TWO VERY HANDY MEN – August 2017
As a paramedic, one of the things that becomes apparent is how different people deal with emergency medical problems. I was (and still am) involved with Girlguiding UK, and given my current job, its unsurprising that I had my first first-aid badge as a Rainbow aged 5. I’ve grown up with a little bit of an idea of how to help someone in a medical emergency. Employers often have a mandatory requirement for staff to have first aid certificates, or there to be a designated first aider on site. Thankfully, not many first aiders will ever need to put their skills to the test. However, that changed for two workmen in July.
Morgan (a plumber) and Paul (a builder) were doing some renovation work on a property in a rural Buckinghamshire village when the property owner shouted for help. They found the owner, an elderly male, on the floor having sustained a leg injury that was bleeding heavily and needed emergency help. Instinctively, they both quickly put their first aid training into action; the two men elevated the patient’s leg and applied direct pressure to the wound. On my arrival, I was met with the patient lying on the floor with one leg elevated on a chair and Paul applying pressure with a bandage wrapped neatly around the leg. The atmosphere was completely calm and the three men were chatty. Had it not been for the copious amounts of blood on the floor, I may have believed this was something much more minor. I ascertained that the patient had been climbing down from the sofa when he had caught the back of his knee on the glass table top as he stepped down, causing him to fall and causing a cut to his leg. Blood had spurted everywhere until Morgan and Paul applied a dressing and elevated the leg above the level of the heart. They phoned an ambulance immediately, so it wasn’t too long before I arrived.
With the direct pressure and elevation, the bleeding had slowed down but had still soaked the bandage. After checking the patient was physiologically stable and giving some oxygen, I removed the dressing to inspect the wound and apply a new dressing. It was deep, right down to the artery at the back of the knee. Having disturbed the dressing, the wound quickly started bleeding again with more velocity. For the second time that day, Paul applied direct pressure whilst Morgan helped me collect more equipment as I prepared to put a special bandage on the wound. We have special dressings for blood loss, similar to what is used in the Military, one that helps the blood to clot and another one which applies pressure to a wound. I applied both of these with the help of Paul, whilst Morgan continued to reassure the patient. I then called on Morgan’s professional advice. As a plumber, he was much more used to working with fluid than me, and together we worked out that there was at least 750ml of the patients’ blood on the floor. Despite the new dressing, the patient had lost quite a bit of blood and the wound was still bleeding. With him starting to feel unwell, I put a small needle into his vein to give him a drug which helps to clot the blood when there is an injury. I also gave him some pain relief.
I’d already asked for an ambulance to transport the patient to hospital, and whilst we were waiting Morgan and Paul continued to reassure the patient, chatting about this and that, whilst I continued to monitor and make sure there was no more blood loss. They had already informed the patient’s wife of the ‘little fall’ and so when she arrived, she was understandably quite shocked. However, Morgan went straight to reassure her whilst Paul and I stayed with the patient.
Reassurance is so important in casualty care, and Morgan and Paul did this throughout the incident. The scene was so calm when I arrived because of the reassurance they had given to the patient as well as the first aid they had administered before my arrival. As a paramedic, it was really good for me to be able to walk in to what was a quite serious incident and it to be a relatively calm scene. There are many people – even with first aid training, never mind those without – who, when they would have seen so much blood, may not have helped or if they did, wouldn’t have reacted as quickly or done such a brilliant job as Paul and Morgan. Had they not acted as quickly as they did, the patient would have lost a lot more blood. Morgan and Paul performed above and beyond what would ever be expected of a first aider and their actions saved a man’s life.
In recognition and appreciation of their quick thinking and action, I nominated them for an award from South Central Ambulance Service. We also got in touch this their employers, Garrard Construction working through Contractor Connection at Crawford & Company, who have also recognised Morgan and Paul’s good deed. The patient was home within the week of the incident, having had some internal and external stitches and is making a full recovery with two conditions: his wife has banned him from climbing on the sofa and the glass table has been re-homed. Paul and Morgan also went back to finish their jobs within the house refurbishment, with a newly stocked first aid kit, which I think they’re hoping they won’t have to use again. But if they do ever need to open it again, I have no doubt they will approach with the same calmness and reassurance as they did with this incident. Of course, isn’t the reward for work well done the opportunity to do more?!
THE POWER OF THREE – June 2017
As the summer starts, we’ve had a pretty good month as a team of specialist practitioners in North Oxfordshire. There are four teams on each station and each team has a Team Leader (manager), Clinical Mentor (who guides development of staff and students), and a Specialist Practitioner (SP). Therefore, there’s usually four of each of these roles on station, who come together to make up an overall leadership team.
