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The search and rescue helicopter paramedic:

an emerging role

Edward Griffiths, search and rescue winchman paramedic, Bristow Search and Rescue, Caernarfon Airport, North Wales.Email for correspondence: skerries3@btinternet.com

Search and Rescue (SAR) winchmen are part of a four-person team crewing SAR helicopters around the UK. They are on-call 24 hours a

day to be winched down to rescue and provide emergency care to casualties in austere, otherwise inaccessible locations. Predominantly aviators and rescuers, as well as being paramedics, they are called upon to work in the most challenging conditions, necessitating great skill and courage (BBC News, 2015). This article will critically analyse the paramedic role of the winchman through exploration of its current and future enhancements. It will begin by critically debating its development, focusing on the tactical and strategic empowerment that the recent transition to higher education has brought. It will then reflect critically on the difficulties of developing the role into one of advanced practice. It will critique the challenges involved in advancing clinical capabilities to provide a more appropriate, cost-effective solution within the wider health workforce to dealing with victims of major trauma in austere, inaccessible locations.

Tactical development of the SAR paramedicThe SAR paramedic role is at an exciting stage in its development. Not only is it transitioning from a predominantly military-provided service to a civilian contracted one, but also SAR paramedics are now transitioning from being trained to being educated.

The current SAR paramedic training provider has embraced the aspirations of the Paramedic Evidenced-based Education Project (Lovegrove, 2013) and the College of Paramedics (CoP) (CoP,

2014b) by educating SAR paramedics to academic level 5 in England, Wales and Northern Ireland. This has equipped and empowered them to utilise professionally desirable graduate attributes to enhance their role (Kilner, 2004). This is not only achieved at the coal-face but also indirectly, by giving them the tools to drive their profession at a strategic level. This article will begin by critiquing the tactical effects on SAR paramedic practice of the transition from the Institute of Health Care Development’s (IHCD) Business and Technology Education Council (BTEC) level 4 training syllabus, to a higher education model.

Traditionally, SAR paramedic training followed that of the ambulance services’ IHCD BTEC level 4 programme. This method of training has attracted criticism in the past by many authors who considered it as surface learning. They suggested it focuses primarily on the performing of clinical skills as a reaction to recognised signs and symptoms, but encompasses little underpinning knowledge (Kilner, 2004). It is described as a rote method of training that fosters learning through the memorisation of mnemonics and protocol-driven practice (Ryan and Halliwell, 2012). Focusing on the ‘doing’ rather than the ‘thinking’ (Wood, 2012), it fails to promote true learning, preventing practitioners from knowing the ‘hows’ and ‘whys’ of their practice so that informed decisions can be made (Ryan and Halliwell, 2012). By offering little scope to challenge practice, or explore the reason for adopting a particular skill, knowledge is created without a depth of understanding (Emms and Armitage, 2010).

As the demand on the ambulance service changed, this method of training became insufficient to meet the requirements of the role.

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80% of the IHCD curriculum had focused entirely on life-saving protocols and promoted a ‘treat and transport’ model. But the majority of the patients now encountered on the street didn’t fall into this category (South and Wenman, 2012). The Department of Health (DH) found that despite 999 calls increasing by around 6–7% each year, only 10% of them had a life-threatening emergency (DH, 2005). This resulted in around half of 999 patients being transported to, and then discharged from, the emergency departments, without significant treatment or referral (DH, 2009). It appears that many patients could have been more appropriately cared for at home or by other urgent care services (DH, 2009). It was evident that the current curriculum had unsuccessfully attempted to define the paramedic role, rather than the requirements of the role defining the curriculum (Kilner, 2004).

The Association of Ambulance Chief Executives (AACE) (2011) recommended that paramedics needed greater underpinning knowledge and skill to more effectively address the remaining 90% of patients they encountered. Paramedics needed to be developed to offer a greater range of unscheduled, urgent care with an aim to facilitate patients remaining at home or exploring other more proportionate, appropriate care pathways (AACE, 2011; NHS England, 2013). The greater autonomy, professional knowledge and the higher level interventions required to make this possible were gained through higher education programmes (AACE, 2011; Lovegrove, 2013). This additional education better equips paramedics to manage complex, minor or undifferentiated presentations more effectively, thus minimising the requirement for transportation to hospital (Catterall, 2012). The overall aim of this strategy is that patients would receive the ‘right care, at the right time and in the right place’ (NHS England, 2014).

