EMS for Democracy: The Case of Människan Bakom Uniformen

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By Mark S. Weiner
Published in Ambulance Today, Issue 3, Volume 13, Ahead of the Curve, Education and Technology Special, Autumn 2019

A hard rain was falling on the streets of Stockholm that night as a man lay unconscious in the parking lot, his face illuminated by flashing blue lights. While onlookers snapped photographs—me foremost among them, because I was observing this special simulation exercise—police led the dazed bus driver from the scene and the medics got to work.

A neck brace. A spine board. TBI? An elevated train raced overhead with a deafening roar. Where was that smoke coming from? A firefighter dragged a hose through the hazy dark.

More medics arrived—more blue lights on, off, on, off. They carefully boarded the bus through the rear, boots thumping as they walked. A man sprawled in the aisle was complaining of chest pain. Smoke began to billow through the door. What to do?

On the tarmac in front, meanwhile, the lead medic checked that his patient was secure, and he prepared his team for the lift. His glasses reflected the flashing blue lights back into the shadows. “One, two, three,” he called. His team wheeled the stretcher toward the open doors of the waiting ambulance.

Perfectly done—textbook.

He’s just a teenager, I thought admiringly, as I walked through the smoke, hoping that my camera would survive the downpour. I was thinking not of the patient, but of the medic. I was thinking in fact of
all the participants in this special evening organized by Människan Bakom Uniformen (MBU), the Person Behind the Uniform. Most of them were young people from rough, ethnic minority neighborhoods.

MBU students navigate a high-level simulation involving a bus

I caught the gaze of one of the firefighters. “Bra,” I said admiringly (that’s “good” in Swedish). He nodded, smiled, and reached for a nozzle to switch off the smoke. The second patient smiled as he walked off the bus.

Novelists use fiction to reveal the truth. Literature creates a moral universe that allows readers to see the world as it really is. One could say something similar about EMS simulations. A fictional emergency exercise reveals something basic about the nature of the profession—and in the case of MBU, I think it shows something in particular about its social and political role. It highlights its public importance well beyond medical outcomes.

In a book that I am beginning to research, I aim to explore this broader aspect of EMS, which I believe is underappreciated even within the profession itself. The book has the working title of A Social Theory of Emergency Medical Services, and in writing this essay, and a series of occasional articles to follow, I hope to explore some of its themes in an open-ended way. In doing so, I am reaching out to you, the readers of Ambulance Today, for input and advice.

The largest underlying questions of the book are these: How can we understand ambulance work not simply in medical terms, but in social and political ones, too? What social and political values are enacted by EMS personnel in their daily professional practice and by the EMS system more generally? Finally, what is the social and political role of EMS in a modern liberal democracy?

These are somewhat unlikely questions, I know. I have been led to ask them through an unlikely train of events. Before I return to that rainy night in Stockholm, let me share a story about how I got there in the first place—a story about how two different ways of thinking gradually came together.

I have spent my career not in ambulances, but rather in libraries and lecture halls. By training, I am a professor of cultural history and constitutional law. I teach students about the basic principles of democracy, and the books that I have written consider how those principles are expressed in social practices. Many of them touch on issues of citizenship and civic belonging, and they have a philosophical bent.

Snapshot of a training exercise between professional medics and MBU students

One day when I was at my kitchen table writing one such book, I heard a crash. Or, rather, I felt it—the sound struck me like a body blow to the core. By the time I reached the old sedan that had smashed into a wall at the end of my street, carbolic smoke was filling the cab. Through the window I could see the driver, a bariatric middle-aged man, twitching and foaming at the mouth, turning blue as I wrenched open the door and began tugging at his jammed seatbelt. I felt utterly helpless.

I started hack coughing. Frantically coming up for air, I saw that a crowd had formed. Among the onlookers was a young gentleman in a button-down shirt. “You!” I shouted, pointing straight at him. “You. Come help.” The only time I had ever pointed at someone like that before was when asking a student an especially tough question in class. Together we dragged the driver from the car and lay him on his side. He vomited and began to breathe in rasping gulps.

A few minutes later, he was whisked away in an ambulance. “We’ve got it from here,” intoned one of the EMTs as I sat on the curb, dazed and panting. Sirens blared as I watched them pull away.

When one of my first EMS instructors asked, months later, “so what was the emergency you thought you couldn’t handle that brought you to this course?”, that was an easy question.

One EMS course led to another, and another, and eventually I found myself with a basic EMT license—and that very nearly led to … nothing. After I certified, I looked for ways to participate in wilderness search and rescue (I spend a lot of time outdoors), but opportunities near me turned out to be scarce. Without regular training, my skills began to wane. Things got busy. In time, I began to count my EMS training as just an interesting interlude.

Then the world threw me another curve ball. I was at an academic conference in New York, about to deliver a philosophical paper, when I heard a voice call out, “has someone called 911?” I turned and saw a colleague slumped against a wall, gasping for air, his eyes bulging. This time, I reacted differently. My training kicked in just enough for me not to fumble things completely.

When the pros arrived in an ambulance a few minutes later, I handed them my notes. “Thanks,” said one of the EMTs, looking them over. “Really helpful.” I am con dent that they must have been the most poorly organized, illegible set of patient vitals he had ever seen, but his words still felt good. Letting my EMS education go to waste suddenly seemed like a very bad idea.

I recertified. I renewed my license. I began to volunteer for a suburban ambulance service not too far from my home (I am still just a probationary fledgling). Then, as I watched my colleagues work, trying to learn from their example, I naturally began to ask the kind of questions about EMS that I have been asking about other institutions and practices throughout my life: questions not about technique, about how to do, but rather about societal significance. When first responders do what they do best—saving lives—they also send important social and political messages to the whole community. What messages do they send?

Cooperation between professional medics and MBU participants during the main simulation exercise

Take lights and sirens. On one hand, they serve a utilitarian purpose: to clear a path so an ambulance can reach its destination swiftly and safely. That’s why there is growing empirical literature about whether driving with them is truly helpful or, ironically, increases EMS vehicular accidents.

But consider lights and sirens not from the perspective of a medic behind the wheel, but rather from that of average citizens going about their business blocks away. For them, the siren’s wail isn’t utilitarian; whether they hear it or not is immaterial. Instead, it plays a cultural role. The siren tells a story: “there has been an emergency, perhaps an accident, but medics are taking care of the victims.”

