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AimsThis study explores the opinions and experiences of Irish Defences Forces’ (IDF) graduates from University College Dublin’s Diploma in Military Medicine Care (DMMC). It aims to identify which aspects of medical education are relevant for the development of military graduates in the role of Combat Medical Technician (CMT) in future.MethodsA validated Clinical Learning Environment Score tool was adapted and incorporated into an online survey. This was sent electronically to 71 graduates. Responses were anonymous.Results38 (54%) graduates responded. Student feedback was positive regarding teaching and clinical placements in the DMMC. In total 16 (42%) students reported use of their new skills in their daily work. Of the 9 (24%) deployed overseas, all used their new skills. Emergency and occupational health skills were used more frequently, while advanced skills were used rarely.ConclusionAn increased emphasis on frequently used skills should be considered. Links to healthcare services would be of benefit to graduates in skills maintenance. Key advanced skills, such as intravenous cannulation and advanced airway management are rarely used but mechanisms to maintain them will improve the relevance of the programme to the CMT role. A change in how the IDF acknowledges qualifications may support more graduates in advancing and maintaining their career in the military medical workforce.

Background: Paramedics new to research need to know how to optimise the quality of proposed research studies. A prehospital mixed-methods study design required guidance, not only from an academic perspective but also from experts within paramedicine. Paramedic engagement was defined as an exercise where paramedic researchers and paramedic clinical academics could be involved as advisory professionals. Aim: The aim of this paramedic engagement was the revision of a proposed research design on how senior clinical advisers determine futility in pulseless electrical activity in out-of-hospital cardiac arrest. Method: Five research paramedics and four clinical academics were interviewed by email using semi-structured questions. A generic qualitative inquiry with inductive content analysis was applied. Results: Paramedic engagement identified five themes: rewording the proposed study title; acknowledging that paramedics withdrew resuscitation; the implications of prolonged futile resuscitation; the need for autonomous paramedic decision-making; and improving research methodology. Conclusions: Professional paramedic engagement meant a number of complexities were identified within prehospital research and and pragmatic solutions were provided to the limitations in the proposed design. Novice researchers within paramedicine would benefit from early paramedic engagement to facilitate the design of research studies, provide guidance on methodology and identify limitations to improve the overall quality of prehospital research proposals.

Background: Evidence to support device choice in intraosseous access is lacking in UK paramedic practice. Being unable to access the sternum with devices may result in under-treatment because of the inability to gain timely vascular access. This represents a shortcoming in current practice and a need for further research. Method: A literature review was conducted to find suitable studies and these were critically appraised. The data were synthesised to draw conclusions that could either influence practice or inform research. Study results were analysed in order to examine the following outcomes for devices most successful in terms of insertion rates; insertion times; ease of use; and flow rates. Cost-efficacy was also taken into consideration. Results: Forty-eight relevant articles were identified in the search and 18 were analysed. Of the 18 articles, 7 were randomised controlled trials and 11 were observational studies. Results varied widely with differences in reporting making the synthesis of data problematic. However, there was sufficient evidence to conclude that semi-automatic devices are superior to manual ones. Conclusion: Weaknesses in the evidence and inconsistencies between studies limited the conclusions that could be drawn. There is a strong mandate here for further research.

For a paramedic, delivering a death notification (DN) is one of the most difficult and stressful messages they will have to communicate in practice. Stress and anxiety in both recipients and paramedics have been documented through a limited literature base. The current review seeks to understand the existing educational tools and training around DN, and evaluates the applicability of these in the pre-hospital environment.

Background: Universities are now frequently exploring international placements and learning experiences for paramedicine students. This has given rise to questions about the quality and meaningfulness of overseas student experiences within the paramedic curriculum. Aim: This study investigates whether a university-organised overseas trip provided a useful clinical and cultural learning experience for undergraduate paramedicine students. Methods: A 60-question survey was administered to participants, with questions chiefly focusing on clinical and cultural experiences during the overseas trip. Statistical software was used to analyse continuous and categorical survey data. Findings: This international trip appears to have provided a very useful cultural learning experience, but a sub-optimal clinical learning experience for students (even despite child births, emergency room presentations and blood-draws). Conclusions: A validated survey instrument which builds upon current knowledge and literature could be used more widely to evaluate and better understand the dimensions of quality in overseas paramedic student placements.

