More on Change

Following on from my previous post - here's one of the changes that are going to be trialled in London in the very near future. The Evening Standard, a London daily newspaper, has titled it "UK paramedics sent to emergency calls without ambulances". Slight newspaper sensationalisation is evident in the title and may scare the public a little, so briefly - here's the plan and how it'll work. Single responders will be sent in FRUs (fast response units) to the calls that are deemed as appropriate. Having recently completed an 18-month secondment on such a vehicle, I see no problem with that.

As a single responder, you are in an emergency vehicle that carries pretty much everything that an ambulance does, except the transport devices such as trolley, carry chair, spinal boards and the like. FRUs up until now have been tasked to respond quickly, start treating the patient, and then hand over to a crew that is sent to back them up. The thinking behind it is that the FRU paramedic/EMT is then free to attend another call. Whereas a call turnaround time for an ambulance is somewhere around the hour mark, on the FRU it was often less than half that.

The difference with the new model is that a transporting vehicle will not be automatically dispatched at the same time (in theory) as the FRU, except in the most serious cases, but that those in control will wait for instructions from the FRU paramedic on scene who can give a better assessment as to what sort of further response is needed. This, to me, is a small admission that the dispatch system we use is somewhat flawed. Having said that, the system can only go by what the call-taker inputs, and the call-taker in turn can only go by what they are being told over the phone.

There are other flaws. Calls to serious RTCs and other traumatic injuries are very often not categorised in the highest banding, and could in theory leave a lone paramedic dealing with a multi-casualty incident. I understand that any intelligent dispatcher will take one look and send the ambulance anyway, but in an era where there is more and more intention to rely on computer systems, turning around and asking for human input smacks of a contradiction.

Despite all my reservations at this point, I'd be glad to be one of the first paramedics to trial it had it have been trialled in the area in which I work. I would, however, have certain conditions that I'd like to ensure were adhered to. The main one would be that if I turned up on scene and requested immediate back-up, that it'd be on the way there and then. Too many times as an FRU paramedic I've had to wait for the transport to arrive despite repeatedly pleading with the control centre to find me someone to take the patient.

It's not a lack of confidence in my skills or treatment abilities. It's not that I'm desperate to "get rid" of the patient and hand responsibility to somebody else. I like and accept the responsibility, I enjoy treating patients, and I thrive on the extra challenge that is often presented when dealing with a critical patient on your own. But I recognise when the patient needs more care than I can give them.

Equally, if I decided that a patient didn't need transport to A&E, I'd like to know that the system was in place whereby other medical professionals would recognise and accept any diagnoses or referrals, and I'd like the public to be aware that I'm trained and qualified enough to make those decisions. This was the idea of the Emergency Care Practitioner (ECP) role that has been running in London for the last few years, but was never fully put into successful operation. The staff that took on the role were and still are dedicated, motivated paramedics who undertook a large amount of extra study and training, and are now being left high and dry as the role is phased out. It just never had the understanding and backing that it needed, and was never fully accepted by external agencies.

I'd love to think that this trial is being undertaken at least partially from a clinical point of view. I suspect economics has had more of a say. I may be an optimist, but I'm not naive. I have my reservations about this trial, but am more than happy to give it a go. No-one yet knows a full job description or scope of practice for this new role (probably entitled Advanced Paramedic), or whether there will be extra training involved, more pay, or any other details. But we know it's coming. This is one of those things where front-line crews need to be involved in the decision making process, and as far as I know, they haven't been, certainly not to any great extent.

More communication between the sides might surprise us all. The front-line staff might find that they want to be a part of the changes, even pioneer them, and management might find that they have willing partners, rather than unwilling subordinates.

Overall, change is a necessary thing for an evolving profession such as the one of a paramedic. Change breeds teething problems. These will exist at every level, public understanding, call taking, dispatch, front-line and external agencies. The trick will be to iron out these problems and turn them into a viable, working model, that will ultimately benefit not only the target-setters and finance department, but also the most important people.

Our patients.