That story has a profound political importance. One of the first purposes of government, at least in liberal democracies, is to protect life. Government’s ability to protect life is indeed one of the basic justifications for the state’s existence. In the words of the American Declaration of Independence of 1776, life is an “unalienable right,” and it is to secure life that governments “are instituted among men.” When an ambulance siren sounds, it signals that this basic aspiration of government is being fulfilled.

MBU founder Janina Sabra shows the signed helmet she received as thanks from first responders and MBU participants

Switching on lights and sirens, then, is an act of political communication as well as a utilitarian tool. Switching them on proclaims the benevolent character of public authority. Medics using the siren make this proclamation nearly every day they work, weaving it deep into the social fabric.

Or consider the interaction between a medic and patient. On one hand, the encounter is a pragmatic one. Making patients feel secure, taking their vitals, treating major injuries, getting them to definitive care—that’s the chief goal of EMS. Yet something happens in the encounter that also goes to the core of civic life.

A long line of philosophical thinking, reaching back to G. W. F. Hegel in the nineteenth century, tells us that people come to know themselves as members of their political communities only when they are “recognized” as individual subjects by an institution that wields public authority. Indeed, Hegel argued that it’s only by encountering and being recognized by something or someone outside themselves that people become full psychological beings at all.

In these terms, when a medic approaches a patient, he or she implicitly announces—as a community representative—“I see you.” When the patient in turn responds by placing trust in the medic, he or she accepts a relation of dependence on the community that is providing for his or her care. He or she comes to self- consciousness as a community member through EMS as an institution. The patient sees his or her own image reflected back in the mirror of the medic’s eyes.

Mark Weiner in conversation with Swedish Ambulance Nurse/Ambulanssjuksköterska, Leila Haddadi

This psychosocial moment of recognition means that the way medics interact with patients is significant for political, as well as medical reasons. When a patient feels disrespected, it not only erodes the conditions for optimal treatment but also degrades public life. Remember the 1990 hit single “911 is a Joke,” by the American rap group Public Enemy? Watch the video. It builds its wide-ranging critique of American society on the back of a completely slanderous portrayal of EMS.

As unfair as its portrait is, the video teaches an important lesson. For civic culture, a medic who acts dismissively toward a patient is the medical equivalent of a police officer who roughs people up without cause.

Alternatively, medics can treat patients in ways that foster community cohesion. For instance, when a patient speaks a foreign language and a medic can say a word or two of greeting in it, the medic “recognizes” the patient as a full person, which in turn can help bind together the separate parts of
a pluralistic society. Likewise, when medics invite patients to participate in their own care, for instance by asking them to hold a bandage on their own wound, they encourage a sense of personal agency and self-sufficiency, which helps support democratic life.

Finally, consider the fact that one of the most common locations to which medics are dispatched is a family home. Patients often need our care precisely when their families are incapable of handling a health crisis on their own.

According to Aristotle, the family is the core political association that gives rise to all later, more complex political units. Family to tribe, tribe to village, village to city, and, now, city to nation— the family lies at the heart of it all. In arriving on scene at a home, then, first responders step in and perform one of the key roles of the family, caring for one another, but they do so as agents of the larger political community.

Moreover, by doing so they participate in a vital drama of public sacrifice. In assuming the family’s role, first responders often put themselves in personal jeopardy. They suffer in all the ways that readers of this magazine know well. They expose themselves to blood-born pathogens. They confront the danger of angry bystanders. They endure post-traumatic stress.

In all societies, modern as much as ancient, complex as much as simple, such sacrificial activity makes community possible. And it draws the boundaries of the community to include those for whom a sacrifice is made. (This dynamic, indeed, lies at the ancient core of most religions, but that’s another matter.) We are used to thinking about the personal sacrifice of ambulance medics as the basis of their public reputation as heroes. But it also establishes and fosters the cultural preconditions of civic life.

The stakes of EMS, in short, are social, political, philosophic, and even metaphysical. I think most of us recognize this fact instinctively, and we may even talk about it in a general way in after-work conversation. But I believe that we could help ourselves professionally, and personally, by speaking about these issues more than we do, and by developing a systematic way to understand them.

Close up of the famed MBU helmet, a testament to the deep bonds and inspiration created through the program

This brings me back to MBU. Channeling Hegel and Public Enemy, both philosophy and politics came to mind as I watched the emergency simulation in Stockholm’s deep December dark. That was no surprise: I had been prepared by my conversations with Janina Sabra.

Sabra, 31, is the tough yet caring director who heads up MBU from its base in Gothenburg, a bustling port city on Sweden’s west coast. I was spending the 2018-19 academic year in Sweden as part of an American citizen-diplomacy program, and I had been speaking with Swedish ambulance personnel in various cities as a way to get to know the country. Along the way, I heard about MBU, and I thought it could provide an interesting window into Swedish society. Sabra offered to show me the group’s headquarters.

As we strode through the swinging glass doors of a youth center in the eastern half of the city, two bearded hipsters playing guitar on an old couch looked up and smiled. Both clearly had ethnic roots in the middle east. In the meantime, a young woman wearing Doc Martens, whose parents hail from east Africa, was preparing sandwiches in the communal kitchen. Her hand gestures were straight out of American hip-hop, even though she had never been to the United States. Sabra led me up a set of open metal stairs to her office, where she proudly displays a hardhat signed by dozens of first responders—a gift of gratitude for her work.

The children of immigrants, Sabra and her colleagues embody one of the most significant facets of contemporary Sweden: it’s a country in the midst of a demographic revolution. Long known for its ethnic homogeneity—in 1930, only 1 percent of the population was foreign born, half from neighboring Nordic countries—Sverige has become a coveted destination for economic migrants and asylum seekers. Today the foreign-born population stands at nearly 19 percent of 10.1 million inhabitants. The majority of new arrivals are Muslim, an important point of difference in historically Lutheran and now deeply secular Sweden.

Humour acting as the best teacher during an MBU training session

Many of these foreigners have ended up living in the majority-minority districts that the Swedish government officially calls “socially vulnerable areas.” Swedish ghettos. Sabra grew up in one herself. Not surprisingly, social tensions have emerged in these neighborhoods, and first responders have been among the first to feel the heat. In a spate of headline-grabbing incidents, for instance, minority youth in numerous cities have pelted emergency vehicles with stones. Police have been the most common target, but re trucks and ambulances have also been on the receiving end of the violence.