At the moment, there are three SPs at our station: Gemma, Chrissy and myself.
Gemma is the newest addition to our team. She originally worked at the opposite end of SCAS for the Hazardous Area Response Team (HART) but more recently has developed her skills to become a SP. Thanks in part to her roles within HART, she’s incredibly organised and is the main person for organising our team – from our specialist kit to our SP training. Since she’s been at our station, she’s also developed a question corner, where members of staff email questions and she posts the question and answer on the wall for all to read and learn from. It works really well to share learning in this way, and it means we’ve learnt a lot in the process! Similarly, she also ran her own team’s training day too, covering how SPs are used, the treatment of head injuries and an equipment refresher. Teams have training days (usually followed by a social) every six months. It’s a really good opportunity to refresh and learn from each other’s experience, as well as catch up with colleagues outside of work.
After 10 years in the ambulance service, Chrissy decided to become a SP and qualified over two years ago. Within our team, she looks after our specialist kit and makes sure we use the best products for our patients following what the research says. Chrissy is one of the most approachable people I have ever met, so is often found supporting student paramedics or other members of staff. As well as working at our station, she also spends half her time at the First Aid Unit in Chipping Norton. Over Easter, she saw the 10,000th patient that the unit had seen since opening and has recently been in the Oxford Mail sharing a cake with others who run the unit to celebrate. You can read their article here: http://www.oxfordmail.co.uk/news/15286089.First_aid_unit_celebrates_10_000th_patient/
And, I think you know enough about me!
So far, the summer has been great. I was with a Student Paramedic from Oxford Brookes University at the start of the summer and the SP Hub (who screen calls and dispatch us to the most appropriate jobs for our skill sets) was working really well. Over our first shift together, we saw three patients: An elderly lady who had worsening and debilitating hip pain; a young man who had accidentally drilled through his finger; and an elderly man, but not for reasons you’d expect.
Our first patient was a delightful elderly lady who had been left with severe hip pain after a lifetime of equine activities. She’d accidentally run out of her prescription pain killers and without them was unable to move. Left with no alternative and unable to get in contact with her GP or her family, she phoned 999 for help and was very apologetic for having bothered us. After looking at her normally well-kept pain management routine, I was able to supply the same analgesics she needed. These and cup of tea later, she was up and about and keen to get on with her day. Whilst she doesn’t ride anymore, it was her turn to muck out the horses at the local yard, so we left her with her daughter to continue her day.
The young plumber who drilled through his finger was our second patient. Unsurprisingly, after drilling through his finger, he had promptly fainted and that’s what had led to an ambulance being called. This incident was seen by the SP hub who thought I might be able to help and so sent me and the student I was with. Whilst he had fainted (and I can’t blame him, I think I would do too!), he hadn’t actually drilled through his finger. He had only a small laceration to the fleshy part of thumb, avoiding all bone and muscle. He’d been pretty lucky, as even an inch further in and he would have needed to see the specialist team at the John Radcliffe Hospital in Oxford. We performed a cardiovascular assessment and monitored him to ensure he had recovered from the faint, and then cleaned his hand. I showed the student how we apply steristrips and then put a special finger dressing on. I have no idea what it is, but I love finger dressings! They come with a bobbin (a metal cage) that the bandage is moved over onto the injured finger; I just find them very therapeutic to apply!
Lastly was our elderly gentleman. Living alone, he was quite independent but had carers call in twice a day to help with washing up and for a chat. One of the carers had just left his house to run an errand for him and in the 15 minutes she’d been gone, he’d disappeared! We were subsequently called, but the house was locked up and there was no sign of the gentleman. An hour later (with multiple laps of the estate and us walking around the village in the rain), the man returned to his house complete with a cake – he’d been to the local shop and got caught chatting to a friend. Having lost track of time, he’d forgotten the errand his carer had gone on and was quite bemused to return home to myself and my student paramedic, the carer and her manager and, at this point, his daughter and grandson. After establishing there was no illness, injury or other problems, the others stayed to enjoy his cake and cuppa, we left and made it back to station to finish our shift.
That’s what I love about this job – you can never really predict it. Fortunately, none of these patients needed admission to hospital or to attend the emergency department as we were able to treat them at home or on scene. This is exactly what my job role was set up for.
The start of the month also saw me working a nice sunny weekend at the First Aid Unit. Although inside, it’s really a very pleasant place to spend a summers day working and seeing some very summer related problems: everything from a sprained ankle from a works do; minor BBQ related burns injuries and a more serious occasion when someone allergic to bees was stung by one during their picnic (they went to hospital by ambulance).
