East Midlands Ambulance Service Research Articles

Spotlight on Research

Journal of Paramedic PracticeVol. 15, No. 6 Spotlight on ResearchSpotlight on ResearchGregory A. Whitley, Pete GregoryGregory A. WhitleyParamedic Research Fellow, East Midlands Ambulance Service NHS Trust and Lecturer in Paramedic Science, University of Lincoln, UKSearch for more papers by this author, Pete GregoryAssociate Dean and Head of School of Allied Health and Midwifery, University of Wolverhampton, UKSearch for more papers by this authorGregory A. Whitley; Pete GregoryPublished Online:2 Jun 2023https://doi.org/10.12968/jpar.2023.15.6.261AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Whitley GA, Wijegoonewardene N, Nelson D, Curtis, F, Ortega M, Siriwardena AN. Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: a systematic review and meta-synthesis. JACEP Open. 2023; 4:e12940. https://doi.org/10.1002/emp2.12940 Crossref, Google ScholarGulickx M, Lokerman RD, Waalwijk JF et al.. Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. Eur J Trauma Emerg Surg. 2023. https://doi.org/10.1007/s00068-023-02262-4 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 June 2023Volume 15Issue 6ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 2 June 2023 Published in print 2 June 2023 Information© MA Healthcare LimitedPDF download

Perceptions and experiences of medical student first responders: a mixed methods study

ContextMedical Student First Responders (MSFRs) are volunteers who respond to emergency calls, managing patients before ambulance staff attend. The MSFR role provides opportunities to manage acutely unwell patients in the prehospital environment, not usually offered as part of formal undergraduate medical education. There are few previous studies describing activities or experiences of MSFRs or exploring the potential educational benefits. We aimed to investigate the activity of MSFRs and explore their experiences, particularly from an educational perspective.MethodsWe used a mixed methods design, combining quantitative analysis of ambulance dispatch data with qualitative semi-structured interviews of MSFRs. Dispatch data were from South Central and East Midlands Ambulance Service NHS Trusts from 1st January to 31st December 2019. Using propensity score matching, we compared incidents attended by MSFRs with those attended by other Community First Responders (CFRs) and ambulance staff. We interviewed MSFRs from five English (UK) medical schools in those regions about their experiences and perceptions and undertook thematic analysis supported by NVivo 12.ResultsWe included 1,939 patients (median age 58.0 years, 51% female) attended by MSFRs. Incidents attended were more urgent category calls (category 1 n = 299, 14.9% and category 2 n = 1,504, 77.6%), most commonly for chest pain (n = 275, 14.2%) and shortness of breath (n = 273, 14.1%). MSFRs were less likely to attend patients of white ethnicity compared to CFRs and ambulance staff, and more likely to attend incidents in areas of higher socioeconomic deprivation (IMD – index of multiple deprivation) (p < 0.05). Interviewees (n = 16) consistently described positive experiences which improved their clinical and communication skills.ConclusionMSFRs’ attendance at serious medical emergencies provide a range of reported educational experiences and benefits. Further studies are needed to explore whether MSFR work confers demonstrable improvements in educational or clinical performance.

Evaluation of the effectiveness and costs of inhaled methoxyflurane versus usual analgesia for prehospital injury and trauma: non-randomised clinical study