It’s unclear just how widespread these incidents have been, but it would be difficult to overstate how deeply they trouble citizens in a country known worldwide for its respect for state authority.

One especially dramatic incident took place in Gothenburg in 2009 and led to the creation of MBU. Sabra speaks sadly when she talks about it, her voice trailing off into silence. Some young men standing on a bridge pushed a breadbox-sized rock onto a passing re truck below, smashing the front window and sending a firefighter to the hospital. He soon left the service in frustration. Episodes of petty violence had been common at the time, but this felt like an escalation. Concerned service members felt that something needed to be done, fast. But, ironically, what they created wasn’t fast, but slow.

Människan Bakom Uniformen is a community outreach program with a twist. Rather than the usual one-off meet-and-greet, it’s an extended, focused seminar that requires significant time and effort from everyone involved. Imagine a college class called “First Response 101,” taught by the coolest professors you’ve ever met, with individual sessions devoted to different branches of the field: EMS, re, police, private security guards, and even tram operators.

Each MBU term runs for a full 10 weeks and includes about 20 participants between the ages of 15 to 25. Attendance at all sessions is mandatory to earn a certificate of completion, which adds real value to school and job applications. After each semester ends, graduates are encouraged to continue to be a part of the organization in a leadership role, tutoring new participants and serving as MBU ambassadors in their communities. It’s all about time, commitment and focused attention—yet despite its demand for resources (in fact, I would guess precisely because of the good things those demands produce), what began in Gothenburg has now spread to over a dozen cities throughout the country.

The program begins gently. Participants and first responders play games and shoot the breeze, enjoying each other’s company. Each student receives a stylish black T-shirt bearing the MBU logo. There’s plenty of comfort food—this being Sweden, that means cinnamon buns and coffee. The participants create a warm community based on good times. But the next meetings—each lasting three hours, at night—are far more dramatic and intense.

MBU founder, Janina Sabra

Sabra leans forward in her chair as she explains. Half of the sessions feature first responders talking frankly about the difficulties of their work and participants sharing their own prejudices about first responders. That can be tough, but the groundwork for serious exchange was laid in previous sessions. On other nights—and this is the part that interests me most as a scholar—participants are taught practical emergency skills by each service. They study CPR. They learn how to roll a patient on backboard. They climb a fire ladder. They use handcuffs. They drive a tram as it is pelted with stones, and they learn how to respond to an argument on board. The kids not only step into the shoes of first responders, they step into their boots.

Now that the participants are equipped their new real-world abilities, the program culminates in a multi-casualty incident—one that goes all out for realism. Sabra invited me to watch the exercise taking place in Stockholm a few months later.

From my home in Uppsala, I took a night train to a dark suburban station and met my contact, Ambulance Nurse Daniel Björsson, 43. Tall, bald and muscular, he looks like a Viking from Erik the Red’s medical response team, if Erik the Red had employed EMTs. I knew he was a deeply respected member of his service—an obvious leader.

Earlier that year I had tagged along with Björsson on an all-night shift to see the Stockholm service in action. I had watched him hold up a half-naked girl as she vomited into a bag after drinking herself into a stupor, take an ECG of a man panting on his bed as his wife watched on anxiously from above, and coordinate EMS response to a multi-alarm re in a high-rise apartment block. Now I would see him in a very different role—a civic one.

Could an EMS simulation play a positive part in helping Sweden through its demographic revolution? And if it could, what might that reveal about the nature of EMS? Björsson was going to help me find out.

Ambulance Nurse, Daniel Björsson

Björsson invited me to sit in the back as he drove an ambulance to the scene of the simulation. Sitting in the front passenger seat was a diminutive girl dressed in the service’s green-and- yellow uniform. If she had been holding a couple of electric cables in her hands, I suspect that the excited energy she was radiating could have been used to power the ambulance itself. She was absolutely still and silent while she waited for dispatch. The call came through the crack of the radio. Priority one.

For its drama and adrenaline-inducing special effects, the scene at which we arrived surely would have made Steven Spielberg proud. There was a large red bus pulled over at the edge of a parking lot, stopped at a distinctly strange angle. A man lay beneath the front wheel. The back door of the bus opened and out stepped a long line of talkative young women in headscarves. They began snapping pictures. With the rain, smoke, and flashing lights, it felt just like the scene of a major accident.

Björsson pulled his ambulance into position. The girl in the passenger seat stepped out. Remembering that her hair fell beneath her shoulders, she secured it tight. She got the stretcher from the cab. The last time I saw her, she was wheeling it toward the bus.

Björsson was proud of how his students worked that night—especially proud of the young medic who took care of the injured man at the foot of the bus. He did just as he had been taught to do. “Sometimes you think they don’t listen—but they did!” Björsson laughed. But what struck him most, he said, was that the young man had actively assumed a leadership role during the incident. He took command. I witnessed that myself. “On my count: one, two, three”—it was the voice of a young man growing up through EMS, imagining himself performing a vitally important civic role.

The main simulation involving a casualty with a bus, organised from MBU

Could he or his peers ever look at EMS the same way again? Would they ever look at Sweden in quite the same way again—this place for which they were learning to take responsibility and, thereby, make their own? Could I ever look at EMS the same way again, seeing how it was used here as a vehicle through which young people could envision a society in which they would take care of others at the same time that others pledged to take care of them—a society of mutual interdependency?

EMS was helping bind this society together. But perhaps that’s what it’s always done, and is always doing, even as each of us focuses our attention on the patient immediately in front of us.

The opening scenes of the high-level simulation, organised by MBU, involving a bus

There are many other ways that EMS has a social and political role beyond its medical outcomes. Can you help me think about them? Are there some that you would especially like to see addressed in these pages, or in my book? I would love to hear from you, either directly or through Ambulance Today’s social media platforms. Next time, I’ll be meditating on the cultural perception of ambulance personnel as “heroes”—who are nevertheless apparently not important enough to pay sufficiently, and on the frequent conflation of EMS and police.

To share your thoughts, feedback and ideas over this article and any others by Mark Weiner feel free to get in touch with us via: https://chat.whatsapp.com/AmbulanceToday

Mark S. Weiner, Ph.D., J.D., EMT-B, is the author of The Rule of the Clan: What an Ancient Form of Social Organization Reveals about the Future of Individual Freedom, among other books. In 2018-19, he was the Fulbright Distinguished Chair in American Studies at Uppsala University.