The biggest thing for me is, whilst I am working on my own, I’m not really: I have two ‘on-call’ SPs I can message (or call) if I want to run something through. Working as a trio of SPs, we regularly run through patient management with each other and reflect on incidents we’ve attended. It helps us share learning and increase our own individual knowledge. As a team, we work together on our station to offer things for other members of staff, whether it is a question corner, a journal club or just informal chats in the crew room. Fortunately, outside of work, we’re also pretty good friends. Once a month or so, we have a regular SP day, which started off meeting at local teashops, but has gradually evolved into day trips further afield including Edinburgh, Germany and more recently Ireland (not on SCAS expenses!). Our manager affectionately calls us the SPs on tour! As part of the changing way SPs are allocated to incidents, we had a photograph taken by our colleagues, who insisted we pose like Charlie’s Angels after much laughter and amusement (I think the hats and the leprechaun might have helped with this!). We did have a slightly more professional picture taken, but the point was how much hilarity we had in getting there. Whilst I find my job incredibly worthwhile, teamwork absolutely makes it so much more delightful. So whether it is Charlie’s Angels (without Charlie), the Three Musketeers or a Neapolitan ice cream (personally, my favourite analogy), I think we can all agree that good things come in threes.
EDUCATION, EDUCATION, EDUCATION – Saturday 20 May
I mentioned in my last blog about how we as specialist practitioners are impassioned to support our colleagues to develop their practice. It’s a part of being a clinical leader on station and each station of specialist practitioners have a role in this to contribute to their station team. However, we as individuals also all have our own interests in our field of practice, and mine is most definitely education and research. Education and research might sound to be really stuffy, but they really are not. Have you read Jess’ blog? She’s having lots of fun at the SCAS Education Centre transitioning from a New Zealand Paramedic to a Buckinghamshire SCAS Paramedic and learning all sorts of new things. So it really is a key part of the job.
As well as being a specialist practitioner, I am also a Lecturer in Paramedic Science at Oxford Brookes University. I mainly teach on the minor injury and minor illness modules (as these are mostly what I practice ‘on the road’ as a specialist practitioner), but I am also the research lead for the programme and so I teach research too. Pretty much everything that happens in healthcare is based upon research. We call it evidence based practice (practice being what you are doing, like being a paramedic). So, actions paramedics take are supported by clear reasoning (evidence), and then using their own professional judgement as well as taking into account the patient’s preferences. This relies on a good understanding of research: how to find it, how to understand it, and working out if it’s any good! It might not sound it, but it’s relatively simple and once you’ve grasped the basics, it’s easy to keep finding it, reviewing it, and making small positive changes.
However, research is quite an academic skill and it can be daunting to some paramedics. But, I am really passionate about it and the difference it can make to our practice, and one of my challenges is to demonstrate this to others working in the ambulance service! Fortunately, within SCAS there is a whole team dedicated to research, with ‘research paramedics’ who help to guide the clinical direction of the Trust. They do a lot of ‘behind the scenes’ work to promote best practice and ensure new ideas or equipment are incorporated into our practice.
With my dual role, I quite often have student paramedics observing with me during the shift. I love having the opportunity to observe how the students are incorporating what they have been taught into practice and test them on areas they might not understand so much yet. It’s not about testing their ability, but more about seeing them develop their knowledge and skills. It is a great reward when you encounter a student you have mentored as a qualified paramedic ‘on the road’ and can see their development, both personally and as a clinician. I have recently had student paramedic Matt out with me. He’s also one of my students at Oxford Brookes (students at Oxford Brookes have their ambulance practice placements in SCAS) and is sitting his final exams and assignments to qualify as a paramedic this summer. We had two shifts together and he asked me to test him on everything and anything, so we could work out where he wasn’t so strong and then revise those areas. Matt is a credit to the paramedic science programme, and with relatively few weak spots we decided we’d go back and revisit the anatomy and electrophysiology within the heart. A solid understanding of human anatomy is incredibly important when you’re in a job that looks after the human body! I always welcome a refresher and so during some ‘down time’ on the shift, Matt told me everything he knew about the heart and we went through it step-by-step. I think we both remembered a few things that had fallen into the recesses of our minds, and that’s what I love about teaching in education – being reminded some of the smaller aspects that are important pieces to create a complete picture.