BackgroundWe aimed to investigate clinical benefits and economic costs of inhaled methoxyflurane when used by ambulance staff for prehospital emergency patients with trauma. Comparison is to usual analgesic practice (UAP) in the UK in which patient records were selected if treatment had been with Entonox® or intravenous morphine or intravenous paracetamol.MethodsOver a 12-month evaluation period, verbal numerical pain scores (VNPS) were gathered from adults with moderate to severe trauma pain attended by ambulance staff trained in administering and supplied with methoxyflurane. Control VNPS were obtained from ambulance database records of UAP in similar patients for the same period. Statistical modelling enabled comparisons of methoxyflurane to UAP, where we employed an Ordered Probit panel regression model for pain, linked by observational rules to VNPS.ResultsOverall, 96 trained paramedics and technicians from the East Midlands Ambulance Service NHS Trust (EMAS) prepared 510 doses of methoxyflurane for administration to a total of 483 patients. Comparison data extracted from the EMAS database of UAP episodes involved: 753 patients using Entonox®, 802 patients using intravenous morphine, and 278 patients using intravenous paracetamol. Modelling results included demonstration of faster pain relief with inhaled methoxyflurane (all p-values < 0.001). Methoxyflurane’s time to achieve maximum pain relief was estimated to be significantly shorter: 26.4 min (95%CI 25.0–27.8) versus Entonox® 44.4 min (95%CI 39.5–49.3); 26.5 min (95%CI 25.0–27.9) versus intravenous morphine 41.8 min (95%CI 38.9–44.7); 26.5 min (95%CI 25.1–28.0) versus intravenous paracetamol 40.8 (95%CI 34.7–46.9). Scenario analyses showed that durations spent in severe pain were significantly less for methoxyflurane. Costing scenarios showed the added benefits of methoxyflurane were achieved at higher cost, eg versus Entonox® the additional cost per treated patient was estimated to be £12.30.ConclusionWhen administered to adults with moderate or severe pain due to trauma inhaled methoxyflurane reduced pain more rapidly and to a greater extent than Entonox® and parenteral analgesics. Inclusion of inhaled methoxyflurane to the suite of prehospital analgesics provides a clinically useful addition, but one that is costlier per treated patient.

Ambulance attendance for substance and/or alcohol use in a pandemic: Interrupted time series analysis of incidents.

IntroductionThe ambulance attendance for substance and/or alcohol use in a pandemic (ASAP) study explores incidents during the COVID‐19 lockdown in the East Midlands region of the United Kingdom (23 March–4 July 2020).MethodRetrospective cross‐sectional count per day of ambulance attendances from the East Midlands Ambulance Service Trust. Ambulance attendances relating to alcohol or other drug use in the year prior, during lockdown and weeks following, were examined using interrupted time series analysis by patient demographics and geographical location.ResultsA total of 36 104 records were identified (53.7% male, 84.5% ethnicity classified as White, mean age 38.4 years). A significant drop in the number of attendances per day at the start of lockdown (−25.24, confidence interval − 38.16, −12.32) was observed, followed by a gradual increase during the ongoing lockdown period (0.36, confidence interval 0.23, 0.46). Similar patterns were found across genders, age groups 16–64 and urban/rural locations.Discussion and ConclusionThe pattern of ambulance attendances for alcohol or other drug use changed during the COVID‐19 lockdown period. Lockdown significantly affected the use of ambulances for incidents involving alcohol or other drug use, impacting on health‐care services. Further research into hazardous use of alcohol or other drugs during the lockdown periods is needed to inform policy, planning and public health initiatives.

Randomised controlled trial of an innovative hypoglycaemia pathway for self-care at home and admission avoidance: a partnership approach with a regional ambulance trust.

Hypoglycaemia is a common and potentially life-threatening condition in people with diabetes, commonly caused by medications such as insulin. Hypoglycaemic events often require in-patient treatment and/or follow-up with a diabetes specialist nurse (DSN) or GP to make adjustments to medication. This referral pathway commonly relies on patient self-referral to primary care, and as a result many patients are not actively followed up and go on to experience repeat hypoglycaemic events. Randomised controlled trial in partnership with East Midlands Ambulance Service NHS Trust. People with diabetes calling out an ambulance for a severe hypoglycaemic episode and meeting the eligibility criteria were randomised to either a novel DSN-led pathway or to their general practice for routine follow-up. Primary outcome was proportion of participants with a documented consultation with a healthcare professional to discuss the management of their diabetes within 28 days of call-out. 162 people were randomised to one of the pathways (73 DSN arm, 89 GP arm) with 81 (50%, 35 DSN, 46 GP) providing full consent to be followed up. Due to lower than anticipated randomisation and consent rates, the recruitment target was not met. In the 81 participants who provided full consent, there were higher rates of consultation following the call-out when referred to a DSN compared to primary care (90% vs. 65%). Of the 81 participants, 26 (32%) had a second call-out within 12 months. Consultation rates following the call-out were high in the DSN-led arm, but there was insufficient power to complete the planned comparative analysis. The study highlighted the difficulty in recruitment and delivery of research in pre-hospital emergency care. Further work is needed to provide more feasible study designs and consent procedures balancing demands on ambulance staff time with the need for robust well-designed evaluation of referral pathways.