The More You Know…

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By Joseph Heneghan, Editor
Published in Ambulance Today, Issue 3, Volume 16, Ahead of the Curve, Education and Technology Special, Autumn 2019

Albert Einstein once incisively remarked that “Education is not the learning of facts, but the training of the mind to think”. There is a subtle difference here between the traditional ideas of education and training which we pick up in our school years, and the true meaning of education and learning which we find in real life. And this subtle difference holds great weight and poignancy in emergency healthcare.

Very quickly, when we leave school and adult life and responsibility are dually thrust upon us, we realise the importance of adapting. We learn very quickly that life does not follow a script, and that the set things we have learned at school are not always 100% applicable to that scenario. Life and its many guerrilla-esque lessons, which seemingly spring up on us from nowhere, very quickly teach us that the most valuable lesson we can adopt is indeed how to learn in the first place. That we will never have all the answers to every possible scenario, as the array of possible scenarios that can hit at any one point is just too vast and uncertain.

The only thing we can do to prepare ourselves is to learn two things: how to learn quickly and how to think even quicker on the spot. How to take a core lesson, and to spontaneously adapt it to the situation lying on the ground in front of you.

Learning never stops and is about adapting to a situation in order to solve it. Here’s a problem, now give me a solution. Yes, it’s an incredibly similar problem to the one you encountered with that neonatal case last week, almost identical in fact, but it might not be the same. Are you going to give me the same solution? Thinking quickly and adapting, as I say. Using a mix of lessons and experience to grope your way along in the dark, fishing out details along the way, until you get to an understanding, and then a solution.

Yes, learning never really stops. Certainly, the more educated I get, the thicker I realise I am. Every new lesson reveals further pools of unexplored knowledge I never even knew existed. This shows me that, no matter how expert I get, there is always something more to learn. Someone who has been there and done it before me. Is their method outdated in my eyes? Maybe they haven’t heard the most recent study we were taught in class last week? Maybe the problem is that my understanding of learning is still too naïve, as the modern-day teachings and new discoveries can be mixed with more ‘old school’ approaches quite beautifully, often leading to a very balanced mix of high technical ability with exemplary shows of understanding and care.

There are many interesting articles in this edition of Ambulance Today, as usual. The overall focus has been on education and training, as well as a slight focus upon technology. I suppose, without quite realising it, I was going for a unifying theme of development in this respect. Either way, despite the amount of truly stimulating and thought-provoking articles in this edition, I feel that two in particular really embody what I am trying to say here.

Firstly, our South African correspondent, Mike Emmerich, gives an amazingly insightful discussion on the importance and nature of critical thinking. Here he observes—rather wisely in my opinion as I feel many innocently overlook this point on a day-to-day basis—that “for the lifelong learner, everyone has something of value to contribute, irrespective of what environment or years of experience are on the table”. And I haven’t been able to put it better than that in the past 600 words. You don’t know everything. Never can, no matter how deep your expertise. Other people know things you don’t. Never disregard an opportunity to learn something new.

Secondly, we have an article that I am highly excited to introduce you to. Academic and qualified EMT, Mark Weiner, delivers a piece which looks at what can be learned from the patient’s perspective. This is something which is constantly on the minds of EMS staff, or at least as much as realistically possible anyway. This job takes its toll on you, and you can’t all be flawlessly and consistently empathetic all of the time. Patience and empathy can dip a bit when you go from one truly traumatic call onto another where the person might be being a little bit overly sensitive to the situation, if I want to put it politely. Mark takes a look at what can happen when we are able to overcome this and remember that some people, hurtfully but truthfully, do not see a person trying to help but only see a badge and a uniform.

More so, he not only takes a look at what this means for you, for the public at large, and for society in general, but at how this can then be taken, used, and turned into something truly beautiful where both sides can learn something from each other. As I said. You never know everything. Some people know things you don’t. Never write off an opportunity to learn… even if it’s from the annoying patient shouting in your face. There’s always another perspective, always a cause behind the action, always a piece of information which can help you find a solution.

So, with that, this edition celebrates the many fruits which education and learning have to offer. I hope you thoroughly enjoy it and get as much as you can out of it. Milk it for every useful drop, in the name of education. Experience, learning, education—they are key to expertise and proficiency.

Joe Heneghan,
Editor,
Ambulance Today,
Autumn 2019

In the back of an ambulance, two paramedics tend to a patient who has recently experienced a miscarriage

The Miscarriage Association Launches New E-learning Resource for Medical Professionals

View the Free E-Learning Course Here: Bit.ly/2Gtniu9

Published in Ambulance Today, Issue 3, Volume 13, Ahead of the Curve, Education and Technology Special, Autumn 2019

Dealing with the trauma of a miscarriage is something one can only imagine without having experienced it themselves. Non-profit charity, the Miscarriage Association, explains how they are currently supporting medical professionals in providing care and understanding to women going through that very trauma, through the use of a fantastic new, completely free to use, e-learning resource.

Founded in 1982, the Miscarriage Association is a UK-wide charity that offers support and information to anyone affected by miscarriage, ectopic or molar pregnancy.

Along with a staffed helpline, the Miscarriage Association have developed a new e-learning resource to support medical professionals in providing the best possible care to women experiencing pregnancy loss.

The resource is based on the real experiences of health professionals and those who have experienced miscarriage, ectopic or molar pregnancy, and also includes a cache of films and interactive activities.

“Not being able to answer their questions is very difficult and makes me feel like I’m inadequate in my job, when in fact I’ve just not had adequate training.”

Taking only around two hours to complete, the new resource is an excellent tool for continuing professional development and learning towards revalidation.

Ruth Bender Atik, National Director at the Miscarriage Association, said: “Pregnancy loss can be a deeply distressing experience and the support health professionals give can make all the difference to helping women through this difficult time.

“We know it isn’t always easy for those working in clinical environments to find the time to reflect on the care they provide. This is why we wanted to create a resource that they can dip in and out of and access easily from their phone, iPad or computer, so the training is available to them anytime.”

The five units focus upon different aspects of care, such as having difficult conversations, considering language, and taking care of your own wellbeing while providing that care.