Aim: The current study investigated the positive and negative psychological adaptations that are a result of secondary traumatic stress, and the role of resilience among paramedics and emergency medical technicians (EMTs). Methods: Emergency medical service (EMS) providers anonymously completed four validated questionnaires on: secondary traumatic stress, post-traumatic growth, resilience, and changes in outlook. Relationships between these constructs and demographics were explored. Findings: Overall, EMS participants reported a higher-than-average positive change in outlook. Resilience (p0.05) were detected between years of experience for any attributes analysed. Conclusion: Findings demonstrated significant correlations between secondary traumatic stress, resilience, post-traumatic growth, and changes in outlook in EMTs and paramedics.

Background: The current study describes the design and implementation of a residential aged care facility placement, and reports student experiences using an attitudinal survey across two cohorts. Method: Placements in January 2014 and 2015 were surveyed to identify barriers and enablers to student learning. Descriptive analysis was used to report the frequency of responses for categorical variables. Chi-square tests were used to analyse change in item rank by year. Content analysis was used to analyse text responses. Results: Initial 2014 results show that 75.4% of respondents agreed that they were able to achieve the required learning outcomes during this placement, with 72.8% agreeing that the placement improved their knowledge of community-based care for the elderly. Students tended to agree that the placement improved their confidence as practitioners, and that the experience helped to improve communication skills. Conclusion: This initiative showed that it is possible to enable learning outcomes that are directly related to core paramedic competencies. The placement was associated with improved understanding of age-related health problems. In addition, the placement provided opportunities to observe the role of health professionals in the maintenance of an older individual's health, social and spiritual needs.

The current article describes how an innovative approach to mental health training for student paramedics can prepare the future workforce with the skills and knowledge needed to provide high-quality care. Action research methodology is used to describe the delivery and evaluation of the placement, identifying its key and sustainable learning impacts for all involved. Key to its success was the co-production of the placement from beginning to end, including service users and qualified paramedics. The outcome of the placement enabled students to develop the confidence and ability to provide compassionate person-centred care as well as the skills to cultivate self-care and resilience.

The aim of the current research was to review the first-line response to patient falls in the independent care sector in North East England. The authors used an online questionnaire via ‘Survey Monkey’ software package, and a convenience sample of 24 of 32 independent care sector homes from South Tyneside, representing a 75% response rate. Policies and guidelines for falls were investigated and the findings highlight the disparate responses to incidences in care-home settings. Despite 96% having a policy on falls, only 80% included an assessment of possible injury or harm and 13% included no direct guidance for staff when residents fall. The most common action was to ring emergency services to move patients, even in the absence of physical injury. There was considerable ambiguity around the assessment of injuries and whose responsibility this was, particularly in falls with potentially non-visible injuries. Ambiguity was also present in the management of falls, where there was overlap between accident and falls policies. The current research highlights the need for policy standardisation. There is a potential fiscal impact on emergency ambulance services when they are contacted as the first-line response for falls regardless of the occurrence of injury. This has implications on staff education and the strategic planning of emergency ambulance services. Further consideration on the suitability of falls policies is urgently required.

Paramedics are frequently called to people with acute mental health problems and often assist in caring for and transporting individuals subject to police powers under the Mental Health Act 1983 , sections 135 and 136. Those powers will change when Chapter 4 of the Policing and Crime Act comes into force this autumn. In this short article featured for World Mental Health Day, Richard Griffith considers the impact of amendments to police powers on paramedic practice under the Mental Health Act 1983 introduced by the Policing and Crime Act 2017 , Part 4, Chapter 4.