The effect of the GoodSAM volunteer first-responder app on survival to hospital discharge following out-of-hospital cardiac arrest

AimsBystander cardiopulmonary resuscitation and defibrillation can double survival to hospital discharge in out-of-hospital cardiac arrest. Mobile phone applications, such as GoodSAM, alerting nearby volunteer first-responders about out-of-hospital cardiac arrest could potentially improve bystander cardiopulmonary resuscitation and defibrillation, leading to better patient outcomes. The aim of this study was to determine GoodSAM’s effect on survival to hospital discharge following out-of-hospital cardiac arrest.Methods and resultsWe collected data from the Out-of-Hospital Cardiac Arrest Outcomes Registry (University of Warwick, UK) submitted by the London Ambulance Service (1 April 2016 to 31 March 2017) and East Midlands Ambulance Service (1 January 2018 to 17 June 2018) and matched out-of-hospital cardiac arrests to GoodSAM alerts. We constructed logistic regression models to determine if there was an association between a GoodSAM first-responder accepting an alert and survival to hospital discharge, adjusting for location type, presenting rhythm, age, gender, ambulance service response time, cardiac arrest witnessed status, and bystander actions. Survival to hospital discharge was 9.6% (393/4196) in London and 7.2% (72/1001) in East Midlands. A GoodSAM first-responder accepted an alert for out-of-hospital cardiac arrest in 1.3% (53/4196) cases in London and 5.4% (51/1001) cases in East Midlands. When a responder accepted an alert, the adjusted odds ratio for survival to hospital discharge was 3.15 (95% CI: 1.19–8.36, P = 0.021) in London and 3.19 (95% CI: 1.17–8.73, P = 0.024) in East Midlands.ConclusionAlert acceptance was associated with improved survival in both ambulance services. Alert acceptance rates were low, and challenges remain to maximize the potential benefit of GoodSAM.

The effects of a leaflet-based intervention, 'Hypos can strike twice', on recurrent hypoglycaemic attendances by ambulance services: A non-randomised stepped wedge study.

We aimed to investigate the effect of an intervention in which ambulance personnel provided advice supported by a booklet-'Hypos can strike twice'-issued following a hypoglycaemic event to prevent future ambulance attendances. We used a non-randomised stepped wedge-controlled design. The intervention was introduced at different times (steps) in different areas (clusters) of operation within East Midlands Ambulance Service NHS Trust (EMAS). During the first step (T0), no clusters were exposed to the intervention, and during the last step (T3), all clusters were exposed. Data were analysed using a general linear mixed model (GLMM) and an interrupted-time series analysis (ITSA). The study included 4825 patients (mean age 65.42years, SD 19.42; 2,166 females) experiencing hypoglycaemic events attended by EMAS. GLMM indicated a reduction in the number of unsuccessful attendances (i.e., attendance followed by a repeat attendance) in the final step of the intervention when compared to the first (odds ratio OR: 0.50, 95%CI: 0.33-0.76, p=0.001). ITSA indicated a significant decrease in repeat ambulance attendances for hypoglycaemia-relative to the pre-intervention trend (p=0.008). Furthermore, the hypoglycaemia care bundle was delivered in 66% of attendances during the intervention period, demonstrating a significant level of practice change (p<0.001). The 'Hypos can strike twice' intervention had a positive effect on reducing numbers of repeat attendances for hypoglycaemia and in achieving the care bundle. The study supports the use of information booklets by ambulance clinicians to prevent future attendances for recurrent hypoglycaemic events.

Machine Learning for Predictive Modelling of Ambulance Calls

A novel machine learning approach is presented in this paper, based on extracting latent information and using it to assist decision making on ambulance attendance and conveyance to a hospital. The approach includes two steps: in the first, a forward model analyzes the clinical and, possibly, non-clinical factors (explanatory variables), predicting whether positive decisions (response variables) should be given to the ambulance call, or not; in the second, a backward model analyzes the latent variables extracted from the forward model to infer the decision making procedure. The forward model is implemented through a machine, or deep learning technique, whilst the backward model is implemented through unsupervised learning. An experimental study is presented, which illustrates the obtained results, by investigating emergency ambulance calls to people in nursing and residential care homes, over a one-year period, using an anonymized data set provided by East Midlands Ambulance Service in United Kingdom.

