2018 Elective Report

Portia Rhimes has spent 6 weeks with the London Ambulance Service - read all about her experience below!

The 2019 Student elective will be hosted by the Welsh Ambulance Service. Keep an eye on these pages, more information about the application process will be published here in September.

'My six-week elective, hosted by the London Ambulance Service (LAS), took me all across London with a variety of pre-hospital care providers. No experience thus far has so solidified my desire to work in emergency and pre-hospital emergency medicine (PHEM), or shaped the values by which I want to work as a doctor.

‘My daughter’s stopped breathing’
Hearing the emotion of an emergency through a single headphone in a control centre felt uncomfortable. Perhaps because the inability to reach out and offer physical assistance was a new experience and without a requirement for me to consider a practical plan I was left to confront only my emotional response. The responder remained calm and systematic, as with every other call: he took vital information, reassured callers and guided initial treatment; ensuring an appropriate response to each. Whilst at the 999 and 111 control centres, I also saw the triage system designed to prioritise responses, the dispatch of resources and additional systems such as the clinical hub, which uses skilled clinicians to re-triage appropriate cases and to advise self-care or alternative pathways.

‘Lock up any animals in the house and make sure the front door is open.’
Paramedicine is challenging: The work environment fluctuates, requiring dynamic risk assessment. We went to areas of gang violence, dimly lit streets and dealt with animals and aggressive patients. The work is complex; failed discharges, social concerns, repeat attenders and mental health patients were all mixed in with cases of injury and illness. The networks of patient flow, in part a result of working under multiple commissioning groups, meant that pathways varied by patient presentation, borough, day of the week and time of the day. Before we arrived in the emergency department we had to contend with uncooperative, heavy, frail or bedbound patients, overcome obstacles and the elements and navigate narrow stairways and tight corners.

‘K2, Mamba, Bombay Blue… There’s a lot of Spice around here’
The Joint Response Unit works collaboratively with the Metropolitan Police Service to alleviate the pressure of medical cases on the police by taking over their care. On my weekend night shifts I saw crowds, dark alleys, bar fights, shock and anger as we waited at rendezvous points to be called forward to stabbings, assessed assault victims and comforted a woman after a call out for domestic violence. It was a chance to see drug and alcohol related incidents; to learn different toxidromes, the devastation caused by batch variation and some of the many drug street names.

‘We’ve done everything we can for him.’
The delivery of bad news in hospital is often, not always, aided by its association with illness, with grief and with loss. There is a vast difference, then, in the delivery of the same dreadful news on the steps of a home, with a family in the middle of their daily routine, unsuspecting. The sensitive and paced delivery with which the paramedic I was shadowing spoke to the wife of our patient in asystole was truly exemplary of how to respect and connect to the human emotion of loss. He guided her into understanding what she said she could not understand, and prepared her for what was to be, what would happen, the feelings she and her family might have, and who could be there to support her. I hope to be this holistic supporting my own patients.

‘We are decision makers.’
The role of Urgent Care Advanced Paramedic Practitioners (APPs) is relatively new to the LAS. They can assess and manage patients from home or discharge them, relieving pressure on emergency services and hospital admissions. I observed how they translated their clinical knowledge for each patient and took the time to ensure their understanding. I had already seen how education and safety netting at discharge can make a striking difference to a patient’s immediate and future care and appropriate use of the health service. The APPs safety netting contained no ambiguity: patients knew what had happened to them, what had been done about it, and when and where to seek further help.

‘Get the biscuits; we’re going to debrief.’
The positive attitude toward team support and learning has always drawn me to EM and PHEM. Critical Care APPs have advanced training, increased scope of intervention and targeted dispatch which allows them to provide care to high acuity patients and to lead and support attending teams. Observing their debriefs after we attended trauma or arrests, highlighted how their influence and value extends beyond patient intervention. Shared understanding, identifying learning points and discussing emotions with teams is vital given both the difficulty of some cases and the current limited feedback paramedics receive about their patient outcomes.

‘Just because we can doesn't mean we should.’
Attending clinical governance days I saw how standard operating protocols, primary literature and personal experience were drawn together to create a dialogue focusing on realistic, practical application. I observed as clinicians dissected each other's clinical decision making; a valuable type of practice I would like to use in my own reflective learning. I also heard presentations and discussions about the provision of new services, interventions and equipment; vital in a relatively new, expanding speciality, still defining what it is.

‘Stab vests on! - they might keep us a bit warmer…’
My night shift with The London Air Ambulance saw a busy evening of trauma calls complicated by icy roads and wild wind; storm Emma had hit London and it was -9°C. Rapid sequence inductions were performed in the back of ambulances to keep patients warm and we had to wipe snow off of trolleys before loading patients. I saw trauma surveys and thoracostomies and watched handovers to and management by trauma teams in a Major Trauma Centre. I was taught about Code Reds and Code Blacks and had the most comprehensive teaching I have had on anaesthetics whilst ventilating a patient to target ETCO2 <4.5kPa at 2am in the back of an ambulance blue-lighting to the Royal London.

‘There's an SOP for everything but they're very rigid; our doctors aren't.’
I had several opportunities to observe doctors in the prehospital environment: with the BASICS Essex Accident Rescue Service, with the Essex and Herts Air Ambulance and with London’s Neonatal Transfer Service. I came to appreciate the high degree of situational awareness that was required of them. They have to see the medicine; the physiology, the pharmacology, the interventional capabilities, and predict the immediate and future care needs. They have to see the operational environment; the versatility of skills in the team around them, extrication requirements, receiving unit capabilities and the effect of transfer distances. They have to see the patient and the appropriateness of the interventions they deliver. Before patients even enter a hospital they can require the same level of care offered within them, thus generating a requirement for critical care clinicians capable of dealing with complexity and uncertainty.

‘We need an evidence-based response and we’re getting that’
I had many fantastic opportunities to learn about major incident management, an element of PHEM I find fascinating. With London at the centre of some of the country’s biggest gatherings the LAS has to ensure appropriate medical cover to deal with both the flux of crowds and the potential for major incidents, whilst retaining capacity for their regular service provision. It has also seen some of the country’s most high-profile major incidents, the ripples of which are shaping management and resilience strategy. As well as hearing personal accounts of responses, I was able to learn about aspects of command and control from senior paramedics.
I was hosted for a day by the London Fire Brigade to learn about their immediate emergency care (IEC), their response to incidents such as road traffic collisions, and their role in and preparations for major incident command. I was also able to learn about the comprehensive IEC training and role of the Tower Bridge Royal National Lifeboat Institution crew, whilst getting a spectacular view of London from the water and to observe some of the medical training given to the armed police services. Shadowing the stadium commander and medical cover at the Emirates stadium was a fantastic introduction to crowd medicine - and to football - although only one has inspired my future career.

‘Think about the image your organisation projects.’
Spending a week with the Faculty at the Royal College of Surgeons Edinburgh was a fantastic insight into its work and logistics. From hearing about the development of the sub-speciality on a hike up Arthur’s Seat, to observing the dedication of its sub-committees to ensuring standards of training given to providers and standards of care to patients. Meeting examiners and observing the candidates in the DipIMC and FIMC examinations reinforced that whilst there are values, attributes and skills shared by all pre-hospital care providers there is no one size-fits all in PHEM.
My thanks to The London Ambulance Service, Doctor Tom Evens and the Faculty of Pre-Hospital Care for all of their help and support in introducing me to such an incredible and incredibly important part of our healthcare system. To those considering applying for the 2019 elective, I cannot recommend this elective enough.'

2018 Elective Report

Upcoming System Maintenance & Network Disruption