Managing Right Ventricular Myocardial Infarction: A Prehospital Service Evaluation

04/05/2022


Managing Right Ventricular Myocardial Infarction: A Prehospital Service Evaluation

By Mark Stanley 
Edits by Prof Joanne Garside and Dr John Stephenson 

Introduction
Traditionally, the focus of pre-hospital treatment of acute myocardial infarction is to reduce the impact on the left ventricle while customarily also, the impact on the right ventricle was largely unnoticed. Yet Cohen et al (1974) highlighted the express need for specifically tailored pre-hospital treatment for those with RMI.  Jacobs et al. (2003) further argued two fundamental interventions of pre-hospital care namely, that morphine and nitrates should be avoided in RVMI pre-hospital care. Furthermore, that giving fluids for hypotension is essential to maintain cardiac preload. 

RVMI is however, is a relative rarity occurring in less than 3% of all acute MIs. Nevertheless, RVMI have been found to occur in 30-50% of patients presenting with inferior wall MIs (IWMI) (Kakouros & Cokkinos, 2010) (Namana, et al., 2018). 

Pathophysiology 
The heart forms two pumps; the left ventricle, the high-pressure chamber, and the right ventricle, a low-pressure chamber sensitive to pre-load and after-load changes (Kelly & Cohen, 2008). Right ventricle myocardial damage causes reduced contractility, dilation, compliance and stroke volume, consequentially reducing left ventricular output (Pike, 2009; Kakouros & Cokkinos, 2010). Right ventricle dysfunction is predominantly influenced by venous volume and pressure to maintain adequate return, both of which can be compromised in RVMI (Garcia, 2015), reduction in either has a negative impact on cardiac output, resulting in complications such as hypotension and bradycardia.
Diagnosis of RVMI can be confirmed through clinical examination, the 12 lead Electrocardiograph (ECG), ultrasound and/or magnetic resonance imagining (MRI) (Kakouros & Cokkinos, 2010). In turn, inaccurate diagnosis of inferior MI with right ventricular involvement has a higher incidence of in-hospital short-term mortality (Pfisterer, 2003). More specifically, an IWMI patient with RVMI has a 17% mortality rate compared to inferior MI alone of only 6.3% (Inohara, Kohsaka, Fukuda, & Menon, 2013).
RVMI in-hospital management includes early recognition, early reperfusion, followed by (depending on size of MI), fluids for hypotension, inotropic support such as Dobutamine, while avoiding diuretics and nitrates (Namana et al., 2018; Kakouros & Cokkinos, 2010). 
The aim of this service evaluation, therefore, was to identify factors associated with acute MI diagnosis and possible RVMI involvement, clinical interventions and pre-hospital complications.

Methods
Patient records and 12-lead ECGs were reviewed from September to December 2018. Approval was received from the Ambulance Trust and anonymity was ensured through redaction of identifiable features. 

Data Collection 
1) Diagnostic data: Patient care records were organised and grouped by anterior or inferior MI. 
Within the inferior group, recognised as most often associated with possible RVMI/extension, STEMI anatomical territories were identified. RVMI/extension was also identified for each case utilising criteria for possible RVMI/extension diagnosis (Table 1). 

ECG Criteria

 

Non-ECG Criteria

 

  • IWMI & ST Elevation in lead III > ST Elevation lead II
  • Equal or >1 mm of elevation in the Right chest leads (V3R to V6R)
  • ST Elevation in V1 extending to V5 and V6.
  • ST Depression in lead II unless ST Elevation extending to V5 and V6.
  • ST Depression V2 cannot be more than half the ST elevation in aVF (< ½ = Inferior RVMI, > ½ = Inferior, RV and posterior a significant MI).
  • ST Elevation V1 or V1 – 3 or 4 with no Inferior reciprocal changes

 

  • Inferior wall MI + history of syncope
  • Hypotension systolic BP 90mmHg
  • Blood pressure drop >30mmHg post GTN
  • Bradycardia
  • Bradycardia, 2nd and 3rd degree blocks

 


Table 1 RVMI diagnostic criteria

2) Clinical intervention data was collected, including administration of morphine and glyceryl trinitrate (GTN). 
3) Pre-hospital complications data was included: cardiac arrest; hypotension with a systolic <90mmHg or a drop ≥30mmHg; bradycardia (<60 beats per minute (bpm)); any AV heart block; all periarrest arrythmias.
Data Analysis 
Descriptive findings were used to identify high-frequency outcomes. The association between identified complication outcomes and the interventions of GTN and morphine administration; and between suspected RVMI cases and STEMI territories was assessed using chi-squared testing. 

Results
A sample of 277 patients presented: 23 patients were excluded due to duplicate records (1), lack of adequate data (5), inter-hospital transfers (10) or other conditions (7). The remaining 254 patients were carried forward for analysis (table 2.0).

Variable

Mean (SD)

Age (years)

65.2 (14.3)

On scene to hospital time (minutes)

59.6 (22.1)

Variable

Frequency (valid %)

Gender (n=249)

Male

Female

Not recorded

 

179 (70.5%)

70 (27.6%)

5 (2.0%)

STEMI region/ territory

Anterior

Inferior

Lateral

Inferior(only)

Inferior Lateral

Inferior Posterior

Inferior Post Lateral

Posterior

Post Lateral

 

130 (51.2%)

124 (48.8%)

8 (3.2%)

83 (32.7%)

18 (7.1%)

14 (5.5%)

5 (2.0%)

1 (0.4%)

1 (0.4%

GTN administered

223 (87.8%)

Morphine administered

143 (56.3%)

Occurrence of complications

Cardiac arrest

Bradycardia

Hypotension

Blood pressure drop > 30 mmHg

Blocks (1st degree)

Blocks (3rd degree)

VF

VT

PVC Uni

PVC Multi

 

14 (5.5%)

72 (28.3%)

28 (11.0%)

38 (15.0%)

3 (1.2%)

2 (0.8%)

13 (5.1%)

3 (1.2%)

4 (1.6%)

4 (1.6%)

Possible RVMI

81 (31.9%)


Table 2: Descriptive summary of sample

The complications of cardiac arrest, bradycardia, hypotension and blood pressure drop ≥30 mmHg was identified as occurring in sufficient frequency for exploratory analysis of associations. Other outcomes did not occur with sufficient frequency and were not considered further. The dominance of the inferior territory in the STEMI group precluded the analysis of the effect of all individual MI territories: analysis was conducted on the effect of inferior territory only. 

Cardiac arrest
10 of 223 patients (4.5%) who received GTN and 4 of 29 patients (13.8%) who did not receive GTN experienced a cardiac arrest. Six of 143 patients (4.2%) who received morphine and 8 of 109 patients (7.3%) who did not receive morphine experienced a cardiac arrest. Hence the risk of cardiac arrest in patients who did not receive GTN was approximately 3 times the risk in patients who received GTN, and similar in patients who did and did not receive morphine. Chi-squared tests for association revealed evidence for association at the 5% significance level between GTN and cardiac arrest (2(1)=4.24; p=0.040); but no association between morphine administration and cardiac arrest (2(1)=1.17; p=0.280). 

Bradycardia 
30 of 83 patients (36.2%) classified as inferior STEMI and 42 of 171 patients (21.6%) not classified as inferior STEMI had bradycardia. Fifty-eight of 223 patients (26.0%) who received GTN and 13 of 29 patients (44.8%) who did not receive GTN experienced bradycardia. Forty of 143 patients (28.0%) who received morphine and 32 of 109 patients (29.4%) who did not receive morphine experienced bradycardia. Hence the risk of bradycardia was about 1.5 times greater in the inferior MI territory; approximately double in patients who did not receive GTN compared with those who did receive GTN; and similar in patients who did and did not receive morphine. 

Chi-squared tests for association revealed evidence for an association at the 5% significance level between GTN administration and bradycardia (2(1)=4.49; p=0.034); but no evidence for an association between the inferior infarct territory and cardiac arrest (2(1)=3.69; p=0.055) (albeit with a substantive association) or between morphine administration and low bradycardia (2(1)=0.058; p=0.809). 

Hypotension
Seventeen of 82 patients (20.7%) with inferior MI and 11 of 171 (6.4%) patients not classified as inferior MI had hypotension. Hence the proportion with hypotension was nearly 3 times greater in patients with inferior MI. Chi-squared test revealed the inferior MI territory was significantly associated with hypotension occurrence (2(1)=11.5; p=0.01).