Background: Qualitative research involving paramedics and their involvement in end-of-life (EoL) care has already been published, but there have been no published attitudinal studies specifically relating to do not attempt cardiopulmonary resuscitation (DNACPR) orders and paramedics working in the pre-hospital setting in the UK. Objective: To gain an understanding of paramedic attitudes towards an increasingly common aspect of paramedic practice, focusing specifically on the pre-hospital environment and identifying any corelation between gender, length of service, and level of educational attainment. Design: A paper-based questionnaire was distributed to all paramedic grades, operational out of two ambulance stations of a regional NHS ambulance service in March 2017. The questionnaires were designed using a combination of free-text boxes and Likert scales. A total of 33 questionnaires were issued and 11 completed questionnaires were returned. Results: Respondents indicated the importance of communication in relation to DNACPR orders, as well as the role of allied health professionals and family members in the process. Respecting the patient's wishes was considered paramount, as was educational provision surrounding DNACPRs. Conclusion: The majority of respondents reported that they were comfortable incorporating DNACPR orders in their clinical practice, although more modest responses were returned regarding the level of education received in this area of paramedicine.

This ‘day-in-the-life’ article is the author's first-person account of his experiences as a paramedic working in an inner-city GP practice, while training to be an advanced clinical practitioner. The author aims to illustrate the range and complexity of the role of paramedics based in primary care, and how this role is developing beyond the traditional scope of paramedic practice. The article presents actual patient encounters, which reflect a typical working day in primary care. Through this approach, the author hopes to demonstrate how paramedics can complement and extend the skills of an established primary care team. Furthermore, studying advanced clinical practice at postgraduate level provides new and extended clinical skills and knowledge, allowing paramedics to work with greater autonomy.

There is a lack of understanding on how paramedic students develop their knowledge, skills and attitudes to support people living with dementia and their families. This original qualitative study applied focus groups to explore paramedic students' perspectives. First and third year paramedic students were recruited from two ambulance service providers in the South of England. Data were collected during January and February 2017 and three themes emerged: 1) challenges of communication 2) students' negative emotional response, and 3) lack of social care and pathways. Paramedic students did not discuss person-centred approaches to support people with dementia; however they all acknowledge the impact of dementia as unique to each person, their family and situation. Undergraduate paramedic education needs to support the development of students' communication and interpersonal skills. Both university lecturers and placement educators need to provide consistent, clear, detailed information to enable students to support and care for people with dementia and their families.

The purpose of this paper is to establish the views of a group of Paramedics on Paramedic prescribing. Although at the time of writing the proposal to the Commission on Human Medicines they rejected prescribing for Paramedics, work is still ongoing with various bodies to move forward with the application. A focus group of a small number of Paramedics was held, and the researcher performed a review of relevant literature. The development of the role of paramedic from an ambulance driver to a highly skilled and knowledgeable healthcare professional was discussed. It was established that the profession's close links with higher education institutions would be pivotal if paramedics are to be given prescribing rights. The study concluded that paramedics believe they should be able to become independent prescribers, as it would help further their career, giving the profession added credibility. As paramedics already give a rounded healthcare approach to their patients, this would only be enhanced by prescribing rights, as a ‘complete’ health care attitude could be established.

Purpose: The purpose of this study was to explore student paramedics' awareness of the emotional demands of their future role, particularly regarding the delivery of compassionate care. Problem: There is a dominance of nursing literature in the discourse around compassionate care and emotional labour, and a paucity of research in the paramedic literature. Methods: A survey was issued to a small convenience sample of paramedic students. Excel was used to organise data collected, which was then presented graphically as tables and charts. Results: Key findings were drawn out and it was found that there were some correlations between the literature reviewed and results generated. Conclusion: Student paramedics had identified factors affecting their emotions in placement very early on in their studies. There was evidence of students covering up their emotions whilst in placement. The research reinforced the need for further larger scale and longitudinal studies.

The role of front line ambulance staff in the UK has developed so rapidly that it is almost unrecognisable from days gone by, when scoop and run tactics were commonplace. With additional responsibilities, pressurised decision making and a range of sometimes complex interventions, unique pressures have also developed. The purpose of this article is to review pertinent information relating to how these additional pressures can metamorphose into specific conditions such as post traumatic stress disorder (PTSD). The prevalence of this and other debilitating conditions such as depression and anxiety specific to the ambulance service is reflected upon, whilst existing support from the ambulance service is examined. By broadening both knowledge and confidence relating to this increasingly significant problem, formulation of our own local improvements can take place in the near future.

