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Undergraduate medical education increasingly seeks to engage medical students with in-hospital paramedical practitioners, aiming to inspire a more rounded and holistic clinician suitable for evolving clinical practice. However, paramedics are yet to be engaged in this endeavour at the pre-hospital stage in Australia despite being fundamental to the journey and care of many of our patients, in my opinion. Here, I narrate my experience in shadowing paramedics during my undergraduate medical education in the UK, focusing on two memorable and meaningful patient interactions that have shaped the way I view the patient perspective, the patient narrative and my own practice as a registrar in emergency medicine. I believe that similar experiences could continue to inspire the emerging and dynamic medical workforce, and we, as forward-thinking physicians, should seek to increasingly engage pre-hospital practitioners in our educational endeavours.
IT IS 6 am on a cold winter’s day, and I am sat in a fast response vehicle with my friend Chris, who has been a paramedic for the past 7 years. It’s the start of our shift and we are parked in a car park at the foot of a towering concrete block of social housing flats. For the next 12 hours, Chris and I will attend to the increasingly anonymous population of this city. The prospect of the unknown is exhilarating, fascinating and tantalising. We expect the usual mix of medical patients, trauma, and those patients who ring for an ambulance not because they have an acute medical concern, but because they want a chat, a friendly face and some human contact.
We cradle our weak petrol-station coffee and watch as the city comes to life. Dogs bark at their tired guardians, weary teenagers struggle to fish keys out of skinny-jean pockets, and exhausted shift workers park up next to us, seemingly oblivious to the glorious sunrise.
I am a 3rd-year medical student and have been shadowing Chris most Saturdays for the past 2 years. Every Saturday, we wonder who will be unlucky enough that day to hear our sirens coming towards them and wonder whose lives will change forever.
The electronic claxon of our despatch computer heralds our first call, for a 21-year-old woman with shortness of breath. Downing the coffee, we roar out of the car park. Chris navigates the last few night busses still on the road, and I read the live feed of information being delivered to our on-board computer. We start to formulate a differential – spontaneous pneumothorax, asthma attack, pneumonitis, pneumonia, massive pulmonary embolism – or perhaps more psychosomatic – acute stress reaction, panic attack. Arriving at the property, we buzz ourselves into the graffiti covered lift of yet another tower block. Greeted on the 18th floor by an open door, Chris gives a cursory knock before stepping over the threshold, announcing that we are from the ambulance service. Gasps of relief come from inside, and we make our way into the tiny box bedroom.
The patient is a known asthmatic, visiting a friend for the weekend. In her hurry to leave her own home, she had forgotten her inhaler, and had awoken in the early hours wheezing and desperate for air. Her eyes dart around the room as her chest heaves, her hands shake as her body fights for any oxygen it can find. Chris quickly listens to her chest, sits the patient upright and sets up continuous nebulisers. He cannulates her and delivers a shot of steroid, and then looks her in the eye and breathes with her, talking her down in the process. Over the next 20 minutes, the patient’s breathing settles, she talks fully again, and the frightened look in her eyes disappears. She knows she is getting better, she knows the treatment is working. A second ambulance arrives and Chris readies the patient for transfer to hospital, but there is a problem. She has tickets to a gig today and “won’t miss it for the world” – she has been saving up for months and has pulled a sickie at work this weekend to attend.
She refuses to go to hospital and crosses her arms defiantly as Chris implores her to see reason. Chris discusses the risks of undertreating asthma, including the risk of death. But this is not the hospital, this is the patients’ domain and the usual authority garnered simply by being in the clinician’s environment of the hospital does not apply here. So, with great reluctance Chris checks the patient’s legal competency, and she signs herself off as declining transfer to hospital against medical advice. Smoking cessation advice follows and then we again board the lift down to the car, wondering how long it will be until the address again lights up our on-board computer.
Another coffee later and the claxon fires again. It’s 9 am and we are the nearest vehicle to an 88-year-old woman with fever and shortness of breath about 8 km away. The weak coffee barely hitting our system, we pull up outside a terraced house on a quiet, suburban street.