BP reduction ≥30mmHg
37 out of 223 patients (16.6%) who received GTN and 4 out of 29 patients (13.8%) who did not receive GTN experienced ≥30mmHg BP reduction. Twenty-two out of 143 patients (15.4%) who received morphine and 19 out of 109 patients (17.4%) who did not receive morphine experienced excessive blood pressure reduction. Hence the risk of excessive BP reduction was similar in patients who did and did not receive GTN, and in patients who did and did not receive morphine. 
Chi-square tests for association revealed no evidence for association at the 5% significance level between GTN administration and excessive BP reduction (2(1)=0.148; p=0.701); or between morphine administration and excessive blood pressure reduction (2(1)=0.190; p=0.663). 

Outcome: RVMI/extension
30 out of 82 patients (36.6%) classified as inferior MI and 28 out of 168 patients not classified as inferior MI were classified as RVMI/extension (16.7%). Hence the proportion of patients classified as RVMI/extension was about double in the inferior MI territory. A chi-squared test for association revealed that the inferior MI territory was significantly associated with hypotension occurrence (2(1)=12.3; p<0.001).

Discussion
This study found evidence to suggest associations between hypotension and both GTN administration and inferior STEMI; with GTN administration lowering risk by approximately 3-fold; and inferior STEMI raising risk by about the same factor. Moye et al. (2005) argue the possible cause of the hypotension is due to sensitivity to nitrates. O'Rourke & Dell'Italia (2004), however, presume that the Bezhold-Jarish reflex causes hypotension and bradycardia in IWMI. 

Jaton (2017) maintains that nitrate-induced hypotension is easily treated by posture, and that GTN only has a short half-life limiting its effects yet maintains data from larger studies demonstrate that IWMI and other infarct territories have similar incidences of hypotension. 

Besides hypotension, administration of GTN was also significantly associated with cardiac arrest and low bradycardia, with GTN reducing the risk of these outcomes by factors of approximately 3 and 2 respectively. In-hospital, the administration of GTN during RVMI is avoided. 

Morphine has a vasodilatory effect (Acute Coronary Syndromes, 2017). The importance of excluding certain drugs in the management of RVMI has been noted in previous studies, for example vasodilators, diuretics and morphine (Kakouros & Cokkinos, 2010; O'Rourke & Dell'Italia, 2004). However, we demonstrated no significant associations between morphine and any of the measured complications of cardiac arrest, low bradycardia, hypotension and excessively reduced blood pressure. 

None of the factors tested for association with excessive blood pressure reduction were significant at the 5% significance level; however, a substantive association with inferior MI was observed. A reduction in blood pressure of ≥30mmHg may demonstrate the presence of RVMI: described as post-GTN hypotension or sensitivity to nitrates and ≥30mmHg BP below baseline the administration of GTN should be avoided (Boateng & Sanborn, 2013).

Electrical dysfunction is a complication of acute myocardial infarction (AMI) (Boateng & Sanborn, 2013). RVMI arrhythmias are common and contribute to the development of cardiogenic shock (Creamer, Edwards, & Nightingale, 1991). However, we found no evidence for a significant association between inferior MIs and cardiac arrest. 

Limitations
In the context of an exploratory analysis with no a priori hypotheses, significant associations may be interpreted as inconclusive but are certainly worthy of further study. 

Conclusion
The significant pre-hospital care link between IWMI and bradycardia needs to be taken very seriously, considering the statistically significant number of participants in the inferior STEMI group who became hypotensive post clinical intervention. Clinical interventions that could induce hypotension should be either avoided or given with great caution in patients with IWMI.  Hypotension in IWMI and nitrate-induced hypotension require more research, due to the close association in IWMI and significant BP drop. 
Hence, more in-depth research into this subject is required to evaluate the pathophysiological experience of the patient and to investigate the complications suffered by the patient and interventions in the hope of reducing early in-hospital mortality of STEMI patients with RVMI or RV extension.

The findings of this study lead to the recommendations that:
A right sided chest leads in all cases of IWMI
RVMI should be excluded from the diagnosis in all cases prior to GTN administration  
Further research on the management of RVMI in prehospital settings is strongly indicated












References
(2017). Acute Coronary Syndromes. In S. N. Brown, D. Kumar, M. Millins, & J. Mark (Eds.), UK Ambulance Services Clinical Prctice Guidelines 2016; Including 2017 supplementry guidelines (pp. 152-154). Bridgewater: Class Professional Publishing.
Boateng, S., & Sanborn, T. (2013). Acute Myocardial Infarction. Disease a Month, 83-96.
Creamer, J. E., Edwards, J. D., & Nightingale, P. (1991). Mechanism of shock associated with right ventricular infarction. British Heart Journal, 65, 62-67.
Jaton, E. (2017). Inferior Wall Acute Myocardial Infarction: Not as Preload Dependent as Once Thought. Air Medical Journal, 27-29.
Kakouros, N., & Cokkinos, D. V. (2010, October 18). Right ventricular myocardial infarction: pathophysiology, diagnosis, and management. Postgraduate Medical Journal, 86, 719-728. doi:10.1136/pgmj.2010.103887
(2016). Morphine Sulphate. In S. N. Brown, D. Kumar, M. Millins, & J. Mark (Eds.), UK Ambulance Services Clinical Practice Guidelines, Including 2017 supplementry Guidelines (pp. 347-350). Bridgewater: Class Professional Publishing.
Moye, S., Carney, M. F., Holstege, C., Mattu, A., & Brady, W. J. (2005). The electrocardiogram in right ventricular myocardial infarction. The American Journal of Emergency Medicine, 23, 793-799. doi:10.1016/j.ajem.2005.04.001
O'Rourke, R. A., & Dell'Italia, L. J. (2004). Diagnosis and Management of Right Ventricular Myocardial Infarction. Current Problems in Cardiology, 29(1), 6-47. doi:10.1016/S0146-2806(03)00193-2
Pike, R. (2009). Right Ventricular Myocardial Infarction. Canadian Journal of Crdiovascular Nursing, 6-8.
 

 

So, it's Ramadan!

04/04/2022


It's Ramadan! The holiest month of the Islamic calendar has arrived once more. This year it starts at the beginning of April 2022. Many Muslims throughout the world will fast during daylight hours during Ramadan for 30 days. Muslims demonstrate their fast by refraining from eating or drinking (even water) and sexual relations (yes sex - disappointing for some) amongst other things, from sunrise to sunset. The length of the fast will vary depending on where you are in the world. Muslims wake up before sunrise to have the morning meal – early I know!

Non-Muslims find Islam equally as fascinating and captivating as Muslims do, and one of the most commonly asked questions about Ramadan is, why Muslims fast during this blessed month? 

Ramadan is a month of intense religious observance. Prayer is performed with increased intensity.  This month was when the Quran (Muslims holy book) was revealed. 

Muslims spend time in prayer, reciting the Quran, doing charitable acts, practicing self-discipline and self-control as well as spending time with family and friends and encouraging unity. The month of Ramadan is an opportunity to practice endurance and self-discipline, as well as anger management and the control of malicious speech. It's an opportunity to fine-tune the body and rid it of obesity and sloth, as well as to reap the therapeutic benefits of fasting.

Ramadan is a month dedicated to awakening compassion and connection with others, especially the poor. During Ramadan, Muslims are encouraged to be more generous in their donations. Although Ramadan appears to be a challenging and a difficult month, it is actually a pleasant experience. In houses, mosques, and Muslim communities as a whole, there is a distinct atmosphere. Muslims look forward to Ramadan with tremendous eagerness and anticipation, and many are disappointed when the month comes to an end.

Now that COVID-19 restrictions have been eased, this Ramadan will be considerably different for many people compared to the previous two. People will be able to break their fasts with their families and friends, go to the mosque for congregational prayers, and celebrate Eid al-Fitr (the festival marking the end of Ramadhan) with their loved ones. 

If you're not sure how to help your Muslim coworkers in this month, consider the following suggestions:

    - Don't talk about how "crazy" fasting is in comparison to those who observe lent or Yom Kippur with your fasting pals. I know they are long days but if one billion people around the world can do it, they must not all be “crazy.”  
    - If you see someone eating, don't enquire if they're "cheating" because anyone with a medical condition is exempt. And there are a few other exemptions from fasting such as children, the elderly, and pregnant or menstruating women. So, try not to ask why your female coworker may not be fasting - as mother nature has allowed us a few days off! 
    - Don't make matters worse by apologising profusely and calling attention to people, while also embarrassing other individuals eating in front of them. You're not torturing us while you enjoy your food, if anything you might see me salivating while I enjoy the visual display. 
    - Don't be shy about asking if you can join us for dinner so you can see how Muslims break their fast. 
    - Enough of the don'ts – a little more of the do’s; You may support your colleagues in many different ways. Maybe you could try fasting yourself, it’s an unforgettable experience, trust me. Managers, team leaders and senior colleagues, try and support holiday requests from staff to take time off during Ramadan and/or Eid al Fitr. Allow meal breaks at different times, if possible - to coincide with the breaking of the fast. 
    - Do ask lots of questions; your Muslim colleagues will appreciate your interest in learning more about Islam. And just be open, I myself have tried to have open conversation with colleagues to ensure that they are aware of Ramadan and what it consists of. I've even offered to share my iftar meals with co-workers when I break my fast.  