However, I’m certainly not on my own in doing this. SCAS has paramedics who work as clinical mentors in each team, who are responsible for the development of staff and students in their team. These paramedics work within the wider SCAS Education Team, the group who oversee staff training and development within the organisation. These paramedics do a sterling job in mentoring students from their first year at university through to being qualified paramedics. Many specialist practitioners have also received training to be clinical mentors, and whilst it is rare for a paramedic to have both roles, mentorship fits nicely within the clinical leadership element that specialist practitioners strive for.
Education and research might sound boring, but they’re both important attributes in becoming a paramedic and then developing as a clinician. It’s also not all theory based either; there are a lot of practical skills behind being a paramedic and these are usually taught in simulation. The picture above shows some simulation training our student paramedics at Oxford Brookes take part in with Buckinghamshire Fire and Rescue Service at the Fire Training College in Gloucestershire. This is where students’ (and qualified members of staff) enter a scenario with realistic equipment and act as if it was a real patient, from the conversation to the clinical procedures performed. It’s a really good way to learn and it’s not just limited to the university or education centres; many stations have their own training equipment they can use in their ‘downtime’ to practice. And practice makes perfect, right?
OUT ON THE ROAD – Sunday 30 April
Did you check out my last blog about the First Aid Unit? Well, being a specialist practitioner in SCAS is incredibly varied, meaning I don’t always work at the FAU. Today, I am on what I consider to be our routine allocation, which is driving a response vehicle. You may have seen these around, estate-type cars with green and yellow ‘battenberg’ markings? Whilst the outside looks just the same as those used by other clinicians in SCAS, the inside is slightly different! Specialist Paramedics carry a lot more equipment than a frontline ambulance.
Firstly, we have a few more additional examination tools. These include special scopes for looking into eyes (ophthalmoscope) and ears (auriscope). We have tendon hammers to test reflexes (like your typical knee jerk) and tuning forks to test hearing. We also carry a device called a Toxco. Our colleagues who work in resilience carry this (and a lot more specialist kit), but it means we can easily detect if someone has too much carbon monoxide in their blood, usually following a fire. These tools allow us to complete a very thorough assessment of patients we see, and go a little more in depth than our paramedic colleagues.
We then have three more bags: a wound care bag; a drugs bag; and catheterisation kit.
Within our specialist wound care pack we have equipment to clean and then close and wounds. We also carry tools for primary wound closure (steri-strips, glue and sutures) and every type of special dressing you can imagine, from packing to chronic wounds; dressings specialist for burn care; and also impregnated gauzes that help blood to clot.
We also carry a range of medications, which we supply under a patient group directive (which allows us to supply and administer specified medicines to pre-defined groups of patients, without a prescription). We carry a range of pain killers; antibiotics (for everything from an acute ear infection to a urinary infection); anti-sickness drugs for dizziness or similar disorders; steroids for people suffering with respiratory infections as well as inhalers (many people forget to renew their inhaler prescription, and don’t realise until it’s too late!). We also have many of these in solution form, so we can supply them to children, people who have difficulty swallowing or via a special line into the stomach. It’s about being flexible in who we can treat, and providing care to a diverse population.
Lastly, many of the specialist practitioners can perform urinary catheterisation. This is when a flexible tube (catheter) is used to empty the bladder and collect urine in a drainage bag. It is usually used when people have difficulty urinating naturally.
All this plus the ‘normal’ paramedic equipment that allows us to deal with life-threatening emergencies. As I’m sure you can imagine, it’s a fair bit to carry. Thankfully, I was always good at Tetris as a child, so I do manage to fit it all in!
But how do you become a Specialist Practitioner? Specialist Practitioners can have their foundation either as a Paramedic or a Nurse (or some have both). Additional education is required to specialise in urgent care and this is currently a post-graduate certificate (which is two modules studied at Master’s level), however many go on to complete the full Masters’ programme.
Yet, our role isn’t limited to clinical care. We are also clinical leaders, which mean we are role models on our stations and within our teams. This means that we need to keep up to date with research relating to our role (both as a paramedic and an urgent care specialist) and cascade this to our other colleagues in operations, from emergency care assistants right through to team leaders. Each station of specialist practitioners runs their own initiatives relative to their area and what their personal interests are. Within Oxfordshire, we have regular meetings to review documentation completed by clinicians, and offer feedback for personal development. So many of our clinicians do a great job, it’s really rewarding to give positive feedback from this group. So, our role isn’t just about treating patients at home (or at first aid units) and preventing admission to hospital; as a group of staff we are also passionate to encourage our colleagues to develop their own practice too. Working together well means we can provide the best care to our patient, in the right time and right place. After all, that’s why I chose to become a Specialist Paramedic.