“I was on my own at home. I couldn’t walk, I was on the floor so I had to call an ambulance. The paramedics were wonderful. They called my husband, asked if there was anyone else I needed contacting. They locked my house. They made sure that just the basic little things that really mattered were done and dealt with. And they gave me some gas and air, which I needed.”

Having experienced two miscarriages herself, Cerian Gingell is passionate about improving the care that is provided to those who experience pregnancy loss.

Cerian, said: “Miscarriage is a devastating loss, often without explanation. Nothing can take the
pain away, but a kind word, the correct information on what to expect next, the truth about what’s happening – these things can all help make a horrible experience slightly less horrible.

“To me, good care is saying ‘I’m sorry your baby’s gone, it wasn’t your fault’. It’s letting me cry, answering my questions with honesty and sensitivity, reassuring me that because it’s happened once it doesn’t mean it’ll happen again. It’s about respect, sympathy and honesty.

“I think this resource is so important and will help create more consistent care across the country. Every single person that goes through pregnancy loss deserves to be treated with dignity and compassion. Whether they’re speaking to their GP or being treated in hospital, every contact can have a huge impact on the way that person copes with their loss.”

The new e-learning resource was peer reviewed and produced with the help of Janet Birrell, Gynaecology Matron at Western Sussex Hospitals NHS Foundation Trust, Dr Nicola Davies, GP at The Pinn Medical Centre, Annmaria Ellard, Miscarriage Specialist Nurse at Liverpool Women’s NHS Foundation Trust, Amanda Mansfield, Consultant Midwife at London Ambulance Service NHS Trust, and the Association of Early Pregnancy Units.

Dr. Sarah Bailey, Lead Nurse Recurrent Miscarriage Care and Clinical Research Specialist at University Hospitals Southampton, said: “The Miscarriage Association’s e-learning resource is extremely useful, informative and easily accessible.

“I would thoroughly recommend this excellent training package to any care professional who is involved in caring for women with miscarriage.”

The Miscarriage Association’s staffed helpline and online resources help thousands of people every year to get through the emotional and physical distress of pregnancy loss and, in many cases, to manage the anxiety of pregnancy after loss. They work with health professionals to promote good practice in medical care, support clinical research and strive to raise public awareness of the facts and feelings of pregnancy loss.

You can visit www.miscarriageassociation.org.uk or call the Miscarriage Association on +44 1924 200 795 to find out more. For more details and interview opportunities please contact Ruth Bender Atik, National Director at the Miscarriage Association: ruth@miscarriageassociation.org.uk

You can access the e-learning resource at: Bit.ly/2Gtniu9

Pensions Remain Top on the List of Priorities for Ambulance Staff

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By Colm Porter, National Ambulance Officer, UNISON
Published in Ambulance Today, Issue 3, Volume 16, Ahead of the Curve, Education and Technology Special, Autumn 2019

With all the focus of Brexit you mightn’t have noticed but public sector pensions are back in the news.

In 2015, for an overwhelming proportion of NHS pension scheme members, their retirement conditions deteriorated when the Tories forced through the introduction of the 2015 scheme despite a hard-fought campaign by UNISON to stop this.

A recent legal case, however, has found that elements of the firefighters and judges pension schemes to be discriminatory based on age.

Specifically, the protections that were introduced for scheme members who were closest to retirement when changes to the public sector pension schemes were introduced.

The government have stated that this judgment applies to all public sectors pension schemes, including the NHS, that have similar protection arrangements in place.

Take the example of the protection arrangements in the NHS; if you were within 10 years of your retirement on 1 April 2012 you received full protection, meaning you retained all the benefits of your old scheme.

If you were between 10 and 13.5 years of retirement you continued to build up benefits in your old scheme and moved to the 2015 NHS Pension Scheme but at a later date (this is called tapered protection), while those with more than 13.5 years before their retirement moved into the 2015 scheme on 1 April 2015.

According to the government the difference in treatment provided by the transitional arrangements will need to be remedied across all public sector pension schemes including the NHS.

What form this remedy will take is still unknown but UNISON is working with the other NHS trade unions, employers and government departments to understand the implications this will have on the NHS pension scheme.

In other pensions news, an influential conservative think tank, that’s fronted by Tory grandee Iain Duncan Smith and ironically called the Centre for Social Justice (CSJ), has called for the state pension age to rise to 75 over the next 16 years.

While this is not yet government policy given the CSJ’s influence it’s not impossible to imagine a greatly increased state pension age in years to come.

This stance brings sharply into focus not only the ongoing issue of retirement age in the ambulance service but how out of touch elements of the government are when it comes to ambulance work.

If you follow the logic through, the impact this would have on ambulance workers is staggering. The normal pension age in the 2015 NHS Pension Scheme, which is the age you can take your pension unreduced, is linked to your state pension age.

This means that, if the recommendation from the CSJ was accepted, from 2035, paramedics and other ambulance staff would be working until they are 75 before receiving their full NHS pension.

Something that would be bad for staff, bad for the service and ultimately bad for patients!

At our annual health conference in April, UNISON renewed our commitment to reduce the pension age for ambulance staff.

A motion from the UNISON North West Ambulance branch, which was carried unanimously by conference delegates, called for ambulance staff to have a retirement age of 60 which would bring them in line with the other blue light services.

The ambulance service often suffers from an identity crisis—is it the medical wing of the emergency services or the emergency services wing of the NHS?

At times it feels like the ambulance service gets the worst of both worlds and retirement age is one of the areas where this issue manifests.

However, the fact remains that someone joining the ambulance service today fresh out of school or university won’t have the opportunity to retire until they are 68, while if you were to join either the police or fire service you could retire at 60.

Considering the physical and physiological demands on staff working in blue light services, to have staff in one of these key services working until they are 68 is simply unfair and, as demands on the ambulance service show no sign of slowing down, it is also becoming increasingly untenable.

UNISON believes that this is a problem created by the government and is fundamentally down to them to fix but we would also call on ambulance employers and the Association of Ambulance Chief Executives (AACE) to publicly support a retirement age for ambulance staff that is in line with the other blue light services.

It is only when ambulance employers and trade unions are working together that we will get governments to act on this matter.

