The importance of being drink aware

While many people will be gearing themselves up for a well-deserved break over the holiday period, countless emergency medical services (EMS) personnel will be preparing themselves for the busiest time of the year. Although there are a number of explanations for the increase in callouts surrounding Christmas, one of the major contributing factors is alcohol consumption.

Injuries relating to alcohol come in a variety of forms and can be roughly categorised as follows: unintentional injuries, such as falls, drownings, cuts and burns; injuries as a result of violence, including intimate partner violence and child maltreatment; and road- traffic injuries. Another notable risk of alcohol consumption is alcohol poisoning, which in the worst cases can lead to death.

Alcohol is the biggest single cause of accidents in the home. Every year in the UK there are around 4 000 fatal domestic accidents, 2.6 million accidents that require treatment in A&E departments and many more accidents not accounted for in the hospital admissions statistics (IAS, 2013b).

In relation to violence, around 35% of victims report that offenders are under the influence of alcohol (Greenfield, 1998). Alcohol use is also associated with two out of three incidents of intimate partner violence (Greenfield, 1998).

The impact of alcohol in your system can have a seriously adverse effect on your ability to drive, due to the range of psycho-motor and cognitive effects that increase accident risk on reaction times, cognitive processing, coordination, vigilance, vision and hearing (IAS, 2013b). According to the Department of Transportation and National Highway Traffic Safety Administration (NHTSA) (2012), almost 30 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver every day. This equates to one death every 48 minutes. However, statistics show that during Christmas and New Year’s, two to three times more people die in alcohol-related crashes than during comparable periods the rest of the year, and 40% of traffic fatalities during these holidays involve a driver who is alcohol- impaired, compared to 28% for the rest of December (NHTSA, 2007). In the UK, despite an overall downward trend in the number of reported drink-drive accidents and casualties since the introduction of the 1988 Road Traffic Act, the proportion of drink-drive road accidents in relation to total road accidents has remained constant over the last decade (14%–18%) (Institute of Alcohol Studies, 2013b).

The fewer ambulances that are called out to treat patients who have over imbibed, the more that can be sent to patients suffering from unpreventable life-threatening emergencies such as cardiac arrests. The importance of the public being drink aware this Christmas can therefore not be overemphasised.


Dept of Transportation, National Highway Traffic Safety Administration (2012) Traffic Safety Facts 2010: Alcohol-Impaired Driving. NHTSA, Washington DC

Greenfield LA (1998) Alcohol and Crime: An Analysis of National Data on the Prevalence of Alcohol Involvement in Crime Report prepared for the Assistant Attorney General’s National Symposium on Alcohol Abuse and Crime. US Department of Justice, Washington DC

Institute of Alcohol Studies (2013a) Alcohol, accidents and injuries. njsw5nz (accessed 19 December 2013)

Institute of Alcohol Studies (2013b) Drink-driving factsheet. (accessed 19 December 2013)

National Highway Traffic Safety Administration (2007) Traffic Safety Facts, December 2007. NHTSA, Washington DC

Taken from International Paramedic Practice, published 20 December 2013.


The significance of the Keogh Review

Sir Bruce Keogh’s report on the first stage of his review into urgent and emergency care (NHS England, 2013), published 13 November 2013, presents a significant step in the progression of the paramedic profession.

Along with the introduction of a two-tier A&E system as part of a fundamental shift in the provision of urgent care, the NHS England Medical Director has called for the development of 999 ambulance services so that they become mobile urgent treatment services, noting that paramedics now have the skills that would only be done by doctors 10 years ago. The suggested change comes in a letter to Health Secretary, Jeremy Hunt, and NHS England Chair, Sir Malcolm Grant, where Sir Bruce says:

‘Our vision is simple. Firstly, for those people with urgent but non life- threatening needs we must provide highly responsive, effective and personalised services outside of hospital. These services should deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families’ (NHS England, 2013).

Both the College of Paramedics (CoP) and the Association of Ambulance Chief Executives (AACE) have welcomed the report, and emphasised that increasing demands on ambulance services highlights the need for further investment into the training and education of paramedics.

There are a number of factors said to be contributing to the growing number of A&E admissions, including an ageing population with increasingly complex needs, and people struggling to navigate and access a confusing and inconsistent array of urgent care services provided outside of hospital (NHS England, 2013). However, while the number of people attending A&E departments is on the rise, it must be stressed that those who can receive treatment at home or closer to home, should. According to the report, 40% of patients attending A&E are discharged requiring no treatment at all; there were over one million avoidable emergency hospital admissions last year; and up to 50% of 999 calls requiring an ambulance to be dispatched could be managed on scene (NHS England, 2013).