Paramedics are autonomous health professionals who must graduate into the workforce with complex problem-solving skills, an ability to exercise critical thinking, and clinical reasoning skills to challenging situations, if they are to practise safely. Face-to-face action learning (AL) has long been acknowledged for contributing to the development of such skills, by providing a platform for structured thinking, group working, and a tool for developing participant's ability to ask insightful questions ( Pedler et al, 2005 ) and more recently, action learning in the virtual space is becoming increasingly popular. Virtual action learning has emerged for reasons including globalisation, where the emergence of multi-national and dispersed students has become commonplace ( Dickenson et al, 2010 ) and advances in technology that have allowed more collaborative communication.This discussion paper provides an introduction and background to action learning (AL), virtual action learning (VAL) and explores the appropriateness of these paradigms as a tool for embedding reflective practice and problem-solving skills among undergraduate student paramedics.

Paramedics frequently have to balance patient confidentiality and patient safety. Patient information is subject to legal, ethical and professional obligations of confidentiality and should not be disclosed to a third party for reasons other than healthcare, without consent. Whilst there is an imperative to preserve the professional/patient relationship, there are occasions where this is not possible. This article considers circumstances when confidential patient information may be disclosed without the consent of the patient and discusses the legal, ethical and professional aspects of decision making in this context. A clinical example from practice is presented where an ambulance crew was called to a 50-year-old man with type I diabetes, which is normally well controlled with insulin. He is employed as a van driver, but has experienced two sudden hypoglycaemic episodes in 3 weeks rendering him unconscious. Once treated, he declines transport to hospital, any onward referral or to inform the Driver and Vehicle Licensing Agency (DVLA) through fear of having his driving licence suspended.

The context or background for the study: This paper was written following a critical analysis and structured reflection on mentoring and teaching a dyslexic paramedic student including approaching from personal experience as well as identifying a gap in research. The purpose of this study was to discover what paramedic mentors can do to improve their interactions with dyslexic stu-dents. Basic procedures: Following the experience of teaching one student, to work on this definition of dyslexia: “difficulties in processing, particularly literacy and the acquisition of reading, writing and spelling’.”; Using an analytical method – qualitative and reflective. Main findings: Inclusive learning helps to fight stigma while improving education for all whether they dis-close dyslexia or not. There are many steps that can be taken by mentors to support stu-dents, including allowing time to think/to practise and support with organising. Conclusions: Inclusive learning benefits all students, not just students with dyslexia. Students do not legally have to disclose a dyslexia diagnosis, so, introducing inclusive learning for all students using accessible and practical learning could benefit more students.

Paramedics are now encountering ever more complex medical situations, and are expected to formulate holistic management plans. This case provides an interesting scenario whereby management was considered not only in conjunction with current evidence and guidelines but also with patient preference. This article will explore the assessment and management of a patient presenting with asthma and a chest infection whilst considering legal, ethical and professional factors.

To ensure morally justified decisions, clinicians are encouraged to apply ethical theories and frameworks. Beauchamp and Childress’ ‘Four Principles’ approach to medical ethics, or ‘Principlism’ for short, is highly regarded as a simple methodology for considering ethical dilemmas, and is common to many undergraduate clinical programmes. On occasion, ethical dilemmas are complex and one or more of the four principles come into conflict with each other. Critics of the approach have suggested that there is a lack of guidance on how to resolve this conflict. This paper will argue that principlism facilitates an organised and thorough method of reflecting upon an ethical problem and is well suited to the pre-hospital setting. The problem of how to resolve conflicts between the principles will be explored, demonstrating the merit of the approach through its application to a real-life moral problem from the pre-hospital setting.

Thanks to improved recognition, management, and overall societal acceptance of atypical gender identity presentations, number of transgender patients is increasing. Written by a transgender female, this paper draws from both personal experience and academic literature and discusses what it means to be transgender and the latest biomedical research into the aetiology of transsexualism. Clarification of common terminology is addressed to ensure an appropriate rapport to be built by the prehospital clinician without alienating the patient during the clinical examination and assessment. Specific considerations that may present to a clinician outside of hospital, with information about history taking, drug therapy and mental health challenges surrounding the condition are then discussed. The paper concludes by stating that paramedics and ambulance clinicians must recognise the health care needs of transgender patients and advocate for them to help eliminate discrimination.