Colm welcomes feedback from ambulance staff and can be contacted at:

Email: c.porter@unison.co.uk
Facebook: Facebook.com/unisonambulance
Twitter: Twitter.com/UNISONAmbulance

Dealing with Compassion Fatigue- Front line responders gather in Glasgow

A group of over 80 front line responders gathered in Glasgow last week (24 October) to take part in C7 Church’s seminar on compassion fatigue led by renowned US-based licenced psychologist and PTSD specialist, Dr Don Lichi.

In his first visit to the UK, Dr Lichi delivered a free, interactive seminar to an audience which included members of the NHS, first responders, teachers, farmers, community volunteers and charity workers.

During Dealing with Burnout and Compassion Fatigue, Dr Lichi explained to participants how burnout is caused and how to recognise the symptoms of compassion fatigue. He shared tangible tips with participants to help regain strength for work and tangible steps to take to avoid future burnout and achieve a healthier way of life.

Dr Lichi, said:

“For the past 40 years, I have worked with people who are in ‘care giving’ professions where compassion fatigue is prevalent so to share this knowledge with the people of Glasgow is an honour.

“These front line responders are there for us at times when we are in the greatest need and it is essential that their self-care needs are recognised in return. Simple steps such as building good friendships, taking care of your body and mind, checking in with your emotions and developing good relationships all help to combat burnout.

“Participants were open and welcoming and I am grateful to Pastor Jason Cask, Senior Pastor at C7 Church, for inviting me to Scotland to deliver this seminar.”

Pastor Jason Cask said:

“At the heart of everything we do at C7 Church is the community and we really wanted to do something which would help the people of Glasgow. 

“Having met Dr Lichi in 2018, I knew he could really help our city’s front line workers. The seminar was fantastic, he really unpacked compassion fatigue and provided all participants with practical tools to help them in their day to day life.”

From the Africa Desk of Ambulance Today: The Challenge of Critical Thinking in EMS

https://chat.whatsapp.com/Africa Desk Feedback

A portrait photograph of the author, Michael Emmerich, smiling whilst wearing a cream coloured suit with a white shit.
By Michael Emmerich
Published in Ambulance Today, Issue 3, Volume 16, Ahead of the Curve, Education and Technology Special, Autumn 2019

This Africa Quarterly will be exploring the advantages of being a critical thinking emergency medicine practitioner, and how it can positively benefit, us, our colleagues and our patients; and most importantly why we don’t really have an option but to be critical thinkers.

In Rosen’s Emergency Medicine, Chapman, et al, describes the critical thinking process as having three parts: medical inquiry (history, physical exam and diagnostic testing), clinical decision-making (a cognitive process that evaluates information to diagnose or manage a patient’s condition) and clinical reasoning, which involves both medical inquiry and clinical decision-making.

The challenge of the EMS educator/facilitator is how to instil those 3 concepts into the practitioner’s patient care approach, as the result will be a more focused practitioner who has learnt the value of critical thinking and life-long learning. Critically thinking is to be desired by EMS providers at every level, yet the concept isn’t easily defined, quantified or taught.

That’s because critical thinking only becomes real in practice; clinicians, critical and lateral thinkers are moulded in the field. Theory, guidelines, protocols and linear thinking is learnt in the classroom. That is not to downplay the importance of class time, as that is the foundation on which critical thinking rests. What follows on, is experience, continuing education, currency of competency and clinical mentoring. Learning that patient treatment plans fit into the continuum of clinical reasoning, as all patients are different. On the streets, patients don’t follow the script as per your last patient simulation. Thus, the gravity of responsibility you have, becomes intimidating.

Professional Development Word Circle Concept with great terms such as learning, mentoring, practice and more.

Carl von Clausewitz, in his treatise “On War” wrote: “Any complex activity, if it is to be carried on with any degree of virtuosity, calls for appropriate gifts of intellect and temperament.”

This doesn’t mean that everyone who learns something, immediately becomes an expert. For the lifelong learner, everyone has something of value to contribute, irrespective of what environment or years of experience are on the table. Part of lifelong learning is contributing to the pool of knowledge. Effective teaching, just like effective learning, begins with listening before talking. Lifelong learning is a commitment to taking moments out of each day, reflecting on the processes and patients, pushing to improve our knowledge, skills, patient care and attitudes.

Every patient contact is a clinical mystery waiting to be solved, by you the (detective) practitioner. They are relying on your educational experience, critical thinking, your knowledge that you integrate and update continuously – right down to that “interesting paper” you read last night! No patients are created equal, today’s cardiac patient will not match tomorrow’s, not all cardiac arrests are equal. Hence, we cannot rely on overly simplistic guidelines/protocols. We need to critically analyse each patient and rhythm strip against our font of knowledge and our vested clinical practice guidelines.

Critical thinking skills ask us to use our brain and not blindly follow a pre-set protocol. Evidence-based medicine keeps changing and blindly following a protocol would be short sighted and not always in the best interest of optimal patient outcomes. Seeking, questioning, evaluating, integrating and sharing every day is an opportunity to get better at our passion (chosen profession), where patients rely on us for their lives. Knowledge and decision-making should be based on clinical findings on that case on that day—it’s not just a set of psychomotor skills and blindly followed protocols.

As a thoughtful science-based practitioner, learn to be iconoclastic, adopt a questioning, reflective approach to your practice. My mantra when looking at new and/or challenging concepts/modalities is as follows: “Is it evidence based, current, documented, cross referenced and is there a perceived bias (mine or the writer’s)?”

As a thoughtful science-based practitioner, learn to be iconoclastic, adopt a questioning, reflective approach to your practice. My mantra when looking at new and/or challenging concepts/modalities is as follows: Is it evidence based, current, documented, cross referenced and is there a perceived bias (mine or the writer’s)?”

All pre-hospital emergency care practitioners should strive to be clinicians/critical thinkers, irrespective of their level of care, age or experience. Continuous lifelong learning ensures competence and confidence, allowing you to have the lateral thinking skills to break the linear cookbook approach to patient care. So, where to from here?

“Paramedics displayed the ability to problem solve, critically analyse, perform complex reasoning and work cohesively with the patient as well as in a group. They were adept at rapidly forming clinical impressions in the critically ill with minimal information, and were able to modulate their interventions accordingly, while simultaneously continuing to gather data as they performed life-saving measures. Experienced paramedics are seen to gather, process and utilise information differently to the new graduate, portraying an interconnectedness of conscious and sub-conscious processing drawing on information from multiple sources culminating from both professional and personal experiences.”