While the ambulance paramedic is predominantly dealing with an ageing population requiring urgent (not emergency) care (NHS England, 2013), the SAR paramedic is faced with a different demographic of patient altogether. The majority of casualties necessitating the deployment of a SAR helicopter are usually those in austere, inaccessible locations presenting with emergency injuries or illnesses (Dykes et al, 2009). Most of them are relatively young, healthy adult males either at sea or participating in adventurous activities overland (Dykes et al, 2009). This results in around 80% of casualties being victims of traumatic injury (Howes et al, 2011). By predominantly focusing on treating life-threatening conditions followed by transportation, the IHCD training model seems already appropriate for the SAR paramedic’s

caseload. However, the SAR paramedic’s practice is still enhanced by higher education, particularly when faced with emergency or critical casualties in the challenging SAR environment.

The pre-hospital arena is austere and often unforgiving: ‘Practising in this chaotic environment necessitates elements of speed, versatility, improvisation, physical and emotional control and interpersonal finesse...’ (Nelson, 1997: 168). This is certainly true of the SAR environment. The SAR paramedic often works alone, faced with severely injured or ill casualties, in difficult environments and sometimes within weather or fuel restrictions (BBC News, 2015). The consequences of missing a rescue window could be of significant detriment to overall casualty care. They may now face a difficult ground-based, technical rope rescue lasting several hours. For casualties at sea this could mean a long sail into the nearest port. The setting in which they practice often limits the SAR paramedic to fitting in medical procedures (BBC News, 2015). This results in their overall ability to manage the emergency scene (rather than focus exclusively on clinical interventions) being one of their most highly prized attributes (Campeau, 2008). To achieve the best overall outcome, it is necessary to resist focusing entirely on the clinical needs of the patient and take a more holistic approach to the management of the mission’s aviation, rescue and clinical requirements. It is here that the tactical benefits of the higher-educated SAR paramedic gives them the edge over their IHCD-trained colleagues.

This new higher-educated generation of SAR paramedic not only has the ability to recall and implement guidelines, but it also possesses greater underpinning knowledge and has the ability to critically analyse those guidelines (CoP, 2014b). Together with the principles of evidence-based practice (EBP) ( Jones and Jones, 2009), they use these attributes to specifically tailor their care to the unique, challenging, sometimes extraordinary circumstances of the SAR environment. Rather than blindly following a strict A to E protocol they are able to provide more realistic, proportionate and achievable care, and still meet the all-important rescue window. This concept is advocated in pre-hospital care by the National Association of Emergency Medical Technicians (NAEMT):

‘Guidelines for patient care must be flexible...they [guidelines] are not the definitive be-all-and-end-all steps that cannot be violated by thoughtful, insightful analysis of the situation and application of appropriate steps to assure the best possible patient care in each unique situation’ (NAEMT, 2011: 38–39).

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Advancing clinical capabilitiesAn opportunity now exists to progress the professional competencies of the SAR paramedic by developing the role into one of advanced practice. This article will continue by critically reflecting on the difficulties of advancing the clinical capabilities of the role.

Advance practice and specialist roles are nothing new in the paramedic profession. The UK is too diverse in terms of demographics, distribution and available care services to have a ‘one-size-fits-all’ model of care (NHS England, 2014: 17). What works in central London may not be appropriate for rural East Anglia. Various Trusts have developed specialist paramedic roles such as community paramedics and critical care paramedics, tailored to the specific needs of their patient demographics (Bigham et al, 2013). This has been achieved in line with the CoP (2014a) Career Framework. Evidence suggests that these roles are proving successful, particularly in the urgent care setting. The percentage of 999 patients not requiring transportation to hospital approximately doubles when being treated by a specialist paramedic (AACE, 2011).

But these roles are not without their criticism. While one size does not fit all, it is not possible to ‘allow a thousand flowers to bloom’ with respect to pre-hospital healthcare models (NHS England, 2014: 17). Although an advance practice national examination has been piloted (Newton, 2011), many of the specialist roles operate under a set of locally determined competencies (Bigham et al, 2013). This flexibility enables a tailored role to meet specific requirements but it lacks national recognition, comparability and transferability. The

key challenge in the development of these roles is addressing patient needs while balancing service flexibility with a need for national conformity and governance. Conformity to national competencies gives the role greater identity. This enhances the NHS’ ability to work jointly with the roles in finding more viable ways forward for the communities they serve (NHS England, 2014).

By fulfilling roles in aviation and rescue, the SAR winchman is arguably already a specialist paramedic, but not in the clinical sense. Traditionally they have adopted UK ambulance practices and guidelines. An opportunity exists to also enhance the role of the SAR paramedic into one of advanced clinical practice.