There are challenges with fasting and working long hours but they can be eased or even overcome. Talk to your friends, colleagues and managers for support. One of my obstacles in Ramadan is praying the five daily prayers on a shift however, managers allowing time off to pray, especially at sunset, is very considerate and helpful. I have also noticed changes being implemented for staff such as prayer rooms being set up which is really beneficial in Ramadan. 

Fasting strives to bring the privileged and poor closer together, as the privileged experience hunger and learn to respect and appreciate those who are less fortunate. I hope you all have some time this month to contemplate, heal, and find peace. Remember those who have passed and keep them in your prayers while you appreciate moments with loved ones that are still with you. Ramadan Mubarak! 

Some phrases you can say to your Muslim colleagues: 

‘Ramadan Mubarak'
This means Blessed Ramadan, may Ramadan bring us blessings. It's the equivalent of saying Happy Ramadan.

'Ramadan Kareem'
This means Generous Ramadan, wishing people many good rewards during the month.


Article by Nagina Zaroof, MCPara

A Pioneer For The Paramedic Profession 

07/03/2022

A Pioneer For The Paramedic Profession 

Advanced Practitioner in Critical Care, Vicki Brown MCPara, has achieved many firsts during her illustrious career. Here, she talks to Natasha Weale, Press and Communications Officer at the College of Paramedics, about her paramedic journey and the job ad which started it all. 

When Vicki Brown was a little girl she always dreamed of becoming a vet. But somewhere along the way she swapped animals for humans and became one of the UK’s most accomplished paramedics, most recently becoming the first person to be registered on the Faculty of Pre-Hospital Care Register of Consultant (Level 8) Practitioners by qualifying from a purely paramedic background. It’s a remarkable achievement but then, Vicki, who lives in Gloucestershire, has spent her entire career pushing boundaries and challenging the status quo.  



“I’m very driven, work-wise and I’m always looking for the next challenge,” she confesses. “I’ve been called a trailblazer but really I just want to be a good role model for the next generation so that they know what can be achieved in our profession with a lot of hard work and determination.”  

Vicki, who is an Advanced Practitioner in Critical Care at Great Western Air Ambulance Charity (GWAAC), began her career as a trainee technician with Gloucestershire Ambulance Service in 2002, after seeing an advert for the job in her local paper.  

“To be honest, I’d never considered a career in paramedicine,” she explains. “Before I started as a paramedic, I worked as an assistant racehorse trainer and at the same time, also trained to become an acupuncturist. I suppose it was while I was doing the acupuncture that I became more interested in helping people, and after a friend suggested paramedicine, I thought ‘why not?’”  

Having successfully secured the job as a trainee technician, Vicki worked her way up to become an ambulance technician and then qualified as a paramedic in 2004, after completing a six-week course in Bolton. Between 2004 and 2006, while she was based in Gloucestershire, Vicki gained her teaching qualification and also became the station’s operational manager, proving, even in the early days of her career, that she was going to be a force to be reckoned with.  

By 2006, however, she had set her sights on working for the air ambulance service, despite it being very male dominated. “I realised it was going to be tough and had been told by people I knew who worked for the service not to get my hopes up. But I’ve never been one to shy away from a challenge and became even more determined to get through the application process,” she reveals. 

And succeed she did. Vicki was seconded to County Air Ambulance, now known as the Midlands Air Ambulance Charity (MAAC), which covers the counties of Gloucestershire, Worcestershire, Shropshire, Staffordshire, Herefordshire and the West Midlands for five or six shifts a month, while continuing to work as a road paramedic for Gloucestershire Ambulance Service. It was while working for County Air Ambulance that Vicki completed her HEMS Technical Crew Member Course, learning everything from aircraft safety, the weather, navigation and map-reading to helicopter inter-communications systems and the use of on-board medical equipment.  

In 2009, she achieved her Post Graduate Certificate in Pre-Hospital Critical Care and three years later joined GWAAC as a full-time critical care paramedic, now known as a Specialist Paramedic in Critical Care. She admits: “I’ve always been a bit of an adrenaline junkie so I think that’s why becoming a HEMS paramedic appealed to me so much. I loved going to trauma calls as a newly-qualified paramedic and now, working for the air ambulance I get to help the most critically ill and injured patients. When these people are having the worst day of their lives, knowing that we’re doing the utmost for them, and trying to make it better for them, is something I find very rewarding.”  

Working for GWAAC, which covers the areas of Bristol, Bath and North East Somerset, South Gloucestershire, Gloucestershire, North Somerset and parts of Wiltshire, means Vicki will either be on shift 7am to 7pm or 1pm to 1am. In her team, she could be joined by a critical care doctor, a trainee doctor, a Specialist Paramedic in Critical Care or a combination of all three roles. Alternatively, she could be on her own. There is a 30-strong clinical crew at GWAAC which, on average, attends five critical incidents a day. She says: “You never know what the day is going to bring but we always spend the first 15 minutes of each day preparing the drugs we’ll need for all the critical care incidents we’ll attend and checking that the equipment we require is available and in good working order.  

Next, we’ll have a briefing to go through the aviation side of things and confirm that everything is prepared and operational, and then once that is over, we’ll wait for the jobs to come in. Any downtime we have is spent training, which could mean simulation training or talking through recent cases to pick up and identify any learning points.”  



And learning, it seems, is at the heart of everything Vicki does. While she admits that she’s a naturally curious person, it’s her quest to broaden her knowledge, skillset, competence and ultimately, the profession itself which have propelled her into a different league altogether. Four years after completing her MSc in Advanced Practice, Vicki was appointed an Advanced Practitioner in Critical Care at GWAAC in 2020, in what was the first of its kind within the pre-hospital critical care environment. The role was developed and approved as a career pathway by SWASFT.  

In order to achieve this career milestone, Vicki had to have a Masters degree, carry out a minimum of three years working in Critical Care, two of which in a Pre-Hospital Critical Care Team, a Diploma in Immediate Medical Care, a completed Non-Medical Prescribing qualification and an extensive portfolio evidencing her work. She also needed to undertake a clinical examination and interview. On her final assessment, her performance was described as a ‘demonstration of mastery’ by the examining faculty which comprised of consultant clinicians in pre-hospital care, emergency medicine and intensive care.  

“That was very nice to hear,” she confesses. “But for me, the biggest thrill has been getting to the stage where I can do more for my patients because I can administer a lot more drugs now than I could before and autonomously, I can do interventions such as a thoracotomy or a resuscitative hysterotomy which I never thought I would have been able to do as a paramedic.”  

Not content with everything she has achieved, Vicki has continued to smash the glass ceiling by becoming the first paramedic in the country to be registered on the Faculty of Pre-Hospital Care Register of Consultant (Level 8) Practitioners by qualifying solely from a paramedic background. She achieved her registration last December after providing evidence to the Faculty of Pre-Hospital Care of her experience and knowledge by submitting portfolios of clinical and operational experience and attending an interview.  

It now means Vicki can do every intervention a doctor can do, outside a hospital setting, except for a pre-hospital emergency anaesthetic. But, of course, this is on her ‘To Do’ list, along with developing a Consultant Practitioner in Critical Care pathway for SWASFT. “That’s the next step,” she reveals. “I’d like to go into hospitals and undertake the anaesthetic competencies, as well as further in-hospital training but it’s just not possible at the moment because hospitals are too busy.”  

Despite being the first paramedic on the register to reach consultant status in pre-hospital care, the role doesn’t currently exist within SWASFT so Vicki is pushing hard to get it acknowledged, with the hope that one day it will be a nationally-recognised role in the profession.  