Paramedic Judgement, Decision-Making and Cognitive Processing: A Review of the Literature Australasian Journal of Paramedicine: 2019;16 Meriem Perona, Muhammad Aziz Rahman, Peter O’Meara BHA

The implications of this need to be reflected in our practice through ongoing mentoring, partnering the experienced with the novice, reflection and feedback post scene time, all which will go some way to encourage improvement in skills, competency and learning, which then translates into improved patient outcomes.

Tell Michael what you think about this article through WhatsApp via the following link:

https://chat.whatsapp.com/Africa Desk Feedback

If you have any ideas for special feature articles on ambulance care in any part of Africa, we would like to speak with you about them.

Equally, if you have any news items you would like us to run either in our magazine or digitally then please email the editor via: joseph@ambulancetoday.co.uk

Ronnie ‘Thankful’ For Cardiac Arrest

Cardiac arrest is probably the most serious type of medical emergency. It is literally a heart-stopping event, and the chance of survival is slim.

But since he came through a triple cardiac arrest earlier this year, Ronnie Lee says his life has been transformed for the better. 

“If I could turn-back time and stop it happening, I wouldn’t,” says the 40-year-old from Gloucester.  

“My life was in a downward spiral. I wasn’t looking after myself, and I was praying to God for help.

“This is the biggest second chance I could have asked for.

“My life has changed for the better. I have stopped smoking, and I’m trying to lose weight. I feel like a totally different person now. It’s been the blessing of my life.

“I know I wasn’t supposed to die that day,” he added. “Thank you from the bottom of my heart to everyone. I’m alive.”

Ronnie experienced pain experienced pain in the centre of his chest when he was at home in March. He called South Western Ambulance Service NHS Foundation Trust (SWASFT) for help.

He spoke with 999 call handler Steph Ruby, but the pain worsened and he had difficulty breathing. Ronnie was having a heart attack.

Neighbour Andy Evans came to his aid, and continued the emergency call until crews arrived.

Paramedic Aimee Scott and ambulance crew Lauren Gardner and Rebecca Crabb treated Ronnie at his flat and conveyed him to hospital. They were supported by a volunteer community first responder.

But when Ronnie’s heart stopped in the ambulance, the situation became even more critical.

Thankfully the paramedics managed to restart his heart by giving him immediate CPR and shocks with a defibrillator.

His heart stopped twice more in the ambulance, but on each occasion the paramedics managed to resuscitate him.

After being stabilised in Gloucester Royal Hospital, he was transferred to Bristol for surgery to unblock two of his arteries.

Despite being briefly re-admitted to hospital in August, Ronnie has been able to do much of his recovery at home.

He visited Staverton Ambulance Station on Wednesday 23 October to thank the ambulance team in person. 

Paramedic Aimee Scott said: Ronnie recognised something was wrong and dialled 999. He was supported by his caring neighbour who stayed on the line with the Control Hub until assistance arrived.

“Ronnie was experiencing a Myocardial Infarction (heart attack). He was extremely unstable, resulting in him going into cardiac arrest multiple times in the ambulance. This required us to complete immediate CPR and defibrillation. Thankfully we were able to achieve ROSC, which is a spontaneous return of circulation.

“As he remained unstable, we had to divert to the nearest hospital for staff to stabilise him and continue with his care prior to a secondary ambulance transfer to the heart specialists.

“Ronnie proves that starting the chain of survival with early CPR and defibrillation improves patient outcome. It is an honour to be part of such a fantastic team where we have achieved such an amazing outcome. I am grateful that I have been able to meet Ronnie and see how well he is doing!”

Outstanding young life savers recognised at the St John Ambulance Everyday Heroes Awards 2019

London – Monday 7 October 2019 – A remarkable 11-year-old boy who helped save the life of his Grandad when he had a heart attack and a quick-thinking teenager who went to his brother’s aid after a serious biking accident were among the outstanding winners honoured at St John Ambulance’s Everyday Heroes awards, held at the Hilton London Bankside this evening. 

Logan Chatfield – who was just 10 years old when he was called on to save Grandad Paul Walsh’s life – is one of the youngest ever recipients of the charity’s Young Hero award, which recognises outstanding bravery and first aid skills. He had learned the first aid procedure for heart attacks only a week before, as part of his training to become a St John Ambulance Cadet. 

15-year-old Jack Smith from Leeds was also honoured with another Young Hero award for stepping in when his younger brother Connor sustained life threatening injuries after crashing his bike. Connor was impaled on the handlebars, severing his femoral vein, but army cadet Jack immediately put his first aid training into action, stemming the blood flow while calling for emergency help. 

The third Young Hero award of the night went to two teenage brothers aged 15 and 16 who went to the aid of a neighbour they had never met after he tried to take his own life. Gabriel Walker, who learned St John Ambulance first aid at army cadets, performed chest compressions, while his brother, Jack, relayed information to and from the emergency services. 

These inspirational young people were celebrated for their bravery, courage and life saving skills at the annual Everyday Heroes event. This honours individuals, volunteers and teams who step forward in their communities and in the moments that matter to help loved ones, colleagues, customers or even strangers in need. 

Now in its eighth year, the awards – sponsored by Zoll – were hosted for the second time by Reverend Richard Coles, celebrity vicar and one half of 80s band The Communards.  

Richard Coles said “I was honoured to be invited to host the Everyday Heroes awards again this year and had no doubt that I’d hear another set of amazing stories – I certainly haven’t been disappointed. The young people commended tonight have really stood out and I believe the future of our communities is in good hands if they are anything to go by. I hope their stories will inspire many others to volunteer, learn new skills and be confident to help when it really matters.” 

As well as recognition for young people, Everyday Heroes also rewards the kindness of strangers, colleagues and St John volunteers in three other categories: Community Hero, Workplace Hero and Volunteer Hero.  

Winners included: 

·         St John Ambulance’s Homeless Service in Hastings, which has been improving access to healthcare and providing support for homeless and vulnerably housed people in Hastings and St Leonards-on-Sea for 15 years 

·         a racecourse groundskeeper who performed CPR on a colleague and  

·         two St John volunteers who talked a young suicidal male down from the edge of a cliff. 