Background: Studies have highlighted paramedics are inadequately prepared to care for patients who are at the end of their life, due to the historical focus of their training on acute medical management. This appears to cause conflict with paramedic perceptions of their role. Objective: To gain an understanding of paramedics' perceptions, confidence and concerns towards dealing with end of life care patients and their families. Design: An online survey comprising open and closed questions was distributed to all paramedics in a regional ambulance service in the north of England. Demographic data included: National Health Service (NHS) grade, personal experience, education and training to contextualise the data. A total population sample across differing organisational roles was used for paramedics in a regional ambulance service in the north of England. Responses were obtained from 182 staff. Results: NHS grade and length of service as a paramedic influenced the participant's confidence and concerns when dealing with end of life patients. A large number of participants (n=126, 70%) identified validity of documentation as a concern with 83 (46%) highlighting fear of litigation and 90 (50%) identifying that conflict with families was a concern. Support from other services was viewed as a contributing factor to increased paramedic involvement in end of life care. Conclusion: Most paramedics viewed end of life care as central to their role, but there was a need for further specific education to help enable paramedics to feel more confident, competent and supported in ensuring patients receive optimal care.

Informed consent is a concept that has grown in importance over the last 40 years. It is now a key concept in modern healthcare practice and underpins all patient encounters. Any consent to assessment or treatment should be gained in an informed manner and failing to do so can lead the clinician open to accusations of negligence. Despite this many clinicians have only a vague or incorrect understanding of the concept of informed consent and what does, and does not, constitute it. The following article attempts to clarify the latest thinking in English law regarding informed consent drawing largely from the United Kingdom Supreme Court (UKSC) ruling on the subject in 2015. There then follows a discussion of a number of areas where paramedic practice in particular may be failing to meet modern standards of informed consent. It will be argued that consent in paramedic practice is often poorly sought and documented and that paramedic practice often becomes ‘defensive’ and in doing so fails to meet the required standards for informed consent.

Purpose: To gain an understanding of how Black and Minority Ethnic (BME) groups respond to information about paramedic courses, their experience of the enrolment processes and their experience of paramedic training. Methodology: Telephone interviews were conducted with qualified paramedics and student paramedics from BME groups. Findings: Interviews revealed issues in relation to the accessibility and understanding of information on paramedic education and a lack of information in preparation for paramedic courses, causing unrealistic expectations. A lack of diversity in the student population, incidences of racial offence (unconscious or conscious), and a lack of visibility of BME staff in the ambulance service as well as in the wider community were identified. Practical implications: The results produced from this evaluation may contribute towards a series of recommendations in order to better inform practice to increase the diversity of students entering into paramedic science and in order to avoid issues such as student attrition

An innovative policy implemented by a UK Ambulance Service allows paramedics to refer patients to a GP Acute Visiting Service scheme. Initial evidence suggests that this alternate route of care can decrease hospital admission rates, decrease A&E waiting time and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that are not captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic's perspective. All notes were transcribed, coded and analysed using a Grounded Theory approach. Four main themes emerged: 1) barriers to referral including wait time, process, and lack of confidence, experience and training 2) approaching the patient with the GP referral scheme in mind 3) frustrations with GP decision making and 4) awareness/understanding of the scheme's impacts. This study provided valuable insight into the paramedic's perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP's perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success.

This article looks into the current difficulties many UK paramedics face when trying to manage patients presenting with a mental health condition in a safe and respectful manner; particularly when the patient requires some form of treatment but refuses this against medical advice. By utilising a reflective format, the article explores some of the laws surrounding treatment without consent and how these may aid or hinder a paramedics' ability to provide good quality care to patients in these situations. Confusions surrounding said laws have been extracted from the case report and discussed in more generic terms in order to be more readily applicable to other similar cases. In doing so, the article attempts to provide a clearer format of understanding of the laws and management of these situations, both for the benefit of future patients and the emergency services alike.

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this month's instalment, Andrew Kirk discusses common pulse sites and correct technique for obtaining a patient's pulse

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this instalment, Karen Simpson-Scott takes an in-depth look at electrocardiograms and the vital readings they provide for clinicians

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. Here, Rory McKelvin discusses haemostats; what they are, how they work, when and where to use them, and how to do so effectively.