“It means having to write lots of documents and policies on what the competencies are behind this role but once I complete it SWASFT will then have a clear career pathway for all paramedics in their service and hopefully, it will inspire a future generation to reach the pinnacle of their careers,” says Vicki, who was the 2019 winner of the Paramedic of the Year award at the Association of Air Ambulance Awards of Excellence. It's clear that Vicki has certainly blazed a trail for other Specialist Paramedics in Critical Care to follow yet, ironically, she doesn’t see herself as different to anyone else. “If I can do it then anyone can,” she says. “Yes, I’m the first one but I’ve always looked at the bigger picture, about what we can achieve as a profession. I think the more you do, the more you want to do. I’ll never stop thinking about that next challenge or striving to break barriers. It’s who I am.” 

 

 

 

Celebrating International Women’s Day: where does this leave the paramedic profession?

07/03/2022

Celebrating International Women’s Day: where does this leave the paramedic profession?

Authors 
Caitlin Wilson  
University of Leeds; North West Ambulance Service NHS Trust  
ORCID iD: https://orcid.org/0000-0002-9854-4289
 
Larissa Stella  
Prothero East of England Ambulance Service NHS Trust  
ORCID iD: https://orcid.org/0000-0002-5440-8429
 
Julia Williams  
South East Coast Ambulance Service NHS Foundation Trust; University of Hertfordshire
ORCID iD: https://orcid.org/0000-0003-0796-5465
 
 
International Women’s Day 2022 has adopted the theme #BreakTheBias. It is encouraging people to look at how we can break the bias in our communities, in the education system and in the workplace. It promotes a vision of a gender equal world – one where diversity is celebrated and differences are valued. With growing numbers of women working in unscheduled, urgent and emergency care settings, what progress are we making within our working roles?  
 
Of the 1.3 million staff employed by the NHS, more than 75% are women, but how many work in UK ambulance settings? The ambulance workforce has been traditionally dominated by men; however, times are changing and now women represent 42.5% of ambulance staff across all service roles (NHS England, 2021). For UK paramedics, the Health and Care Professions Council (HCPC) reports 41.7% of paramedic registrants to be female and our profession remains the only one with more male than female registrants (HCPC, 2021). Looking to the future, hopefully this gender imbalance will be addressed by the increasing numbers of women on pre-registration degree programmes across the UK.  
 
But do women think of the health challenges they may face when entering the paramedic profession? There is evidence which shows shift-work negatively impacting both mental and physical health, including female reproductive health – that is, menstruation, pregnancy and the menopause (Harrington, 2001). Night shifts and long working hours can alter a woman’s circadian rhythm, affect hormone levels and disrupt the menstrual cycle. For women of child-bearing age, shift-working has been linked to increased risk of spontaneous abortion, low birth weight and prematurity (Fernandez et al., 2016; Stock et al., 2019). All women will experience a menopause transition when their oestrogen levels decline, and their menstrual periods cease. This typically occurs at 51 years; however, up to 10% of women can experience early menopause or premature ovarian insufficiency, which are both associated with typical menopausal symptoms (National Health Service, 2018). Also, transgender, non-binary and intersex people can experience the menopause. We should not forget our male colleagues in this discussion. As they work alongside us as crewmates or office colleagues, they too will experience our health challenges, and some will experience the male menopause as their testosterone levels fall (National Health Service, 2019). Menopausal symptoms can be challenging, and impact on personal well-being, workplace attendance and performance. Employer consideration of flexible working; maternity, paternity and adoption leave; childcare arrangements; alternative roles; and improved staff support may allow women and men to successfully balance work and family life and remain valued members of the ambulance workforce before retirement. Currently, there appears to be a paucity of evidence as to why and at what age women (and men) leave the ambulance profession and this is an area that would benefit from further exploration. 
 
 Linked to this is a need for more research on the daily experiences of women working in the ambulance setting. Bullying and harassment, including sexual harassment, have been reported in ambulance services in the UK and internationally. The ambulance profession has been referred to as a ‘boys’ club’ culture that is resistant to change (Manolchev & Lewis, 2021). In some countries there are examples of women-only ambulance services that provide female healthcare to communities with specific cultural requirements (Arab News, 2017; Julian, 2014). Understanding the roles, responsibilities and experiences of ambulance women in diverse clinical settings will enable appropriate support resources to be developed and female working lives to be improved.  
 
When we begin to look at leadership roles within ambulance services and across the broader NHS, these positions are predominantly held by men (NHS Digital, 2018). Figures from the UK Government (2021) Gender Pay Gap Service suggest that across ambulance services in England, women occupy lower paid jobs compared to men. This is illustrated by women making up on average only 42.8% of the highest hourly pay quarter, while the other quarters are split 50:50. This gap is narrowing within ambulance services and across the NHS over time, but more change is needed to support women to take up these leadership positions – ideally supported by research. 
 
 Speaking of research, this is one avenue of career progression for paramedics and one that is increasingly gaining traction in the UK. While no data are collected on the gender of research paramedics or ambulance staff pursuing clinical academic careers, the gender split of research leads in UK ambulance services is similar to that of senior positions overall: five out of 13 research leads are women. However, it is inspiring that the College of Paramedics head of research is a woman, and here on the British Paramedic Journal editorial board, both women and men (3:5) are represented. 
 
But what about when it comes to disseminating our research? Nowadays, conference organisers consider a balanced selection of speakers – be that of gender, ethnicity, topic areas or roles. And what about publications? The BPJ editors have recognised this journal does not collect author demographic information (including gender), so cannot report this information. We are now discussing the introduction of a voluntary gender-identity question for authors. This will enable us to report author gender and relevant gender-related trends in our research publications.  
 
Lastly, while the focus of this International Women’s Day editorial is on women in the ambulance service and paramedic research, it is not our intention to dismiss the challenges of men and non-binary individuals in the ambulance and research workforce. We recognise the need to work together to advance the evidence-base for the whole paramedic profession.  
 
Author contributions  
CW and LSP are joint first authors as they developed the initial draft for this manuscript. All three authors jointly revised the manuscript for publication. All three authors are on the BPJ editorial board.  


First published in 
British Paramedic Journal 1 March 2022, vol. 6(4) 1–2  
© The Author(s) 2022  
ISSN 1478–4726  
https://doi.org/10.29045/14784726.2022.03.6.4.1  
Reprints and permissions: info@class.co.uk  
The BPJ is the journal of the College of Paramedics: www.collegeofparamedics.co.uk 
 
References  
 
Arab News. (2017). Dubai launches women-only ambulance service. https://www.arabnews.pk/node/1123636/offbeat.  
 
Fernandez, R. C., Marino, J. L., Varcoe, T. J., Davis, S., Moran, L. J., Rumbold, A. R., Brown, H. M., Whitrow, M. J., Davies, M. J., & Moore, V. M. (2016). Fixed or rotating night shift work undertaken by women: Implications for fertility and miscarriage. Seminars in Reproductive Medicine, 34(02), 74–82.  
 
Harrington, J. M. (2001). Health effects of shift work and extended hours of work. Occupational and Environmental Medicine, 58, 68–72.  
 
Health and Care Professions Council. (2021). Registrant snapshot – 1 September 2021. https://www.hcpc-uk.org/about-us/insights-and-data/the-register/registrant-snapshot-sept-2021/.  
 
Julian, H. L. (2014). New Jewish ambulance in Brooklyn ‘for women only’. The Jewish Press. https://www.jewishpress.com/news/breaking-news/new-jewish-ambulance-in-brooklyn-for-women-only/2014/06/19/.  
 
Manolchev, C., & Lewis, D. (2021). A tale of two trusts: Case study analysis of bullying and negative behaviours in the UK ambulance service. Public Money & Management. https://doi.org/10.1080/09540962.2021.1934995.
 
National Health Service. (2018). Menopause. https://www.nhs.uk/conditions/menopause/.
 
National Health Service. (2019). The ‘male menopause’. https://www.nhs.uk/conditions/male-menopause/.
 
NHS Digital. (2018). Narrowing of NHS gender divide but men still the majority in senior roles. https://digital.nhs.uk/news/2018/narrowing-of-nhs-gender-divide-but-men-still-the-majority-in-senior-roles.
 
NHS England. (2021). NHS celebrates the vital role hundreds of thousands of women have played in the pandemic. https://www.england.nhs.uk/2021/03/nhs-celebrates-the-vital-role-hundreds-of-thousands-of-women-have-played-in-the-pandemic/.
 
Stock, D., Knight, J. A., Raboud, J., Cotterchio, M., Strohmaier, S., Willett, W., Eliassen, A. H., Rosner, B., Hankinson, S. E., & Schernhammer, E. (2019). Rotating night shift work and menopausal age. Human Reproduction, 34(3), 539–548.  
 
UK Government. (2021). Gender pay gap service. https://gender-pay-gap.service.gov.uk/. 