PP16 Modelling of patient outcomes after emergency treatment for out-of-hospital cardiac arrest by paramedics and community first responders

BackgroundPatient outcomes for out-of-hospital-cardiac-arrest (OHCA) should include shorter term response resulting from care delivered by first aiders (CFR) and emergency services as well as any longer term response achieved following handover into hospital care. We construct statistical models of: Return of Spontaneous Circulation while under emergency care (ROSC), and Discharge Alive from hospital (DA).MethodsData on 15,103 OHCA patients aged 4+weeks from East Midlands Ambulance Service NHS Trust were gathered across a 3 year period April 2014 – March 2017. Both outcomes were represented by binary variables (yes=1, no=0). Duration variables: waiting time (WT; time from 999 to emergency service arrival at the patient’s side), total treatment time (TOT; time from emergency service arrival to patient handover at hospital), time to ROSC (TtoR; time from emergency service arrival to first ROSC achieved). Statistical analyses were to be conducted on complete records (2825 patients) and involve fitting of a bivariate probit model to the joint outcome (ROSC, DA) and a probit model to the conditional outcome (DA|ROSC=1).ResultsCFR attendance had no statistically significant influence on either patient outcome.Patient outcomes worsened as wait time (WT) increased, but was insignificant versus no effect.Total treatment time (TOT) was significant; with positive influence on ROSC occurrence the longer that time period (estimate &gt;0, p=0.036), but worsening the chance of longer term survival DA (estimate &lt;0, p&lt;0.001).Time to ROSC (TtoR) was the key driver in the DA|ROSC=1 model (estimate &lt;0, p&lt;0.001), evidencing the better the chances of longer term survival DA the sooner ROSC is achieved.ConclusionsOur Results show that OHCA patient outcomes depend crucially on the quality of clinical care provided by the emergency services. Next steps include the need to gather granular data evidencing the pre-hospital care that is administered to patients by paramedics and community first responders.

The feasibility of paramedics delivering antibiotic treatment pre-hospital to 'red flag' sepsis patients: a service evaluation.

Background:Sepsis is associated with a 36% mortality rate, rising to 50% for septic shock. Currently, when an East Midlands Ambulance Service clinician recognises ‘red flag’ sepsis, only the oxygen and fluid elements of the ‘Sepsis Six’ care bundle are delivered, omitting the antibiotic therapy. For a patient in septic shock, every hour’s delay in antibiotic therapy is associated with a 7.6% increase in mortality. Ambulance clinicians are therefore appropriately placed to assess and commence treatment at the earliest point of recognition. The aim of this evaluation was to assess the feasibility of training paramedics to recognise ‘red flag’ sepsis, obtain blood cultures and administer a broad spectrum antibiotic, meropenem, to patients in the pre-hospital environment.Methods:A prospective six-month feasibility pilot evaluation was conducted in May 2016. Paramedics were trained and given access to a broad spectrum antibiotic, meropenem, along with a patient group direction to administer the antibiotic to ‘red flag’ sepsis patients. Training included sepsis recognition, taking of blood cultures and patient group direction compliance.Results:Twenty paramedics volunteered and successfully completed the training. Of the 113 patients that were identified as ‘red flag’ sepsis, 107 (94.6%) were confirmed as infected by the receiving hospital. Ninety-eight blood samples were successfully drawn by study paramedics, with only seven (7.1%) reported as contaminated samples, compared with 8.5% of samples taken by staff in the receiving ED during the same time period. Ninety patients (80%) assessed by paramedics as meeting the criteria were treated with meropenem, and patient group direction compliance was 100%.Conclusion:Paramedics can safely deliver pre-hospital antibiotics to patients with ‘red flag’ sepsis and obtain blood cultures prior to administration, with a contamination rate comparable with local hospitals, following a short training course.

PP18 Interim analysis of ambulance logistics and timings in patients recruited into the rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 (right-2)

BackgroundStroke is a severe condition with high morbidity and mortality. Despite treatment effects in acute stroke being predominantly time dependent (e.g. thrombolysis and thrombectomy), proven treatments are hospital based and...