In this new monthly feature, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontlines, highlighting the importance of these skills and how to perform them. In this month's issue, Rory McKelvin discusses best practice use of a combat application tourniquet.

There is an increasing number of research projects conducted that requires the recruitment of participants in the pre-hospital or emergency setting. A complicating factor in pre-hospital and emergency research (PHER) is that potential participants may lack or lose the capacity to give a valid consent. The lack or loss of capacity is ethically and legally complex for researchers and Research Ethics Committees (REC) whose approval must be gained prior to commencing a study. This paper explores those challenges by drawing upon a number of case studies of pre-hospital research in which adult participants are likely to lack the capacity to consent. The paper begins by outlining the development of the legal provisions for conducting research with participants unable to consent for themselves within the jurisdictions of England and Wales. The paper goes on to explore how researchers can meet the legal requirement for research, how to frame the issues for the purposes of ethical review, as well as offering ethical guidance for practices within the research field.

Advance refusals of medical treatment present complex dilemmas with ethical, moral and legal facets. A competent patient may refuse any treatment, even where the decision may lead to an untimely death. The same holds true with respect to an incompetent patient with an advance directive made when that patient was competent and there is no reason to believe that the patient has changed his or her mind. Advance statements arise from respect of patient autonomy and the introduction of The Mental Capacity Act 2005, which aims to provide consistently better protection and greater empowerment for vulnerable people and their autonomous rights. This article outlines how the patient's right to choose in advance how they are to be treated if not competent to make his own treatment decisions is a positive development in the law. However, it may be of limited effect, as the majority of people will probably never make an advance statement. As a result, we should educate both patients and doctors about their rights in relation to medical decision-making, particularly as our increasing ability to prolong life makes decisions to terminate life-sustaining treatment more common. In order to respect patient autonomy, avoid harm to patients and reduce the risk to paramedics of civil or criminal liability, paramedics need to determine the legal validity of advance directives before making their treatment decision. In cases of uncertainty treatment decisions should be made in the patient's best interests while legal advice is sought as to the validity of the directive.

This study aimed to gain insight into the feelings and perceptions of family members who witness an adult family member resuscitation. Little is known about family members' experiences and their needs and priorities. Resuscitation is a complex and highly emotive situation but guidance for paramedics to support families either in the decision-making process or to remain present is limited. Policy developments around improved and shared decision making are not evident in any guidance for resuscitation for paramedics. Paramedics have always been involved in resuscitation in the family home, but as they remain on scene for longer periods, it is important that the issue of family participation is addressed and specific guidance produced to enable paramedics to offer more focused and enhanced support to them, and involve the family members in the decision-making process which is a requirement from recent policy developments.

There is limited research within the UK investigating the effects of shift work on paramedics. Paramedics have relatively high rates of sickness levels and there are links between shift work and health. This study explores UK paramedics’ perceptions of the impact of working shifts. Methods: Exploratory qualitative research was utilised to investigate the perceptions of UK paramedics on the impacts of working shifts. Two focus groups were completed involving 11 paramedics. The transcriptions were analysed using thematic analysis. Results: Paramedics described factors associated with working shifts that mirror research already completed within different occupations: effects on physical health, fatigue, family life, safety and performance; but paramedics additionally described factors that are more limited to working in the paramedic profession such as a broader range of psychological stressors and organisational factors. The theme of psychological health was a wider theme that went beyond shift work and encompassed the overall paramedic role and the unique and stressful nature of the work. Conclusions: This research has allowed an insight into the perceived effects of shift work on UK paramedics and exposes the challenges paramedics face in their working environment. There is a suggested link between the relatively high rates of sickness and the effects of shift work and paramedics’ overall working environment. Further exploration and recognition of the effects of shift work on UK paramedics is recommended.