 

 

The Power of Advocates and Supporters

07/03/2022

The Power of Advocates and Supporters 

Gemma Howlett MCPara, member of the College of Paramedics Diversity Steering Group introduces Nicola Hunt MCPara, Chair of London Ambulance Service (LAS) Women’s Network. 


As part of my work with the College’s Diversity Steering Group I have had the great pleasure of talking to, and hearing stories from a variety of truly inspirational people, for which I will be forever grateful. For previous International Women’s Day celebrations, I have interviewed Yvonne Ormston, one of the very few women to have held the title of Chief of an ambulance service and Becky Connelly, a true advocate for equality and diversity, who is a pivotal member of the Diversity Steering Group. This year, I got to interview another exceptional woman, Nicola Hunt, the Chair of the newly-formed London Ambulance Service Women’s Network, and one of the first HCPC apprentice board members. Hers is a story of phenomenal determination, difficult circumstances, the overcoming of adversity and one that showcases the importance of role models and champions. It highlights the pivotal part played by the people around us who dare us to be better, who help us in different ways at different times in our journeys. The people who have such a profound impact on you that they not only help you but prompt a desire in you to pay it forward, for you to go on and be the person in someone’s corner, encouraging them to reach their potential, to reach for big things.  



Nicola joined the London Ambulance Service in July 2005, a week after the 7/7 bombings. While some people may have questioned their decision after witnessing such a horrible event, Nicola knew that this was the career for her. She was excited to start and threw herself into the role with great passion and enthusiasm. The joining age at the time was 21 so Nicola had some time from leaving school before she could embark on her career. She never considered university, growing up in a socio-economically deprived part of London, it just wasn’t something that people like her did, or so she thought at the time. Nicola had at the time undiagnosed dyslexia and ADHD so found some aspects of education challenging due to a lack of the right support. No one in Nicola’s family had been to university so it was not something that she gave any thought to. Instead, Nicola enrolled in a local college and did a BTEC diploma in public services. She joined as an Emergency Medical Technician (EMT) and loved the role; she remembers the feeling of excitement and thrill whenever the emergency phone rang. She always looked up to the paramedics in the service and hoped that one day, she too would reach that level. In 2014, Nicola finally took the plunge and successfully enrolled on to a paramedic course, nine years after first joining the service. By the time Nicola had earned a place on the programme she had two young children and it was difficult to balance the demands of study and work with being a mum. Nicola hired a nanny, which took up more than 50 per cent of her monthly pay check, but she felt it was one of the only options she had.  

Nicola achieved her paramedic qualification and was proud of her achievements but with over 10 years’ experience in the ambulance service she had started to feel restless, frustrated by what she felt was a lack of opportunity. She had a performance and development review with a team leader and discussed how she felt. She had had enough and felt like she was going nowhere. Her relationship with her children’s dad had broken down, in part due to the sacrifices she’d had to make and the amount of time she’d had to dedicate to her dream of becoming a paramedic. She felt like a victim. This meeting turned out to be pivotal in what Nicola went on to do next. The team leader listened and then asked one question, ‘what are you going to do about it?’ Taken aback initially, the question was a good one. Nicola discussed her desire to go into education, she wanted to help students in general but particularly ones like her, ones with learning difficulties, ones who needed more or just different support to achieve what they were capable of. If she wanted to do these things then she was going to have to go after the opportunities and put herself in the mix. Shortly afterwards, and supported by LAS, she enrolled on her BSc top-up degree with the University of Cumbria. Racked with self-doubt, initially Nicola questioned her decision to take part and didn’t really believe that she would be able to complete the programme.  

But thanks to the truly supportive approach of team and course leaders Nicola excelled, proving to herself that she wasn’t the problem; she just needed fair and reasonable adjustments, support that suited her, and a course team that encouraged her. It felt good, it felt like for the first time the sky was the limit. Sadly though, fate once again conspired against Nicola. Her mother, one of her main inspirations, a strong woman who had grown up in tough circumstances, and who struggled to make ends meet while striving to offer the best for her children, became terminally ill. Nicola studied one of the modules on her top up degree at her mother’s palliative care bedside.  

Nicola’s mother died with Nicola and her sister sat at her bedside. The first inspiring and strong woman in her life was gone but had left a determination and fierce spirit in Nicola, one that has clearly helped overcome much adversity and will continue to do so when needed, I am sure. Nicola started her longed-for role in education. The woman who as a school leaver, did not think university was for her, now had a first-class honours degree and was starting on her postgraduate certificate of education. Which it is important to say, she passed with flying colours also.  


Elaine Rudge 
3rd November 1947 - 23rd November 2019

The journey into education also led to another pivotal person in Nicola’s journey. Whilst working in the education department Nicola met one of the senior directors of the organisation. Nicola recalls being on a Teams call from home with senior leader, Tina Ivanov one day (Tina no longer works at LAS) and her daughter asked her who she was. Nicola said “this is my boss, one of my big bosses” and her daughter said “but she’s not a man, she can’t be the boss.” Society, the world, and her experiences up to now had told Nicola’s daughter that bosses were men. There had been no specific conversations on this in the household as far as Nicola could remember, it had just been absorbed. This was something that both Nicola and the director wanted to address. A video arrived for Nicola’s daughter from the leader telling her that if she wanted to be the big boss one day then she absolutely could, and she should aim high. What a role model for both Nicola and her daughter. It is much easier to be what you can see, which is why representation really does matter. The version of what is possible, what is perceived as ‘normal’ is set very young and can take a long time to redress. Nicola sought counsel from this senior figure, voicing her frustrations, her want for change and her desire to progress. The woman advised that she try and get some board experience, to start to understand how decisions are made. This was a clear goal, but Nicola initially had no idea how to achieve it.  

Then by a very happy coincidence, the HCPC launched their innovative and trailblazing apprentice board member position. The HCPC were actively looking for people with no previous board experience and would provide mentorship from senior council members for the apprentices, they wanted them to be actively involved in public interest matters (HCPC, 2020). The advice was to gain experience on a board and now here was the opportunity. Nicola applied for the role and was surprised to be interviewed by an all-female panel, including the chair of the council, Christine Elliot. Nicola recalls being notably taken aback by the panel, her image of a board was typically male. 

The board that had embraced her, that had accessibility and opportunity in mind when they launched the apprenticeship scheme, was clearly different from what was the norm. They wanted to provide access to the seat of power for those who would not normally be granted it. Maybe because they were women, maybe because they too had faced obstacles, barriers, limited opportunities, a tough ride to even get to the glass ceiling, let alone smash through it. Whatever the motivation, it provided Nicola with an amazing chance and experience that she embraced wholeheartedly and one that she was not going to let pass her by.  

The experience allowed for a view into decision-making, how complex the systems are, the considerations that need to be made, the processes that need to be followed. It was a world away from Nicola’s original assumptions and perceptions. Every member of the board gave her time, understanding, they listened to Nicola’s views and wanted to understand her story. Nicola was given a mentor, another woman to help navigate her through the process, to help her make the most of the opportunity. Nicola feels strongly that due to the female representation on the board it helped her feel seen, it helped her feel heard. They all had very different stories, some were privileged in terms of education, and opportunities, some were not. 

Nicola’s preconceived ideas and assumptions about who got to sit on a board were all challenged. It stands to reason that if more boards were diverse then the more people would be willing to involve themselves in them, to want to be part of the decision-making processes, to feel enabled to do so, this would inevitably help to move away from white middle class male dominated boards. Nicola learned for the first time how to run a formal meeting, how it is formatted, how board papers are used and why they are needed, an understanding of the thoroughness, and therefore perceived slowness of decisions. When her year-long apprenticeship ended Nicola was back on the lookout for the next opportunity, the next position where she could make a positive change. 

As Nicola explained, the HCPC apprenticeship had offered her an experience that she may never have gone for if she had not been encouraged by that team leader to change her situation, by being motivated and pushed by the senior leader in her organisation, she would not have had access to unless some of the actual and perceived barriers had been removed, if the welcome sign had not been so visibly put up. I hope that more organisations start to embrace this practice and find ways to welcome all onto boards and into senior roles by actively removing barriers. Achieving her academic qualifications, getting out of the rut she had found herself in and making positive changes and embarking on the role helped Nicola in many ways. She has embraced her ADHD and understands it more, she now views it as her superpower, it makes her more determined to achieve, when she sets her mind on something she will do everything she can to get it. The role with the HCPC also helped build her confidence, it helped her see her worth, that she was important, she did and should have a voice. The opportunity encouraged Nicola to not only want to be involved in the network but gave her the confidence to want to chair it.  