INTRODUCING GEORGETTE EATON, SPECIALIST PARAMEDIC, OXFORDSHIRE
I write my first blog post from Chipping Norton First Aid Unit. If you’ve not heard of either, Chipping Norton (affectionately known as ‘Chippy’ locally) is a market town in West Oxfordshire. And a First Aid Unit is exactly what it says in the title: it’s a small unit that can treat a wide variety of problems from cuts and sprains to minor infections. It was set up by a much loved and respected colleague, Gary Toohey, to provide out-of-hours first aid cover to the local area as well as relieve the stresses within the Emergency Departments (ED) at the nearby hospitals. Many people attend ED when they could be treated just as well (and probably quicker) at a first aid unit, or a minor injuries unit. There is, however, a key difference here: first aid units do not have X-ray support, whereas most minor injury units do.
This unit is relatively small, with a desk overlooking the car park (and viewing any potential visitors), cupboards and a dressing trolley lining one wall, with an examination couch at the back. However, we stock everything and anything required to treat minor ailments and injuries. Additionally, since we’re a rural community service, we have on the odd occasion provided the first steps in treatment for those experiencing heart attacks, severely broken bones and even delivered babies – although thankfully, there is a maternity suite upstairs!
Either way, we are a busy little unit manned by one Specialist Paramedic (and sometimes an accompanying student) at a time. On the first weekend in April, that was me. I’ve been a specialist paramedic for four years this year and really do enjoy my job. Working in unscheduled care, similar to the nature of any emergency or healthcare service, you’re never really sure who you might meet, what you might see and where you might go. If only these four walls of the unit could talk…!
I am currently two and a half hours into my weekend shift, and have so far seen three patients: a child with a minor ear infection; an elderly lady who required a dressing change for her sore leg ulcers; and a young male who had cut his thumb during some woodwork. What I love about this particular service we run within SCAS is not only the clinical variety I encounter each day, but that feeling of making a real difference. We can review the child later in the week if their ear infection gets worse, which helps alleviate mums’ anxiety and means we can catch any deterioration quickly. I have redressed the elderly lady’s leg ulcers several times before, and it really is satisfying to see that they are getting better and her mobility is improving – from something as simple as cleansing and redressing a wound! Treating the young man’s laceration also means his wound can be closed in a timely manner, preventing infection among other things, and also meant he didn’t have to wait too long to be seen. It’s not just the difference in the local community; it also makes a difference to the wider health services – alleviating pressure for my colleagues in emergency departments as well as within general practice. Oh! That’s the bell! Outside I can see a teenager in football kit hobbling towards the unit, with one ankle in a bandage. I ought to open the door to our fourth patient of the morning!
Eight hours later….
It has been busy today! Following my four patients this morning (the teenager had a rather bruised ankle from a heroic tackle that won his team the match), I have since seen:
- 3 year old with a high temperature
- 20 year with a subungual haematoma (bleeding under the nailbed)
- 43 year old who had crushed his thumb in the car door- he will be seen by the plastics team at the John Radcliffe Hospital in Oxford tomorrow morning
- 68 year old with vertigo
- An 11 year old with a soft tissue injury to his knee (another football injury, this time requiring an X-ray at the local minor injuries unit)
- 52 year old with an ear infection, who didn’t require antibiotics
- 72 year old with mental ill-health, who required additional social support
- 26 year old who had been bitten by a dog
- 36 year old who required a dressing change (ongoing management for burns from three weeks ago)
- 10 month old with a milk rash
- 49 year old with urinary tract (water) infection. After testing her urine, I was able to give her some antibiotics to get rid of her infection.
There has definitely been some variety! That’s the beauty of this unit, as well as never knowing what or who you might see next, the breadth of conditions we can help out with is really quite vast. I think that’s largely because my background as a paramedic (being autonomous and having to rule out the worst-case-scenario) has really helped me develop how I think about conditions. Plus additional training to be able to identify and treat minor injuries and illnesses really means this unit can just about deal with anything! The other benefit is, if there’s something I’m not sure about, we have a good network of referral routes. So if we can’t treat within the unit, we can help find someone who can. For instance, the gentleman who had trapped his thumb; he had a laceration through his nail as well as a possible fracture. I referred him for an X-ray at a nearby minor injury unit and also organised a review for him within a team who specialise in repairs of wounds or injuries in complex or essential places. I would say a thumb is pretty essential for most things!
So, after a busy day it’s time to restock the dressing trolley, clean the surfaces and the rest of the room, and generally prepare the unit for the morning. I might even have time for some tea; I think I deserve a cuppa!