Background: Climate change will impact on emergency services and healthcare practitioners need to be aware of future challenges. The aim of this study was to assess the effectiveness of a scenario-based educational intervention designed to raise awareness and generate discussion among practitioners and students about sustainability and climate change. Methods: Paramedic undergraduate students completed a Sustainability Attitudes Survey before they participated in a health and sustainability session that focused on resources used in clinical practice and the potential impact of climate change and natural materials scarcity on resource availability. The students completed the questionnaire again following the session. Results: Significant differences between the pre- and post-intervention questionnaires were found for 8/9 attitude statements; there was no significant difference for the statement: the segregation of healthcare waste is important. Students were more likely to accurately report the cost of disposing of clinical and domestic waste following the session. Conclusions: Data suggests that participation in a health and sustainability scenario can improve knowledge about the use of natural resources in clinical practice, where resources come from, and the cost of waste management. Attitudes towards including sustainability and climate change in healthcare curricula were more positive following participation in the health and sustainability session.

Background: Development of new evidence to support pre-hospital emergency care benefits both patients and practitioners. Clinical research must be conducted within a formal governance framework but it is challenging for paramedics to access traditional good clinical practice (GCP) training due to high service demands and some content is of little relevance to the pre-hospital setting. Objective: To establish the content and format of easily accessible research governance awareness training for use by paramedics and other members of the ambulance service as and when appropriate. Methods: A systematic literature review identified descriptions of pre-hospital research training. An online survey sought views about the formal research training undertaken by NHS paramedics and an expert consensus process confirmed the content of training materials. Results: Research governance training was rarely acknowledged in pre-hospital clinical trial literature and was recalled by only one in eight respondents who had assisted with clinical research. A pre-hospital orientated slide set and matching assessment questions were reviewed in two cycles by an expert panel to achieve a consensus on the content and format. Conclusions: Through a structured process of literature review, stakeholder engagement and expert consensus we have developed training and assessment materials which can be used flexibly to prepare paramedics and the wider ambulance workforce for safe hosting of low-risk research activities.

Cardiac arrest is a rarely attended event as a proportion of overall paramedic workload. When paramedics do attend such an event the management focus is largely concerned with clinical intervention and there may not be the capacity or appreciation for offering ongoing support to family members present. Indeed, even training may not have covered this element of care. Regardless of the prognosis for the patient, evidence suggests that there is benefit in directly involving relatives during the resuscitation. Engaging them with carefully considered and informed dialogue certainly seems humane at least. In which case, a structured and holistic approach should be employed where clinical care and emotional support go hand in hand.

For clinicians arriving first at mass casualty incidents, one of the greatest challenges is not focusing attention on one individual patient, but to assess the needs of the many in order to establish prescribed procedures and the resources required. However, for the victims of potentially lethal stab wounds, there is often little that prehospital clinicians can offer over very rapid transport to in-hospital surgical intervention. In this article, the authors explore the conflict between the established and often protracted major incident approach against the immediate needs of someone who has just been stabbed, in contrast to the different management challenges of victims of blunt trauma. A view of the London Bridge attacks is presented from the perspective of a London Ambulance Service advanced paramedic practitioner in critical care. The advantages of having an experienced advanced clinician able to offer early clinical and on-scene leadership manifested in several ways, and these will be highlighted here.

This discussion explores the significance of digital technology to responsive patient care in applied paramedic practice. The authors' previous research identified the relative ambiguity of the role of digital technology in facilitating and supporting patients in practice, and the findings revealed the relative transferability of this finding to wider allied healthcare clinical and professional practice. The discussion encompasses two key debates, namely a) How best the quality of the digital technology patients engage with can be discerned with regard to the vast availability of information and b) what the fundamental pedagogical implications to the way paramedic education in the UK is currently delivered might be in relation to equipping the future paramedic workforce to empower patients and their families and carers in emergency situations. The discussion paper concludes with an overview of the tensions that unregulated apps pose in practice and how engaging with the public about the use of digital technology could be a key aspect for review in UK undergraduate curricula and staff development.

Black or gallows humour has long been recognised as having therapeutic value, particularly when used by individuals dealing with traumatic incidents. With this in mind, it is no surprise that this type of humour is commonly used by emergency services personnel. It is a bona fide coping mechanism which can contribute to the resilience, health and wellbeing of emergency services personnel but one which, to the uninitiated, may appear callous and uncaring. With student paramedics now taking the higher educational route into paramedicine, they will have had less exposure to ambulance service culture before qualifying than would have been the case with the old ‘in service’ pathway. This often results in the type of humour employed by their new colleagues coming as something of a culture shock. This article hopes to go some way to explain why this type of humour is employed, what purposes it serves, and prepare students so that it may appear less shocking when they first encounter it.