The Women’s Network had been started by Alex Ulrich, an LAS APP in critical care paramedic. She was unable to stay on as chair due to taking maternity leave just after its start, but it is thanks to her that it was up and running. She is a pivotal part in the network’s story and Nicola and the rest of the network members, are extremely grateful for her efforts in getting it off the ground. The Women’s Network and the other staff networks in the LAS have been hugely supported by London Ambulance Service Chief Executive, Daniel Elkeles. He has provided support of the networks, allowing people allocated work time to carry out network activities. Allies such as Daniel and other senior figures are vitally important in the fight for equality in any organisation. Six out of thirteen members of LAS’s Board are female. It is heartening to see this representation in ambulance services now. As Nicola observes the support and recognition of the work carried out by network chairs and members is vital, it is a tough road fighting the fight without it, it can lead to anger and frustration, a feeling of hopelessness, it can lead to brilliant people being unable to carry on anymore as the sacrifices become too great.  

It is early days for the network but Nicola has two key aims that she feels are vital for it to work: the safety of women in the ambulance service and career progression of women. Nicola stresses the importance of women feeling and being safe at work, protected from sexual or gender harassment and feels that these issues run at the core of several problems for women nationally in the ambulance sector. Women being represented in roles at senior level, is also high on her agenda.  

Women’s networks across the country need to be at the forefront of this fight. Shining a light on the problem, raising awareness to senior management through network channels, encouraging women to call it out. However, and it is very important to point out, it is not just a problem that women have to solve, that is treading into the realms of asking women to wave down buses for help if they feel in danger rather than addressing the perpetrators.  

Men and women need to be at the heart of the solution at all levels of the ambulance service. But these solutions need to be coordinated, strategised and informed by women. Nicola also wants to help ensure that women have the same opportunities as men in the ambulance service, creating an even field, where all women have the same chances. Pushing for more flexible working opportunities in line with the NHS Flex movement. Challenging culture, enabling a culture that allows people to call out unacceptable and inappropriate behaviour. There is a long list of things to do but I am excited to see what happens next, to see what Nicola and the network can achieve and I urge any women reading this in LAS or in any other service to please join your women’s network, there is strength in numbers. If there isn’t a network in your area, start one. It is important that women have a space to coordinate, to lead, to make things better for all women. There needs to be more opportunities for women, whether we like it or not we still have to fight for these things, the playing field is still far from equal. Men, we need your help too, find out what you can do to help, how you can be an ally. 

I am sure our profession will be enriched by these improvements, but we need everyone to help. #BeTheChange 

 
 
 

 

 

Defying Stereotypes: Women in the Ambulance Service

07/03/2022

Defying Stereotypes: Women in the Ambulance Service 
By Mahdiyah Bandali MCPara, Paramedic 

 
Defined as ‘a preconceived and oversimplified idea of the characteristics which typify a person, race or community which may lead to treating them in a particular way’ by the Oxford University Press (2022), stereotypes exist in every community and can act as barriers to not only understanding an individual’s identity truly, but also for the individual themselves to access different opportunities. In becoming part of the ambulance service, whether it be a clinician, call handler, manager or other, we have all had a unique journey to these roles. Often, many of us will face different hurdles or obstacles that those around us may not be able to empathise with or struggle to understand. These can be formed of many different attributes: the way you look, the accent you have, the place you grew up, which each in turn will come with predisposed opinions within society. And as a frontline public-facing profession, this can become even more of a challenge when we do not have a choice of who we may be sent to. I spoke to three individuals, each with a stereotype they had to tackle in their journey into becoming a paramedic, and their experiences in the ambulance service. 

 
Waranya Kaewkhiew  
Student Paramedic  

 

Did you face any stereotypes during your practice placements as a student paramedic, or even before you came into the profession?  
I tend to just ignore stereotypes or push them to the back of my mind, however they become really evident and frustrating when people, crew-mates and patients, start to play the guessing game of my race in practice.  
 
Southeast Asian women tend to be on the smaller side, and many fellow colleagues, patients and even my family often will comment on how small I am which makes me doubt my place in the ambulance service. It makes me feel like I don’t belong because I’m ‘too small’ to manually handle larger patients or I can’t carry all the equipment. 

How do you feel in terms of your personal progression in the ambulance service as a Southeast Asian woman?  
At first, when I started my degree I was confident and I was ready to do anything and everything to impress my mentor. But my confidence began to drop slowly when I started experiencing racial abuse from patients or even certain paramedics I worked with (this happened once and I’m glad that I haven’t worked with him since). They would start commenting on Thai people being prostitutes which has nothing to do with me but it affects me because I’m Thai. Sometimes it wasn’t just the slurs, sometimes it would be the nice patient trying to guess whether I’m Japanese or Chinese that just got frustrating.  
 
Me, coming to terms with my place in this profession is trying to work on my confidence and strength through family. Sometimes I choose to ignore it, I don’t want to. I’m just scared if I act upon certain comments, it will turn back on me. I guess I’m just trying to work on myself. 

 
Emma Varney  
Paramedic  

 
Tell me about yourself and your journey  
My name is Emma, and I am a qualified paramedic. I have been diagnosed with Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). There is often a very stigmatised stereotype when it comes to autism, and it is often missed in females by health care professionals due to females not meeting the ‘standard’ characteristics of autism. Women with autism are often more likely to be able to mask socio-communicative impairments through methods such as forcing eye contact, preparing conversation ahead of time to use in conversation and mimicking the social behaviours of others.  
 
Male and female autism share some similarities but overall women with autism tend to present differently than men. As a result, many women are still struggling to get the support they need and judge themselves harshly for finding life difficult. A fundamental issue with the current diagnosis procedure is that the behavioural markers used as a diagnostic criteria are based on pre-existing concepts of what autistic behaviours look like. These have been developed based on predominately male populations previously identified as autistic.  
 
How has this impacted you generally and as a paramedic?  
I did not get my diagnosis until later in life when I was 23. I was a well-behaved but quiet child, therefore nothing was ever picked up all throughout my school years. My journey into the profession was not easy, I often felt like I was watching every other student paramedic excel and could not understand why I was struggling so much, especially with my confidence. For a long time, I felt I didn’t fit in to the profession, I was so scared of being seen as different that I became quiet and scared. I worried if I mentioned my diagnosis, people may have a predetermined judgement of how I will act, based on the more common characteristics of autism people are taught.  
 
It was not until I was placed with a mentor who, understood my previous struggles on placement, gave me the support, time and help I needed to shape me into the paramedic I am today. She pushed me in a positive way, with no judgement, only kind words and constructive criticism and because of her I was able to grow and build my confidence, suddenly things clicked into place.  
 
How do you feel now in terms of your place in the profession?  
Overtime, the diagnosis became just that and with the right people around me and the right support I was able to become a confident, strong individual and paramedic and feel I have found my place within the profession. I now use my diagnosis and my experiences to advocate for females with autism and breaking down the stigma that there is around autism, educating people on the possible differences in females with autism in comparison to men and breaking down the stereotypes for individuals diagnosed with autism. 

 
Muna Abdi  
Paramedic  

 

Were there any barriers coming into the profession?  
I was lucky enough to have a very supportive mother, who wished nothing but the best. When I told her about becoming a paramedic, she was instantly my biggest supporter.  
 
Did you come across any opinions or points in practice which made you doubt your place in the profession?  
Not really from colleagues, this came more from patients. I had one patient blatantly say that it’s weird for her to be treated by someone who’s a hijab-wearing individual, which I was slightly taken aback from. However, you also go to patients who are proud to see someone wearing the headscarf working for the ambulance service, simply because they have never seen it.  
 
How did you feel when you came into the profession?  
Coming into the service as qualified was nerve-wracking and one of the main contributors of that was because there were hardly any girls that looked like me. During my time on placement, I had not seen anyone wearing the headscarf. This made me somewhat second guess whether this was the right path for me. However, I don’t regret my decision now. It is coming up to two years since I qualified as a paramedic and I’m glad I made the decision I did. 

 
Stereotypes exist in every community and can act as barriers to not only understanding an individual’s identity truly, but also for the individual themselves to access different opportunities. In becoming part of the ambulance service, whether it be a clinician, call handler, manager or other, we have all had a unique journey to these roles.  

 
Often, many of us will face different hurdles or obstacles that those around us may not be able to empathise with or struggle to understand. These can be formed of many different attributes: the way you look, the accent you have, the place you grew up, which each in turn will come with predisposed opinions within society. And as a frontline public-facing profession, this can become even more of a challenge when we do not have a choice of who we may be sent to. I spoke to three individuals, each with a stereotype they had to tackle in their journey into becoming a paramedic, and their experiences in the ambulance service. 

