Matt Green MCPara, Paramedic Clinical Supervisor at Yorkshire Ambulance Service NHS Trust writes about education standards for paramedics and the current HCPC consultation.
“Time of death 1854 hours.” There. You said it. You ended someone’s life. You’re 21 years old, still living with your parents and barely an adult in many eyes but you’ve just welded one of the biggest emotional swords available. They are dead and it’s because you said so.
You recently registered as a paramedic and completed a few preceptor shifts before going it alone. That was the first real test; the first time without a mentor to depend on and when you’re expected to take the lead and make every decision without error. As if to prove the point, the first job was a 34-year-old male in cardiac arrest.
There he was, laid in the gym beside the treadmill still whirring away. It was looking bad from the start; despite good bystander CPR, there was asystole from the moment you put the pads on. Your ECA crewmate did some sterling CPR while you tried various interventions. A second crew arrived; a technician and an ECA you knew well as a student but were now clinically commanding to save this patient’s life.
You were there 40 minutes; you really did try everything until the sweat beads poured from your bodies. Nothing worked and you pressed on until it was time to stop. You were a long way from hospital, so copping out and conveying there was not an option. “Give it 10 more minutes” you said, reluctant to let it end like this but knowing the literature afforded this patient almost no hope of survival.
The gym emptied save for two earnest police officers who’d arrived in grim anticipation of the outcome. You knelt back and glanced around, thanked everyone for the efforts and stopped.
The formalities swallowed up the next few hours and you felt a conflicting pride that you did your duty, with a vague shaky feeling about what you’d done. You know while directly not your fault; something beyond you must have happened to make the patient die, yet you also know that his friends and family will always know he died at that time, at that place and in the conditions you bare responsibility for. Perhaps they will get to ask you about it at a coroner’s inquest.
When all was said and done, you know you did your best. Later on plenty of more experienced, more qualified paramedic colleagues reassured that you did well and your managers supported you.
The rest of the shift was less life and death; a grizzly child who needed assessing and referral to a GP who wanted lots of detailed information and based on your diagnosis decides they don’t need a follow up appointment today and can be seen in their regular surgery tomorrow. This felt a great outcome; other professionals value your assessment skills, the child’s family had minimal disruption and didn’t need to go to the paediatric emergency department miles away, there is less demand on scarce emergency resources which is good news for the NHS and it’s an overall great use of your professional autonomy.
However, you’re plagued by lucid thoughts; what if you made a mistake; what if you missed photophobia, bulging fontanelles and a non-blanching rash. You absolutely know you didn’t but it plays on your mind…what if you did?
The final patient was being transferred between hospitals; despite being fairly young, the next day her foot was being amputated after a string of complications meant an ulcer never healed and her necrosed foot was unsalvageable. She had fluids running and on 6 different antibiotics and painkillers; you’d been trusted with diamorphine to give PRN during the transfer by the dispatching hospital who had no escort to send with the patient. The patient wanted to talk and mourn her foot. She liked having two feet that worked; she liked the freedom, the independence and the spontaneity they afforded. She is stoic about how she will cope but is coming to terms with how it will affect her life, her perception of herself and she openly says she thinks she will become depressed or have post-traumatic stress disorder or both. She casually asks you about the differences between the two and what you recommend to help her cope with it. “You do know, don’t you?” she says while you tried to reflect confidence and competence beyond your years “you will have studied this” she follows up.
The shift ended; it was ok. It was fun, it was challenging. It was what you thought being a paramedic was all about when you applied.
On the way home you reflect that had you studied medicine you’d still be at university, looking forward to years of supported learning and structured mentorship. In nursing you’d need to build up many years of post-registration nursing study and experience before autonomously practicing like you’ve done today.
But as a paramedic, the autonomy was there on the first day. Expected to give high doses of morphine, diazepam and amiodarone here, delivering a baby there and actively trying to discharge as many patients as possible on scene. It feels like it only takes one person to disagree with one decision once and the HCPC Fitness to Practice process could bare down on you and ultimately strike you off.
Looking forward, one day you’d like to focus on one area of practice. Specialist Paramedic in Critical Care is an option. Perhaps you’ll become a Resuscitation Officer in hospital or a researcher at a university. Maybe you’ll sail the seven seas as a paramedic on a cruise ship or move to a third world country to develop an ambulance service there. Perhaps when you’re ready to put down some roots, working in a GP surgery might be a great work/life balance in a beautiful part of the country. So, so much feels open to you – and it all starts as a registered paramedic.
Just one newly qualified paramedic in just one day assesses, manages, discharges and refers patients with significant clinical risk. They deal with polypharmacy, mental health, life changing moments and wrestle their own aspirations to enjoy a fulfilling career. There are hundreds of new paramedics seeing tens of thousands of patients making millions of risky decisions every year.
It is clear that all paramedics needs to be highly qualified and competent individuals to give them the skills and knowledge to make the most of their experience in practice. Able paramedics give the public confidence and strengthen our professional case for more drugs and techniques to be added to our scope of practice, to provide an even better service to our patients and be a greater asset to the health service.
It is simply not appropriate nor plausible for future paramedics to practice at this level and beyond with anything less than a bachelor’s degree in paramedic science/practice in addition to the experience and mentorship afforded them by well-designed placements with good ambulance clinicians within trusts. This is the right basis for a career of post-registration study and continuing professional development.
If you agree or disagree with this blog post and the standards of education for paramedics to become registered, tell the HCPC’s consultation at https://www.collegeofparamedics.co.uk/news/consultation-on-the-qualification-for-entry-to-the-register-for-paramedics
21 11 2017