02 A pilot study to assess the feasibility of paramedics delivering antibiotic treatment to ‘red flag’ sepsis patients

BackgroundSepsis is associated with a 36% mortality rate rising up to 50% for septic shock. Currently when an East Midlands Ambulance Service (EMAS) clinician recognises ‘red flag’ sepsis, only the...

An evaluative study into the effect of mechanical resuscitation in cardiac arrest within East Midlands Ambulance Service (EMAS)

Aim: East Midlands Ambulance Service (EMAS) introduced 41 Lucas-2 mechanical CPR devices in April 2014 as part of the Paramedicine tool kit. Analysis of Survival to discharge rates revealed that EMAS was significantly below the UK average (9.1%) at 4.32% with ROSC rates were averaging 18%. The aim of this evaluative study was to compare ROSC rates and survival at discharge (STD) between manual CPR and mechanical CPR devices used by EMAS to assess the impact on patient care.

Ambulance service at creaking point

Journal of Paramedic PracticeVol. 8, No. 6 EditorialAmbulance service at creaking pointAlistair QuaileAlistair QuaileSearch for more papers by this authorAlistair QuailePublished Online:6 Jun 2016https://doi.org/10.12968/jpar.2016.8.6.275AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Care Quality Commission (2015) London Ambulance Service NHS Trust Quality Report, 27 November 2015. http://tinyurl.com/hxdhwpr (accessed 26 May 2016) Google ScholarCare Quality Commission (2016) East Midlands Ambulance Service NHS Trust Quality Report, 10 May 2016. http://tinyurl.com/h5r4wfv (accessed 26 May 2016) Google ScholarNHS England (2015) Ambulance Quality Indicators Data 2014–15. http://tinyurl.com/zf2p5jf (accessed 26 May 2016) Google ScholarNHS England (2016) Ambulance Quality Indicators Data 2015–16. http://tinyurl.com/jyls6rt (accessed 26 May 2016) Google Scholar FiguresReferencesRelatedDetails 2 June 2016Volume 8Issue 6ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 6 June 2016 Published in print 2 June 2016 Information© MA Healthcare LimitedPDF download

INVESTIGATING THE UNDERSTANDING, USE AND EXPERIENCES OF OLDER PEOPLE IN LINCOLNSHIRE ACCESSING EMERGENCY AND URGENT SERVICES VIA 999 AND NHS 111: A SCOPING STUDY

IntroductionDuring 2011/12, East Midlands Ambulance Service (EMAS) received 776,000 emergency 999 calls of which 36% (277,000) did not require transportation to hospital. Inappropriate calls can be due to public misunderstanding of when it is appropriate to ring 999. NHS 111 is an alternative free telephone service that enables the public to access health care advice or resources when the matter is urgent but not a 999 emergency. However knowing which service to telephone is not always easy and such a decision can be particularly difficult for older people as symptom presentation across complex co-morbidities can be atypical.A mixed method scoping project was carried out to explore the understanding, use and experiences of emergency (999) and urgent services (NHS 111) by older people aged 65 and over. Here, we report findings from the qualitative workstream.MethodsSemi-structured interviews and focus groups (n=25) using a topic guide were carried out with a purposive sample of older people who had used the 999 ambulance service and/or the NHS 111 service in the East Midlands.ResultsWe found a lack of awareness as to the remit of NHS 111 and confusion as to when this number should be phoned. Older people's expectations of 111 seemed to be analogous to other primary care services. As a consequence, participants were often dissatisfied with the service response; it neither provided useful advice nor reassurance. Greater satisfaction was reported with the call handling process and hospital transportation through EMAS (999) and older people's reported rationale for phoning 999 would seem to suggest appropriate service use.ConclusionDeveloping a greater understanding of how older people decide to contact a service would support future policy and practice implementation. If the remit of a service is unclear and accompanying publicity confusing, older people will continue to dial 999.