 

 

 

My Experiences of Living with Racism All Around Us

By Islam Faqir

21/10/2020

 

From my first ever recollection of experiencing racism, I feel at times, talking to people that they just don’t get it, mainly around how it feels, the thoughts that pass through your mind, the effect it has on you and your family, the resulting apprehensiveness and the impact on your social interactions. Whilst speaking to friends and colleagues, they offer sympathy and empathy, but I ask, do they really know how it makes someone feel, and the cautious behaviour it results in?

I thought I would write this to give context and feelings to my experiences which I have titled,

Have you ever experienced and felt…

My very first recollection centres around playing in the school playground and being called a paki, at that point being a juvenile and not really understanding what the slur means, being at a school that was 96% white… I would just put my head down and carry on playing, but feeling like I was different as it was pointed out my skin colour was different. Of course, going home, I never shared these experience’s because I just didn’t, I can’t really give a reason…

I think back and I can remember being stood in a queue with my dad and a white individual hit my dad in the legs with a trolley and said, "Get of out the way paki." I turned around and swore at the individual, I was in my early teens but I felt protective of my dad. My dad turned to me and said, "Son ignore him, this is something I have experienced many times." I was really angry and asked the individual, who seemed to be a bit older than me, to say it again and I would, well I think you get the picture… My dad again calmed me down and did not rise to it. First, I thought ‘wow my dad has the resilience and calmness to just be a bigger person.’ I now think my dad’s generation just accepted it and that was because to them that behaviour was normal.

As I grew and joined the working world, at times work colleagues would ask if I wanted to go out socially and I would say yes. However, I found after queuing up with my colleagues, I would be pulled out of the queue by the doorman and searched. When my colleagues asked, "Why are you picking on him?", the reply would be because I was black and looked like most drug dealers; ‘Black’. I would eventually get into the venue and try to enjoy myself, but afterwards it would affect me because I would be embarrassed to go out in case this happened again. After joining the ambulance service, this was even more so, I would feel different, I would worry what people may think and how it looks!

BREXIT and how things changed. Not so long after the vote whilst leaving a supermarket, I was walking passed an individual who just blurted out, "You’re all out now.", puzzled I said, "What do you mean?", the reply was or how I translated it, as a result of Brexit I or all people who were not white could return back to where they came from. I did say "Well, where is that?", the reply was "Where you were born." I replied "That would be here then…", the man looked puzzled!

The holiday season is something we all look forward to. There were occasions where I went away with work colleagues, and it would be standard that I would be picked out of the boarding line for a plane, and asked questions. My work mates would laugh and take the mick, which I would laugh along with. However, these experiences would leave me embarrassed and dreading the journey home, as it would often be a repeat.

I had the same experiences catching a flight to the USA with family and we got a lot of looks from fellow passengers. At times I would say "Well they are only doing their job.", but as my partner would point out to the people asking the questions "Why are you only picking on him?". Well we know why, I do not have white skin and I have a Muslim name. I do believe in keeping everyone safe, however, this treatment becomes tiring and I feel weathered by it, as it’s the same over and over, and over.

Other things that leave you demoralised are: 
Sharing with a colleague your interest in a job role, and hearing them tell you the name of the person they already know will get the job. 
Not having people that look like you that you can aspire to be.
Being racially abused at work whilst you are trying to help the person that called for your help, but doesn’t want you to put your black hands anywhere near them.
You go home feeling demoralised and asking yourself where you fit in society and why you are doing the job you are doing.

Being pulled over by the police because you are driving a nice car, being searched before getting on a train whilst on the way to a conference, because they say you looked suspicious (must have meant the case I had with me). I am always polite, as I think ‘they are doing their job’ but it does rile me when they ask what I do and when I say paramedic their tone and behaviours change to, let’s say, a little more professional.

Being described as a terrorist, accused of actions based on what I can only call inhuman ideology, becomes tiresome, hurtful, unwanted and undervalued, being compared with animals, who are only similarity to me is the colour of their skin.

Living with racism is something most people of black, Asian and minority ethnic backgrounds face every day, it is all around us. It does not have to be just name calling, it is behaviours, actions, assumption, jokes. Mostly, people do not realise the impact it has on our thoughts, emotions and mental health. The examples above are only a few of many I could write about, these were just to give substance in how my experiences have affected me.

Islam Faqir
Chair, College of Paramedics Diversity Steering Group


Being a Muslim Paramedic during the COVID19 Pandemic - Beards, Ramadan and Eid

By Shumel Rahman MCPara, North East Ambulance Service

24/07/2020

 

At the beginning of the pandemic I had a big decision to make! Ambulance front line staff were asked to shave off their facial hair, for the FFP3 face masks to fit. I had a religious dispensation; however, I had felt a huge sense of responsibility to protect and safeguard people. I also wanted to do the right thing when it came to my faith. 

After a lot of thought and much deliberation I decided to shave my beard off, to allow the respiratory equipment to fit properly.

This is not a step I took lightly; my beard is not just part of my identity, it is not there just to look cool, even though it does, but it is part of my religion. I have had a beard for well over a decade and I cannot remember the last time I shaved. I consulted many Islamic scholars and teachers, locally and nationally, sought advice from fellow Muslim healthcare professionals and very helpfully from the BIMA British Islamic Medical Association. This was not a simple yes or no answer, however these are exceptional circumstances, totally unprecedented and a unique situation.

I shaved off my beard to protect my patients, colleagues and my family. One of the greatest acts is to save someone’s life. This simple act may help do that.

My faith is something very personal to me and it is not something I often talk about at work unless someone asks me about it. Being a Muslim is an integral part of my life and identity. My faith is like a shield that protects me, it gives me focus and balance, gives me a code to live my life by, a belief system, provides me with important values such as respect, it gives me peace, not just a belief in God.

For a Muslim, Ramadan is a very special time, a time to treasure and looked forward to, a time to reconnect to Allah, a time to focus on my faith, a time for spirituality, a time to spend in the Mosque, a time to spend with family, a time for charity and giving, a time to reflect on what we have got rather than what we have not, a time to think about those less fortunate than ourselves, a time to think about all those who are suffering around the world or who are in despair. It is a time for discipline and centering yourself. A time for family, for friends, for community and for coming together. Oh, it is about fasting too, but the other stuff is just as important if not more so.

What many people misunderstand, is that Muslims fast not out of obligation, but because they want to. I think many people who are not Muslim do not quite understand Ramadan, often people see fasting and Ramadan as a chore or period to get out the way or we cannot be bothered with. For Muslims it is an incredibly special time, that we actually look forward to, a very important time for us, that we love.

This year was exceptional; never have I experienced a Ramadan where we were unable to go to the Mosque, to enjoy Iftar breaking the fast together, spending time with our family or friends. This Ramadan was vastly different, we could not do the things we would normally do. We still had a rewarding and spiritual Ramadan staying at home. This year has been strange, it was completely different. It felt like Ramadan, but then at the same time it did not, if that makes sense.

I was working on Eid, so missed out on some of the celebrations. Normally I would go to Eid prayers, we have outdoor Eid prayer in a local park in Newcastle. Unfortunately, we were still in lock down on Eid, so that got cancelled and I ended up doing my prayers in the back garden. I live with my family, so we managed to celebrate the occasion and ending up having a virtual Eid online with the rest of the family all over the country. I was really hoping we would be out of lock down but unfortunately that was not to be.

I am very pleased to say that just before Eid, the Trust provided me with a respirator hood, that goes over my head and is able to work with facial hair. It is similar to what you see in the movies, like ET. Having the hood allowed me to start growing back my beard just in time for Eid, you could call it a little Eid Ramadan gift.

It has been an extraordinary year for everyone, particularly in the realms of equality & diversity. We have seen the impact of COVID19 on black, asian and minority ethnic communities and healthcare professionals, disproportionately high COVID-19 death rate among BAME people and the effect on BAME colleagues is very scary and concerning. We’ve also seen the brutal killing of George Floyd and the mass mobilisation of the Black Lives Matter movement, globally demanding justice for George Floyd and eradication of institutional and systemic racism, and the conditions which have given rise to racism, which is potentially interlinked with the disproportionate number of BAME COVID19 deaths.

It has been a very strange year so far, Eid Mubarak & stay safe.