It has already been proposed that the provision of key roles in urgent and emergency care, such as specialist paramedics, has illustrated high-quality clinical outcomes and reductions in A&E admissions, but what the Keogh Review adds to the debate is confirmation of this fact.

The need to develop a larger workforce with advanced clinical decision-making skills has never been more apparent. The report also arguably offers good evidence for the need to develop prescribing for paramedics, as this will inevitably have an effect on the reduction of A&E admissions if patients feel they are able to receive sufficient out-of-hours care, which may include the chance to be issued prescriptions.

While this is a significant undertaking, that is expected to take between 3–5 years, it is undoubtedly a triumphant step in the recognition of the potential of the paramedic profession.


NHS England (2013) High Quality Care for All, Now and for Future Generations: Transforming Urgent and Emergency Care Services in England – Urgent and Emergency Care Review End of Phase 1 Report. NHS England, London

Taken from Journal of Paramedic Practice, published 4 December 2013.

Mental health and older people

World Mental Health Day was initiated by World Federation for Mental Health (WFMH) in 1992 to highlight the importance of mental health. This year, the WFMH Board of Directors decided on the theme of “Mental Health and Older Adults”. Running on 10 October, the day focused on highlighting the mental health issues experienced by older people in their communities, and encouraged people to consider their needs for support and services.

There is no denying that people are gradually living longer, as improved healthcare and standards of living have made this possible. In fact, the

current number of people aged 60 years and over is more than 800 million, and projections indicate that this figure will increase to over two billion by 2050 (World Federation for Mental Health, 2013). It is thought that people aged 60 years can now expect to survive an additional 18.5 to 21.6 years (United Nations Population Fund, 2012). According to this statistic, soon the world will have a higher number of older adults than children.

It is therefore of the utmost importance that healthcare systems evolve so that they can manage this changing demographic. Increased awareness and education of common mental health problems of the elderly is a means in which this can be achieved. Whilst many associate elderly mental health problems simply with the effect of diseases such as Alzheimer’s, there are far more elements to bear into consideration.

Depression is common in old age. Whether this is related to grief at the loss of a close friend or member of family, anxiety as a result of a fear of approaching the end of life, or due to mistreatment by family or carers and a subsequent feeling of helplessness, these are just some of the many potential contributing factors that may affect the mental wellbeing of an older person.

For paramedics, there are many situations where they may be dealing with patients approaching the end of life. While this is not limited to older people, it is likely that they will make up a notable part of this group. As Mike Brady (2013) discusses in this issue of the Journal of Paramedic Practice, while paramedics may be comfortable with the practical and clinical elements of practice associated with a patient facing imminent death, such as pain relief, the conceptual and philosophical elements may be less well known.

Brady’s article highlights the importance of ensuring end of life patients receive what he terms a “good death”. While this is undeniably important, the general mental wellbeing of the elderly before they approach the end of life cannot be ignored. As mental health problems can have a high impact on an elderly person being able to carry out even the most basic of activities, awareness of any means to reduce these negative consequences is of great significance.


Brady M (2013) A good death: key conceptual elements to end of life care. Journal of Paramedic Practice 5(11): 624–31

United Nations Population Fund (2012) State of World Population 2012—By Choice, Not By Chance: Family Planning, Human Rights and Development. UNFPA, New York

World Federation for Mental Health (2013) Mental Health and Older People: World Mental Health Day, October 10 2013. WFMH, Occoquan, Virginia

Taken from Journal of Paramedic Practice, published 4 November 2013.

The future of training and education

Since the advent of the paramedic profession, its means of educating and training its members has constantly evolved. The transition from predominantly first aid and transport-focused ambulance operations to more specialised services involving increased clinical decision-making has meant the way in which paramedics are trained has had to adapt to meet these accumulating demands. This increase in clinical capability has also led to the realisation that paramedics can, and do, make a fundamental contribution to unscheduled and urgent care.

As a result of this growing interest in the delivery of paramedic education and training, the Allied Health Professional Health Education Advisory Group (formally the Department of Health’s AHP Professional Advisory Body) commisioned a study that has called for the introduction of a national education and training framework for paramedics (Allied Health Solutions, 2013).

The Paramedic Evidence Based Project (PEEP), which was funded by the College of Paramedics, emphasises the need for a more robust education and training system. As current education and training for paramedics in England is locally determined, very different levels of learning outcomes are being achieved at the point of registration. It has therefore been highlighted that education and training needs to be standardised, and a clear framework enabling this to happen must be developed.

