medical services staffed by paramedics; and
  • Paramedicine is the discipline and the area of medical study and knowledge.

What’s in a name? A whole lot. If we as a want to be taken seriously, we need to be referred to by our professional title. That doesn’t incorporate our vehicle.

It’s our profession.

I am a Paramedic.

International Guidelines and Protocols

Ever wanted to know how other paramedic services work? What drugs they use? What their algorithms look like?

Well, look no further. I trawled the internet, brought my old list up to date and stuck it all in a convenient PDF for your viewing convenience!

http://flobach.com/international-guidelines/

This is by no means an exhaustive list, but it’s a beginning nonetheless. If you know of any guidelines I have missed, please contact me, I’d like for this to grow.

Have fun!

Naming Conventions

Recent misunderstandings and differences in opinion have reminded me of the multitude of names (and misnomers) applied to our line of work.

For clarification and standardisation, I am using the International Paramedic recommendations:

  • The Paramedic is the professional practitioner
  • A Paramedic Service is the provider of emergency medical services staffed by paramedics; and
  • Paramedicine is the discipline and the area of medical study and knowledge.

Source: International Paramedic. Initiation Document (2011), retrieved from http://internationalparamedic.org