Darkness and Isolation

By Izzy Faqir MCPara, Clinical Pathways Manager, Yorkshire Ambulance Service 

08/06/2020

 

I am an NHS Paramedic and a father to 5 children.  I had recently been successful in being appointed as a Clinical Manager for Pathways and started in early February 2020, after trying for a number of years to progress. I identify as disabled, due to an organ transplant, and come from a BME background and I have faced many challenges in my career as a result of both (maybe my next blog will be about that). When I started my new role, I felt like I had a new direction and purpose and was, after a long time, really happy with my life at home and work. 

It was at this time that I started to hear, on the news, how in East Asia a new illness was taking lives and having an impact on so many people. I remember thinking we were all so lucky to be so far away, and never for a moment thought it would bring its devastation so close, and affect my world, as much as it has. Gradually though, I began to see the destruction this disease was having on people, like a darkness spreading from East to West, from North to South. I started to think, would it reach these shores, surely not? I had seen SARS and MERS, but this seemed different. This disease seemed to hold no mercy, particularly for those with health issues.

In March, I was asked to help with the increasing workload, which involved working within 111, and I happily agreed, after all, these were unprecedented times. The dark cloud had reached our shores. As I assisted people; taking their histories and listening to their stories, fears started to rise in the back of my mind, about the fact I am immunosuppressed. I also had rising fear for others around me. One caller, had travelled, with symptoms, from Italy to the UK, by train! All those contacts! I visualised again the darkness spreading and engulfing the world.

Pressure for the ambulance trust to respond effectively to the pandemic increased, of course, and I was told I would have to return to my substantive role in the Emergency Operational Centre. I was becoming really anxious now; going back into an environment with 60-70 people, working within the same room, left me feeling vulnerable and fearful for my own health, and the possible implications that it could have on me and my family. 

Thankfully though, government guidance and discussions with managers confirmed that, as I was in a high-risk group for severe disease if infected, I should be shielded and isolate. 

Well at least I could be safe; however, isolation was just that, I am living in one room in my house, isolated from even my wife and children. I of course wanted to help, I wanted to do something as part of the NHS family of 20 years, I wanted to do my bit. Unfortunately, due to some issues around IT this became a problem and not possible. It should never be underestimated how work brings normality, and as time went on, life without family and work became less and less normal. Time leaves you to think, and while thoughts can leave you happy, more often can be quite depressive as its only you that can snap you out of it.

I certainly did not realise the effect of being on my own; wanting just a cuddle from the kids but this was not allowed, having to watch them play in the garden and not being able to do be with them. All the things we take for granted now were not possible and this weighs quite heavy on your mind, I think back a few months ago and now it seems the world has tipped itself upside down. 

I was also reminded of when I was having dialysis at home and how I felt quite alone then, as I do now. The thoughts and the emotions came back to me. Some days were better than others, but nothing can really prepare you for the cloud that hangs over you. On one hand I was safe, on the other I longed for normality.

I had some contact from work colleagues and those who I can call my friends, such as Gary, Kirsty and Imogen and it was whilst speaking to Imogen, when I said I am grateful that I am safe but this is heavy going, she replied that, in most instances, isolation was deemed a punishment. This allowed me to accept it was understandable that I was finding my situation so difficult, but I also felt guilt. I felt guilt as I was safe, yet my friends were out there and there were colleagues that had passed away. I felt quite upset hearing of these deaths, all deaths of course, but these were people I knew well, that had been taken far, far too soon. Why? For carrying out their duty, for doing what we all set out to do when joining any NHS trust, to help others. My thoughts and prayers go to each and every person who has lost someone to this dark cloud. 

So how to I cope? I think a lot about how fortunate I am in this. I have support in my family and friends, but what about those who do not have that. No school, no face-to-face contact with family or friends, no workplace, no shopping, no clubs and societies. I am paying this price, I am isolated, but I am not fully alone.

I also try to keep myself occupied, catching up on reading, passing the time with boxsets. I started by watching lots of the news to keep up with what’s going on in the world, but now I try to avoid this, for several reasons; it seems to consume you, and as for watching politicians giving advice across the world, in most instances it’s sensible advice, but in others…, well I will just leave that out there…….

I also hold onto the thought that, as with any darkness, there will always be light at the end of this. I know we can do this, but we need to look after each other and care for our mental health. This does not stop us feeling darkness at times, after all we are all human, but we can stand together. My message is to be kind to each other, to the Ambulance family; STAY SAFE.   

 

Covid-19 shines a spotlight on inequalities

By Gemma Howlett MCPara, Senior Lecturer in Paramedic Science at the University of Gloucestershire

4/06/2020

We have lost more people than I am able to comprehend and there is a sadness that hangs over me whenever I think about it, as I am sure it does many of you. We have lost colleagues on the frontline, and our thoughts are with their family, friends and colleagues. Stand down and rest in peace. I fear by the time this blog is released we will have lost more colleagues in green. Such a devastating realisation and something that no one should even have to consider when they sign up for the role. Thank you for all that you have done and continue to do. Thank you also to our colleagues across the NHS where we have again lost people who were trying to help us all. It is a sad time in our history and one death would have been too many, so the true scale of the loss is devastating. 

Amongst the sadness of this crisis, it is true that we have seen some amazing acts of kindness. Major Tom is just one instance of people doing everything they can to help others. We have seen people setting up community support groups, we have seen people donating generously with time, resources and produce to foodbanks. We have seen the beginning of brilliant initiatives like clap for carers, various community initiatives to support vulnerable neighbours and widespread donating such as food or hotel spaces for NHS staff. Our NHS, postal workers, delivery drivers, refuse collectors, teachers are all continuing to work and keeping the country going during this pandemic. There is lots to make us smile in these horribly sad and distressing times. But the sadness is overwhelming, this crisis has highlighted inequalities like nothing else has done for many years. 

The thing that I find simply inescapable and truly horrifying is the startling inequality that the virus has shone a spotlight on. The longer this crisis goes on the clearer it becomes that with what, and where, you started this crisis, will have a huge effect on how well, and indeed if, you come out of it the other side. This stark social and economic divide, and sections of society having such poorer health outcomes than others is not a society we should accept. Inequality is allowing the virus to sweep through these communities in far higher numbers than anywhere else. There is also a shocking difference in the number of deaths in BAME communities, which is startlingly high, both in the figures for NHS deaths and the wider community. As the news breaks of another death, you see another black, Asian or minority ethnic face. Nurses, doctors care workers, no area of the NHS appears to be unaffected. And then you see the news stories that feature others that have died, those not in the NHS or on the frontline and again the visual is clear yet more people from BAME communities, making up a startling amount of the numbers. The first ten doctors to have died of Covid-19, and two thirds of the first 100 health and social care workers, were from ethnic minorities. That translates to 64% of the deaths being BAME staff members, which is significantly disproportionate as only 20% of NHS are from ethnic minority backgrounds (Kings Fund, 2020).

I urge you all to open your eyes to this, to see these stark problems that exist both within our beloved NHS, but also society as a whole. There is a brilliant Guardian article that I urge you all to read that really highlights this issue. It is called “Coronavirus exposes how riddled Britain is with racial inequality”. The Guardian project that looks to stop and remember each of the health and care worker deaths, a look through the photos a startling reminder of the inequity that we are encountering. The amazing video called “You clap for me now”, urging people to not forget that lots of BAME community and NHS staff put their lives on the line too to help us through this crisis. Enlighten yourselves about these issues, seek to understand what is at play. Ignoring it and believing that everything is okay and equal for everybody is not an option anymore. Help change this path, help ensure that this inequality can no longer exist or thrive, do not let those in power let this matter disappear into the archives of history, but pressure on them to make meaningful change.

This is a systemic problem that is complicated and multi-faceted undoubtedly. But each and every one of us can start to open our eyes and start to accept that this is all our problem. “It may be hard for white people to accept that we are part of the problem. Almost all of the us as individuals will say we are not – It’s other white people, but in reality, we are all part of the problem and we should all be part of the solution” This, from the Kings Fund, reflects what I have written in my articles on diversity in Insight, and I’m sure to write again in further blogs. But the standard you walk past and ignore is the standard that you accept. We must all no longer just walk past. This applies to all inequality and discrimination, we can all be part of the solution, part of the change for the better. 

Stay safe and be kind to yourself and others, and #bethechange

Also read, in the June 2020 issue of Paramedic INSIGHT, Coronavirus, a health inequalities pandemic by Gemma Howlett and Imogen Carter.

 
Disclaimer
The opinions expressed by the various contributors are not necessarily those of the College of Paramedics. The inclusion of a blog does not necessarily imply recommendation of its aims, policies or methods. The College of Paramedics will not be liable for any errors or omissions in this information nor for the availability of this information.