The report proposes a model that would lead to an all-graduate paramedic profession by 2019. It also proposes raising the minimum threshold entry onto the Paramedic Register of the Health and Care Professions Council, so that all student paramedics enrol on programmes leading to a minimum award for a diploma in higher education (DipHE) by September 2015.

But what would an all-graduate profession offer in contrast to the current model? According to Andy Newton, consultant paramedic and director of clinical operations, South East Coast Ambulance Service NHS Foundation Trust: ‘Education of the workforce is a prerequisite for lasting change and the core enabler for changing clinical behaviour’ (Newton, 2013). Two of the most important areas that would hopefully see significant development as a result of an all-graduate workforce are clinical decision-making and critical thinking. As the report quite rightly points out: ‘If the service is demanding a higher level of competence and performance, and we are demanding that paramedics are more autonomous and have more autonomy to make decisions and to keep patients out of hospital, then we have to develop them accordingly’ (Allied Health Solutions, 2013).

In the evolving pre-hospital care landscape, where increases in population and, as a result, 999 calls, has meant more pressure on A&E departments, the need for a workforce that can reduce hospital admissions by providing clinical care on-scene has never been more important. It appears difficult then to dispute the benefit of enabling paramedic practice to become an all-graduate profession if it will help to make this a possibility.


Allied Health Solutions (2013) Paramedics Evidence Based Education Project (PEEP). End of Study Report. Buckinghamshire New University, High Wycombe

Newton A (2012) The ambulance service: the past, present and future. Journal of Paramedic Practice 4(6): 365–8

Taken from Journal of Paramedic Practice, published 7 October 2013.

Safety matters: an important issue

While patient safety and treatment are the foremost concerns for practising paramedics, personal safety is often overlooked. Due to the nature of work undertaken by paramedics, the likelihood that they will encounter hostile and dangerous situations is high. The prevalence of binge drinking, which has become

an increasing part of UK culture, has meant that many paramedics working night shifts are faced with inebriated and potentially aggressive patients. This combined with psychotic, confused or panicked patients, emphasises that

this is very much a real problem that needs to be taken into consideration. Only recently has it emerged that staff of the London Ambulance Service (LAS)

have been advised not to visit more than 200 homes without police assistance. The information comes following a freedom of information request, which revealed that

of 390 households on LAS’ Location Alert Register, 226 fell under its most serious classifications (Savage, 2013). The alert register is divided into four categories, with the 226 homes falling under categories one and two, where physical violence, threats with a weapon or ‘aggravated verbal abuse’ lead to the need for a police call-out. As in any other occupation, paramedics should not be expected to work when placed under abuse or in hazardous environments. It therefore begs the question as to the level of risk paramedics are taking when dealing with dangerous patients, as well as a number of ethical concerns regarding when a paramedic should or should not treat a patient.

This issue of the Journal of Paramedic Practice addresses this notable concern for pre-hospital professionals. Robert Kaiser argues that not enough is being done to reduce operational risks for paramedics. He calls for the urgent need of UK Home Office certified stab-resistant vests for all front-line ambulance professionals, disagreeing with many Ambulance Trusts that body armour can be perceived as too confrontational, aggressive or authoritative. Providing recent statistics for the number of physical assaults of ambulance personnel, Kaiser presents a convincing defence for increased personal protective equipment provision.

The conventional advice that is given to those unsure of what to do in dangerous situations is to withdraw and summon support. However, as Iain Bourne points out, this is something which is not always possible or appropriate. Bourne’s article introduces paramedics to the Instant Aggression Model, a guide for the helping professional to help them through dangerous encounters as they happen, moment by moment. By providing paramedics with a step-by-step account of how to act depending on an aggressor’s actions, it is hoped that readers will be able to use this information to positive effect in the workplace.

It might not be possible to eliminate the dangers faced by paramedics, but being aware of potential threats and knowing how to act in hostile circumstances is an integral way to reduce risk.


Savage J (2013) London paramedics need police assistance ‘at 200 homes’. BBC News. london-23501832 (accessed 2 September 2013)

Taken from Journal of Paramedic Practice, published 9 September 2013.

Paramedics and professionalisation

Since the birth of organised pre-hospital emergency care the question of its professionalisation has been met with ambiguity. From its origins in military history as a transport service to its development into the current practitioner role that has become an integral part of the health care sector, the need for its recognition as a profession has become increasingly important.

One of the main concerns regarding professionalisation is that it has no clear definition. Sociologists of professions will dispute the requirements necessary for an occupation to be seen as a profession and so it remains questionable as to how much it relies simply on perception. According to Evetts (2012), professionalisation involves the protection of practitioners of an occupation by only making it possible to practice that occupation if you are trained in that particular category of knowledge. However, surely professionalisation extends beyond mere training?

