4.3.1 Environment
In both of the ambulance services I visited, dedicated education centres existed for the development of ambulance staff in pre- and post registration and specialist courses. In the three centres were a suite of rooms for staff and tutors, which included lavatories and rest areas and offices for managers and tutors. The general layout of all three centres was similar, with at least one large teaching room and several smaller ‘break out’ areas where simulations took place. No simulations I observed occurred anywhere outside either the large classroom or smaller areas, although occasionally simulations do occur outside in the centre grounds, weather permitting.
The settings simulated during scenarios may not accurately reflect real life. During winter months, daylight hours are proportionally fewer than night hours but no simulations I have observed have taken place in darkness. This may not be relevant when going into an artificially lit patient’s house but some emergency calls take place in relative darkness (road traffic collisions at night as an example). The same is true of simulations occurring outside; admittedly I have seen and led scenarios outside but this has only been when the sun has been shining when it seems more pleasant to carry out simulations in the fresh air. Obviously emergency calls take place at all times and in all weathers but this is not reflected in simulations. This may be for a very valid reason; to bring student paramedics and tutors in for an evening has a cost implication, with an uplift of 25% of pay for every unsocial hour worked.
4.3.2 Staffing
Simulation is generally carried out with two student paramedics as the simulated ambulance crew; this represents the historic arrangement of two ambulance staff on a large ambulance vehicle. There are two main types of vehicles used in ambulance services: a) a typical large ambulance, staffed by two crew members and suitable to convey patients and b) an ambulance car, staffed by one clinician who provides a rapid response but is unable to transport a patient. The two-person crew, or double manned ambulance as it is tellingly called, is comprised of any permutation of clinical grade: paramedic, student paramedic, emergency medical technician (EMT) and emergency care assistant (ECA). There is some commonality in these grades nationwide and the same basic principles of clinical grade apply with some small change in title and pay.
However, there appears to be no definitive crew grade outline for these vehicles and cars. Vehicles may be staffed by all grades of staff except new students, who are deemed qualified after one year of service. Emergency medical technicians are ambulance staff with the equivalent of the old style Millar qualification. They comprise a significant proportion of the operational workforce and emergency care assistants (although still relatively rare) are becoming more embedded in some ambulance services. There are no particular staffing requirements for either cars or traditional ambulances and all grades of clinician can, in theory, work on both style of vehicles and therefore, either alone or as a two-person crew. However, staff on a two-person ambulance have specific duties, as either attendant or driver. This is seen somewhat in the simulation event, without the actual driving. As seen in table 4.4, the duties of attendant and driver appear uneven at first glance, although the driving element is significant operationally but absent in the simulation experience.
Table 4.3 – Two-person ambulance crew attendant and driver duties.
ATTENDANT DRIVER
(crew member is said to be ‘attending’)
(crew member is said to be ‘driving’) Will liaise with control centre by radio.
Will walk into patient location first with equipment. Will assess and treat patient.
Will liaise with the patient to formulate a care pathway.
If patient needs transporting to hospital, will travel in the back of the ambulance monitoring the patient and liaising with relatives.
Will hand over the patient to hospital staff.
Will drive to an emergency call. Will help take the bags to where the patient is.
Will work as directed by attendant.
Will help convey patient to the ambulance. Will drive ambulance to hospital.
Will drive to the next call or standby point.
A two-person crew will typically take it in turns to attend or drive, with little overlapping of the role during the emergency call itself. However, it is uncommon to have staff maintain either the attendant or driver role for the entire shift and there is most often a swap of duties agreed by the crew at the start of the shift. This is shown in table 4.4.
Table 4.4 – Two-person ambulance crew share of duties.
Job about crew swap duties between calls.
Half shift about crew swap duties half way through the shift.
Shift about if working at least two shifts together, crew will swap duties on alternate days.
Therefore, the public misconception that it is the paramedic that attends to a patient and the less qualified emergency medical technician or student that drives, is not entirely correct. As seen, there is a swapping of duties to make the shift less onerous and to maintain sharpness of focus and attention. Both roles can be demanding and sometimes require a change of role to aid concentration. However, if the patient is ill or injured to such an extent that they require paramedic intervention, then the paramedic has a duty to stay in the back of the ambulance with the patient. There are also occasional jobs where two crews may be required or more than one clinician in the back of the ambulance to allow for multiple interventions to take place at once; for example the rare cardiac arrest patient that requires transporting to hospital.
4.3.3 Simulation as a single clinician
I did not observe a simulation during the data collection that had anything other than two student paramedics simulating a two-person crew. However, (occasionally) simulation is carried out as a single clinician. This is shown in the pictures at the beginning of chapter one of this study and perhaps more closely represents the growing move in emergency care to single clinician immediate response in an ambulance car. A two-person ambulance crew will generally be called after initial consultation if a patient needs conveying to hospital. Certainly my own experience in simulation is as a two-person crew and I work almost entirely in a car on my own. In the simulations I observed, the two-person crew were not entirely a team and the lead student (the one simulating the attending role) tended to work on their own with limited help and input from the simulated driver. In the observations, the tutor always looked at the lead student in the simulation and expected the lead student to do all of the assessing and treating of the simulated patient. The simulated driver appeared to do little more than carry equipment and work as directed by the lead student, not too far from the driver role in real life. Therefore, the apparent lack of simulation as single clinician and significantly more time as part of a two-person crew may not matter. As seen, the attendant attends whether they are working alone or with another clinician.
4.3.4 How the simulation is arranged
In all of the simulations observed during data collection, the simulated patient was a student paramedic on the same course of study as the simulated crew. The student acting the part of the patient was given the outline for the simulation setting; in other words, what was wrong with them as the simulated patient. The ‘patient’ was chosen at random from the students who were not
taking part in a simulation at that time and this is reflected in most simulations. As discussed in chapter one, where potentially harmful interventions are needed, such as during advanced life support which requires endotracheal intubation, intravenous infusion and defibrillation, the simulation is carried out using a mannequin. Emergency calls that require the significant interventions outlined above, are relatively rare and may explain the comparatively fewer mannequin simulations in a course of study. The final participant in a simulation is the tutor and there appeared to be no relationship between which tutor ran which simulation. Tutors either agreed amongst themselves or were managed by the course lead and the programme appeared to allow time when the entire student paramedic and tutor group were all occupied with simulation. Simulations were set up in several rooms, with a tutor taking one room for the duration of the simulations for either the morning or afternoon. Students appeared to rotate round the rooms and tutors in no specific pattern, although some students appeared to favour some tutors more than others Therefore, although the simulation settings may not accurately reflect actual emergency call settings, the participant roles may echo those seen on an operational ambulance.