Falls assessment and prevention in older people: an evaluation of the Crisis Response Service

The elderly population of the world is growing, with increasing trends of older people falling and accessing emergency services. The Crisis Response Falls Service in Northamptonshire (UK) was designed to identify health and social care needs, promote independence and limit the impact of falls. This paper presents the findings of an evaluation of the service. A mixed-method approach was applied, drawing on the views of service users (via a survey and telephone interviews) and reviewing existing East Midlands Ambulance Service NHS Trust (EMAS) data with routinely collected data from the service. A decrease in the numbers of patients conveyed to hospital following a fall was observed. Best estimates of financial calculations suggest savings. High levels of patient satisfaction were achieved; patients felt treated with dignity and staff were considered friendly, approachable and well-informed. First responder services can provide positive impacts for those who fall in the community. The development and impact of the CRS shows the importance of evidence-based client centred training to inform the approaches taken to supporting those who fall, and the impact of a strong values based approach on the experiences of patients.

Complying with CQC standard 6

Complying with CQC standard 6 How do you ensure that you meet essential standard 6? Contact with all parties involved in the care of a resident begins at the referral stage. A thorough preadmission process takes place. An allocated member of the home’s staff speaks to the prospective residents and their next of kin. A corporate preadmission assessment document is used. At least a ‘show round’ visit is advocated, but trial visits are also encouraged. We request that the resident or representative sign a ‘consent to sharing of information’ document, thus abiding by the Data Protection Act. Existing assessments or support plans are obtained from the allocated social worker or care manager. Once a resident is admitted, appropriate records, such as care plans, are developed, then reviewed and evaluated at least monthly. Staff are advised to ensure resident and relative involvement and other professionals, such as GPs, district nurses, continence and tissue viability specialists and the care home support team, are consulted or invited to attend. A visit sheet is contained within the care plan and visiting professionals are encouraged to write their feedback on this form. There is also a detailed transfer form for movement around services. The home uses external records, such as local surgery or social service documentation, continence screening charts or ‘poor discharge’ feedback forms. Local Do Not Resuscitate and East Midlands Ambulance Service forms are used for end-of-life care, so all parties, such as out of hours GPs, are aware of a resident’s condition. The home has an up-to-date business continuity plan in place, with appropriate agencies listed and contact details of the health protection unit or the environmental health officer in the event of an outbreak.

Cardiac arrest in the young: rare but possible

It can be hard to believe that someone young and active may be at risk from heart problems, but each week in the UK at least 12 apparently fit and healthy young people die from undiagnosed heart conditions. Cardiac Risk in the Young (CRY) is a charity that works to support families affected by the sudden cardiac death of a young person, to help young people who have been diagnosed with life threatening heart conditions and to reduce the number of tragedies that occur. 2010 marked the 15th anniversary year of CRY. Here, Gareth Mallon, a community paramedic and developing tutor for the East Midlands Ambulance Service (EMAS), discusses his personal involvement with the charity in more detail.

What influences pre-hospital cannulation intentions in paramedics? An application of the theory of reasoned action

Intravenous cannulation is a common and important intervention undertaken by paramedics for administration of fluids and drugs in the pre-hospital setting. This study was a partial application of the theory of reasoned action to the prediction of pre-hospital cannulation intentions as part of an evaluation of an educational intervention to change cannulation behaviour in paramedics in line with national guidance. In 2008 a self-completion questionnaire was sent to paramedics from Nottinghamshire and Lincolnshire divisions of East Midlands Ambulance Service NHS Trust, UK. This included measures of prior behaviour related to cannulation, attitude towards cannulation, normative influence related to cannulation and intention to cannulate as well as demographic information. Of the 323 paramedics sent questionnaires 137 (42.2%) responded. Attitude towards cannulation (but not normative or peer influence) was a necessary factor for prediction of intention to cannulate in respondents. Past cannulation behaviour was indirectly related to intention to cannulate through the mediation of attitude towards cannulation. The theory of reasoned action provides a parsimonious way to predict intentions to cannulate. This study suggests that design and evaluation of interventions to reduce inappropriate cannulation should be targeted towards changing attitudes of paramedics, rather than towards addressing behavioural norms. Future research could utilize social-psychological theories to better understand clinical behaviour prior to implementation of complex educational or organizational interventions.

Starting out - I was amazed by the skill and professionalism of paramedics.

On my community placement I joined a 12-hour shift at the East Midlands Ambulance Service NHS Trust. I was apprehensive at first, but as we raced to our first emergency, the adrenaline soon overcame any doubts.