Jean and Keith (not their real names) have lived here for 40 years and have been married for almost 60. Their lounge has escaped the influence of Ikea and instead remains crammed with bulging arm chairs, dusty family photographs, and magazine cut outs of recipes for fish pie.
Jean is in one of the armchairs, and there is sweat on her brow. She hasn’t smoked since the war, but the rattle from her chest is audible from across the room. She’s been unwell with a cough and fever for 4 days, Keith tells us, but didn’t want to bother her GP.
“They are always so busy,” Jean pants. “Other people need them more than I do.”
She looks exhausted, weak, and while the glint in her eye remains, even I know that the pneumonia ravaging her lungs may soon claim her life. Keith looks on silently as Chris delivers oxygen, antibiotics and intravenous fluid. He looks Jean in the eye, calmly telling her everything will be okay. Keith doesn’t know what to do. He seems to understand how sick his beloved wife is, but he is shocked into silence. His friends have told him of similar things that happened to their partners, but he never thought – in this their home – that his Jean would also be a victim to the dreaded winter bug.
Chris turns to Keith and explains what is happening, explains time is of the essence, and asks Keith to pack an overnight bag and apprise his children of the situation. A second ambulance arrives to transport Jean to hospital and Chris speaks to her children on the phone. Chris and I watch as the ambulance departs, before we turn to the living room again – a living museum of Jean and Keith’s love – and we wonder, and we hope.
Shadowing Chris has moulded me into the physician I am today. The experience allowed me to live the themes taught with such sterility in medical school – managing diagnostic uncertainty, understanding the patient journey, understanding the patient perspective, the challenges and strategies around patient communication, to name but a few. Chris showed me the meaning of humble confidence, and decisive decision making under pressure. He and his colleagues taught me to treat the patient, not their numbers, and taught me the importance of being a rounded, versatile clinician, understanding the patient journey starts well before the patient arrives in hospital.
We as educators engage medical students with in-hospital paramedical providers, but not with our out-of-hospital counterparts who collectively transport more than 2 million patients to hospital annually. I think this needs to change.
I believe our paramedic colleagues can teach us more than the technical, and there is tremendous opportunity for educational collaboration between our two worlds. In so doing, we will create rounded clinicians who appreciate not only the themes above, but the thorough work of our pre-hospital colleagues. At my old medical school, medical students now shadow paramedics as part of their MBBS curriculum, and the feedback is outstanding. I think there is tremendous opportunity in Australia for a similar endeavour, and in so doing we will continue to evolve as fully rounded clinicians.
Samuel Bulford is a registrar in emergency medicine in Sydney, and a Conjoint Associate Lecturer at UNSW.
The statements or opinions expressed in this article reflect the views of the authors and do not
Anonymous…the service where the Paramedics in your area work might not have a ‘bypass’ policy and are obligated to go to the neatest receiving hospital.
Also they might have contacted the patients previous specialist hospital but been advised to attend yours.
In the UK we have more autonomy and rely on clinical diagnosis and ‘patients best interests’ and will always endeavour to attend the most appropriate hospital.
What is an in hospital paramedical practitioner?
I was trained in Western Australia and at the time (2001/2002), some of us had the opportunity of an elective in 5th/6th year medicine riding around and learning from the paramedics. It was a great and much valued experience.
I’m a tad confused. The article states “I’m a 3rd year medical student”, I presume the now ED registrar was a student at the time. The article reminds me of being a 3rd year (preclinical) student at UNSW in the 6 year undergrad course in 1973. That year in lived in Roscoe St Bondi Beach with student mates, and the ambulance station was just up the road. Being too poor to have a social life, I asked if I could ride with them some evenings and especially weekends. All informal, no liability complications (in a much less complicated world) and I learned a heck of a lot before I hit my clinical years. Then in 4th-6th year I had a job as a nursing assistant in my teaching hospital and learned a heck of a lot more. All of this made me a better doctor too. I’m sure. I retired two years ago.
And when the patient who was recently discharged from another hospital following management of complex problems the paramedics too often bring them to our hospital instead of driving another 10mins down the freeway with a stable patient, even when our hospital lacks the specialty service they need…..