St John Ambulance’s Chief Executive, Martin Houghton-Brown congratulated all the award winners, saying: “This evening I have had the honour of celebrating with the truly incredible ordinary people whose moments of extraordinary heroism allow us to put their humanity, care and courage in the spotlight. 

“Many of these are young people, who are the healthcare professionals and community leaders of the future, and their courage is just what our communities need and want. St John has been equipping people like this for 140 years and I am delighted that we can honour this long history with a celebration of our Everyday Heroes tonight.” 

Mum and Baby Reunited With Crew After Emergency Birth

A baby boy and his mum have been reunited with a South Western Ambulance Service NHS Foundation Trust (SWASFT) crew – six months after they delivered him in an emergency home birth.

Ellee Styles, 21, went into labour unexpectedly during the early hours of 7 April in her bathroom in the Penhill area of Swindon.

Family members came together to help, and Ellee’s mum called 999 when she started bleeding.

The crew ensured baby Freddy was delivered safely at 3.14am, almost two weeks ahead of his due date. He weighted just 4lb 12oz at birth, and is Ellee’s first child.

Ellee and Freddy went to Swindon Ambulance Station on Monday 7 October to meet-up with the crew.

Ellee, who works as a barmaid in a local pub, said: “I didn’t know I was in labour. But during the night I felt some discomfort, and told my dad I needed to push. Then what felt like seconds later I gave birth.

“My pregnancy wasn’t great, but with help from South Western Ambulance Service my birth couldn’t have gone any smoother. Thank you to the call handler who advised us and to the crew who attended and delivered my tiny baby boy into the world.”

Ellee had been in hospital for a check-up hours before the birth, but she was discharged because she wasn’t showing any signs of labour.

Gerard Plunkett, a 999 call handler in the SWASFT 999 Control Centre, instructed the family how to prepare for the birth, while the crew were on the way. 

Paramedic Gary Ratcliffe and Emergency Care Assistant Christina Clifford arrived minutes later, as Freddy’s head began to emerge.

They were forced to take the door off the bathroom, so they could assist Ellee inside. It was Gary’s 29th emergency baby delivery and Christina’s first.

After the birth they drove Ellee and Freddy by ambulance to the Great Western Hospital’s maternity unit. 

Ellee added: “The call handler was absolutely amazing. He helped my mum to stay calm and do everything she needed to do in case my son was born before medical help arrived.

“Freddy just wasn’t waiting in the tiny box bathroom, and as the crew arrived I was ready to push. They were so calm and encouraging.

“It didn’t really sink in until we arrived home from hospital the next day.”

Gary said: “It’s always lovely to help bring life into the world. And being able to meet up patients afterwards makes our job all the more rewarding.”

Sales of Ambulance Cots to Gather Pace in Line with Growing Number of EMS Providers Worldwide, Fact.MR

The ambulance cots market report projects that the ambulance cots market is expected to reach ~ US$ 223 Mn by the end of 2019 in terms of value, and is estimated to reach ~ US$ 273 Mn by the end of 2029.

Launch of New Ambulance Services and New Opportunities in Developing Countries

There are several air ambulance services and other innovative types of ambulances that are developed in the emergency medical service industry that utilize pneumatic ambulance cots or electric ambulance cots. For instance, in India, motorbike ambulances were launched in Delhi in 2017 and Mumbai in 2018. Similarly, in the U.S., Malley Industries, a supplier of New Brunswick’s ambulances, expanded its fleet into the U.S. market in 2016 with electric and pneumatic ambulance cots. Several private ambulance service providers offer air ambulance services across the world that use electric or pneumatic ambulance cots. The trend of adopting air ambulances in both developed and developing regions is expected to positively influence the growth of the ambulance cots market during the forecast period. According to WHO, 1 ambulance per 50,000 populations is a standard that a country should have or aim to reach, in order to meet the growing demand. However, in Nanjing, China, there are only 50 ambulances for a population of 8 million in 2013. Thus, there is a requirement for more ambulances in the APAC region, which is an opportunity for the ambulance cots market in the region.

Rising Installed Base of Ambulances offer Significant Growth Opportunities

According to the WHO and several scientists, the minimum number of ambulances required is estimated to be one in 50,000 populations across the world. Some countries exceed the number of minimum ambulance requirement norms. To meet the rising incidence of emergencies across the globe and to reduce the duration of response, more ambulances are required. Most countries, such as the U.S., the U.K., and Germany, have ambulances more than the required norms and yet are facing several conditions, such as delay in response, unequal distribution of ambulances in urban and rural areas, and increasing emergencies. This results in an increased demand for ambulance services in these regions that influence the growth of the ambulance cots market. Some countries, such as Singapore and Burma (Myanmar), have ambulances below the required norms. The number of ambulances needed in Burma is around 1149. However, the country recently launched its first ambulance service in 2015 and has only 230 ambulances in its fleet. Other countries, such as Indonesia, have slightly more ambulances than the required norms, and still faces similar problems as those with insufficient ambulances. Thus rising number of ambulances in both the developed and developing nations drive the growth of the ambulance cots market.

Rising Number of Accidents Increasing the Usage of Ambulances – A Key Influencer

According to the World Bank data, 1.3 million people are killed in road accidents every year. Furthermore, there are about 30 million people that are seriously impacted by injuries caused by road traffic. Number of people injured, along with the number of deaths due to road accidents, are factors that are used to assess the number of road accidents. This excludes suicide involving the use of road motor vehicles. In 2014, it was assessed that 22% of GDP per capita in Thailand was associated with deaths and injuries due to the road traffic. India and China also estimated that 14% and 15% respectively of the GDP per capita was associated with road accidents. According to a survey in India, in 2016, a total of 480,652 road accidents occurred that resulted in the death of 150,785 and 494,624 people with serious injuries. The rising proportion of vehicles and accidents are leading to the increasing use of emergency services, such as ambulance, which is expected to drive the growth of the ambulance cots market. 

Key Manufacturers of Ambulance Cots

Stryker Corporation and Ferno-Washington Inc. are the prominent players in the ambulance cots market. Other players in the ambulance cots market are Zhangjiagang New Fellow Med Co. Ltd., Jiangsu Rixin Medical Equipment Co. Ltd., Jiangsu Saikang Medical Equipment Co. Ltd., Dragon Industry (ZJG) Co., Ltd., Omega Surgical Industries, and Paramed International FZ Co., among others.