Within the UK, the Health and Care Professions Council (HCPC) was formed as a statutory regulator of health and care professionals, standardising the education and training received by members of the National Health Service (NHS) workforce and moving that training into the university sector (HCPC, 2013). The HCPC liaises with professional bodies for all the professions that the registrar is responsible for. These organisations do work which may include promoting the profession, representing members, curriculum frameworks, post-registration education and training and continuing professional development (HCPC, 2013). The College of Paramedics (then the British Paramedic Association) was set up as the professional body for the ambulance profession. According to the College of Paramedics, having a professional body has given them the opportunity to change the way that education, training and associated awards are established (College of Paramedics, 2013).

In this issue of International Paramedic Practice, Pip Lyndon James looks at the issue of professionalisation for Australian paramedics. She comments on how at present the Australian paramedic discipline is not considered a full profession by the national or state governments. Despite frequent public misassumption that paramedicine is a registered, highly-regulated industry credited with professional status, this is currently not the case.

It is clear that steps are gradually being taken to reach this ultimate aim. Moving in the direction of other health disciplines, such as medicine and nursing, the advent of paramedic degrees worldwide that are replacing the traditional older in-house training conducted by ambulance services is surely a move in the right direction. While paramedicine has not yet received the professional status it deserves, it is important to bear in mind the distinction between professionalism and professionalisation. Until paramedicine receives professionalisation, it is integral that paramedics continue to act in a professional manner, adhering to codes of conduct and striving towards ongoing professional development.


College of Paramedics (2013) About us. (accessed 21 August 2013)

Evetts J (2012) Similarities in Contexts and Theorizing: Professionalism and Inequality. Professions and Professionalism 2(2)

Health and Care Professions Council (2013) Aims and vision. (accessed 21 August 2013)

Taken from International Paramedic Practice, published 28 August 2013.

The importance of awarding excellence

Last month marked the announcement of the recipients of the Queen’s Birthday Honours, which recognise individuals who have made achievements in public life and committed themselves to serving and helping Britain.

Through the Honours system, there are well-established awards for recognising individuals, and while they are not specific to the ambulance service, they still allow for the acknowledgement of an individual’s outstanding service to the community.

However, since its introduction in June 2012, The Queen’s Ambulance Service Medal (QAM) has allowed ambulance staff to officially receive an award for distinguished service to the public or profession in their operational role (Department of Health, 2011). It is testament to the progression of the paramedic profession that ambulance staff have finally been given the same level of royal recognition as other members of the emergency services. Implementation for the provision of a medal for police and fire services was first introduced by a royal warrant in 1909, in the form of the King’s Police Medal (Gladstone, 1909).

In England, the Association of Ambulance Chief Executives (AACE) is responsible for coordinating the nominations of QAMs, with nominations coming from within Trusts and being seconded by their Trust Chief Executives before being sent for consideration for final nomination by the AACE Board.

According to the AACE, ‘The Queen’s Ambulance Service Medal (QAM) honours a very small, select group of ambulance personnel who have shown exceptional devotion to duty, outstanding ability, merit and conduct in their roles within NHS Ambulance Services (AACE, 2013).’

In the most recent Honours, congratulations have to go to David Bull, education and command training lead at the National Ambulance Resilience Unit (NARU), and Roland Chesney, resilience manager at East of England Ambulance Service NHS Trust, for being awarded the QAM from England and Wales. Further congratulations have to go to Daren Mochrie, director of service delivery at the Scottish Ambulance Service and William Newton, planning officer at Northern Ireland Ambulance Service.

The value of deserved recognition cannot be underemphasised. Appreciation is a fundamental human need, and so praise and acknowledgement of the excellence of hardworking individuals is key to achieving an outstanding work environment. By giving employees something to strive towards, individual performance and productivity can be improved, and job satisfaction can be acquired. The addition of the QAM to the Queen’s list of respected Honours, not only recognises the advances of the work being undertaken by ambulance services throughout the country as a whole, but provides ambulance staff with a standard by which they can aim towards.


Association of Ambulance Chief Executives (2013) Queen’s Ambulance Medals Announced in Queen’s Birthday Honours List. uk/queens-ambulance-medals-announced-in- queens-birthday-honours-list-2/ (accessed 23 June 2013)

Department of Health (2011) The Queen’s Ambulance Service Medal for Distinguished Service (QAM): Guidance for NHS Trust Ambulance Services in England. DH, London

Gladstone HJ (1909) The King’s Police Medal. The London Gazette, Issue 28269: 5281. www. (accessed 23 June 2013)

Taken from Journal of Paramedic Practice, published 13 July 2013.