As the world of palliative medicine is rapidly becoming a fixture in the pre-hospital field of practice, this article looks to explore the ethical and legal issues surrounding pain relief for end-of-life patients by paramedics. Particular attention is focused on the moral and ethical principles of care as proposed by Beauchamp and Childress (2008) , as well as the legal aspects of care as set out by the European Court of Human Rights. Through the use of law cases, this article looks to demonstrate precedence for practice, as well as the implications that arise thereof. This article concludes that, although many aspects are still a grey area for paramedics, the depth of law cases, alongside the moral arguments, show that providing paramedics act with the best interests of the patient at heart and work within a multi-disciplinary team, the administration of analgesia to prevent suffering can be legally and ethically proven.

Reflecting upon practice is an essential process by which we can question, make sense of, clarify, and develop our knowledge and performance as clinicians. Unlike people who work directly with their peers and seniors, the opportunities for paramedics to discuss at length scenarios and cases with appropriate clinicians can be scarce. Johns (2010) identifies reflective practice as a means of professional supervision, which can act as our guiding peer when we need to step back and consider our practice in a structured and organised way. Developing clinical insight using reflective models is a key aspect in the training of the modern paramedic, and a necessary duty for qualified staff to undertake in order to ensure that their practice remains current. To be effective, reflective models must encourage the questioning of what we already know and do, and facilitate the broadening of our knowledge so that we may improve our practice and create new ideas. The author aimed to create a reflective model that fulfilled those requirements in a way that was as accessible to those who are familiar to structured reflection as to those who are new to the process, but was compassionate to the unique role of the paramedic.

Purpose: This project aimed to evaluate the influence of an education session on ambulance clinicians' understanding and awareness of children's distress, distraction techniques and holding in the pre-hospital setting. Methods: An inter-professional education session that focused on raising awareness of children's distress, the use of distraction techniques and clinical holding during pre-hospital care was provided. A mixed methods approach was then used to evaluate both existing and newly acquired knowledge and opinion through the use of questionnaires (n=26) and focus group discussion (n=20). Results: Despite literature suggesting that ambulance clinicians may not use distraction techniques during pre-hospital care, data gained from this project indicates that use of distraction techniques is widespread (92%, n=24) and has been adapted to fit within pre-hospital care. The inter-professional education event was reported as being of value for ambulance clinicians. Conclusions: Ambulance clinicians endeavour to provide a positive experience for children undergoing procedures, despite reported limitations in education, exposure and equipment. By using a collaborative and consultative education event, it is possible to facilitate ambulance clinicians to challenge their practice and improve their reported knowledge of dealing with children during procedures in the pre-hospital setting. Additional work needs to be undertaken to further explore and improve pre-hospital practice in relation to children's distress and clinical procedures.

The paramedic role requires countless sound, logical and sensible decisions to be made. Sometimes paramedics may be faced with decisions that they feel less confident about making. This paper will discuss the types of clinical decision-making approaches. The majority of everyday decisions are made intuitively. The brain uses its experience to match decisions that it has made, observed or contributed. This may not be a reliable method of decision making, especially if you have been unable to gather sufficient information. Pattern recognition is a skill-based activity. Unlike intuition, which can support near-instant decision making, it is done when time permits and there is no need to rush. Under the hypothetico-deductive model of clinical decision making, the clinician sorts the clues and findings into logical groups using previous knowledge of symptoms and anatomical locations and landmarks. Then a hypothesis is formulated based on experience and knowledge of pathological, physiological and psychological conditions. Generally, clinicians need to improve their awareness of clinical decision making: using intuition might well have a role to play coupled with heuristics and bias, but it has its limitations and risks. However, hypothetico-deductive reasoning has a prominent place and should be embedded into education and everyday use.

Recent figures published by the charity Mind highlight the prevalence of mental health problems suffered by members of the ambulance service. Alistair Quaile reports on the current systems in place to support staff and the attempts being made to reduce the stigma attached to mental health.