The National Confidential Enquiry into Patient Outcome and Death (Findlay et al, 2007) reported that airway management and the provision of adequate analgesia was lacking in pre-hospital trauma management. It recommended that pre-hospital responses to victims of trauma need to include someone with the capability to perform advanced airways and rapid sequence intubation (RSI) (Findlay et al, 2007). It also recommended that the provision of adequate analgesia was required for many of these patients (Findlay et al, 2007).

The current solution drawn from the wider health workforce is to supplement helicopter crews with doctors. Roberts et al (2009: 128) agreed with this model stating the, ‘Potential benefits of doctor-led air ambulance units include early definitive airway control... [and] advanced analgesics.’ Skeldon et al (2010) discovered that 83% of the paramedics they surveyed agreed that doctors were required in the pre-hospital setting to provide adequate analgesia and airway management.

But rather than supplementing helicopter crews with doctors to bring these few additional capabilities, an alternative solution exists. Up-skill and empower the SAR paramedics to perform them by taking on a role similar to that of a critical care or advanced paramedic ( Jashapara, 2011). In doing so, the traditionally perceived clinical boundaries of the paramedic title would be broken down. The requirements of the role would dictate its competencies, not vice versa.

A recent study attempting to justify the need for doctors during SAR helicopter winching rescues in Australia concluded that doctors were required based on 40% of the casualties requiring physician only interventions (POIs) (Sherren et al, 2013). But analysis of the data reveals that 42 of the 63 POIs were for the administration of ketamine following the failure of traditional analgesia. Perhaps an alternative conclusion could be that SAR winchmen in Australia need to be able to administer ketamine.

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There is a wealth of evidence attempting to justify pre-hospital doctors on helicopters in preference to advanced or critical care paramedics, but it appears conflicting or anecdotal. Literature reviews from both Jashapara (2011) and Butler et al (2010) summarised that the evidence supporting doctors on helicopters is inconclusive. But when comparing the two, there is one significant, undisputable difference: doctors cost more than paramedics! Jashapara (2011) suggests a cost-benefit analysis that shows that the cost per-life-saved for a doctor is seven times more than for a critical care paramedic providing the same level of pre-hospital care.

A significant challenge to developing these competencies is managing skill fade. In a commendably honest article by Boor (2014), she admits to suffering skill fade after being employed in a specialist paramedic role. She admitted to the basic fundamentals of her practice becoming rusty due to a lack of exposure. Deakin et al (2009) support the argument of a requirement to manage skill fade. They suggest that initial training alone in tracheal intubation does not adequately equip paramedics to carry out the procedure, the skill needs to be maintained to ensure competency. The potential for skill fade of core skills due to a lack of numbers, and a variety of casualties certainly exists for the SAR paramedic (Ministry of Defence, 2015). This problem is mitigated with continuous (monthly) assessment and compulsory continuation training. However, advancement of the role would present an even greater challenge: the mitigation of skill fade of both the core and the new (but rarely used) advanced skills.

Many authors conclude that performing advanced airways (including RSI) and administering ketamine is safely achievable for paramedics. But only if there is a robust, comprehensive training, education and governance system in place to mitigate the challenges (Williams and Higginson, 2014). Williams and Higginson (2014) also suggest that the development of these advanced practices should be based on postgraduate (level 7) programmes. These provide the underpinning knowledge to facilitate the introduction of the advanced analgesic formulary and advanced airway management capability (RSI).

Advanced practice for the SAR paramedic appears a complex, but nevertheless achievable, solution to addressing the requirements of the major trauma casualty in the austere, inaccessible setting. The present answer drawn from the wider health community suffers from inconclusive and conflicting evidence, and, of greatest significance, appears far less cost effective.

Strategic development of the SAR paramedicIt is not only on a tactical level that higher education is transforming the SAR paramedic profession but, significantly, it is the potential at the strategic level which has been enhanced. This final section will critique the strategic development of the SAR paramedic role and analyse how the recent transition to higher education promotes a greater impetus for SAR paramedics to drive and take ownership of their profession.

Paramedic practice has traditionally been viewed as an extension of the emergency department rather than an independent clinical discipline (Simpson et al, 2012). This has resulted in the paramedic role developing as a conglomeration of adapted in-hospital practices (Smith and Eastwood, 2009). It had been ‘founded upon anecdotal evidence and expert opinion’, which has ‘evolved as a product of what doctors have made it’ (Ball, 2005: 898). Archer et al (2008: 2) found that this has caused ‘many evidence gaps related to current pre-hospital policy and practice including management, clinical and service delivery issues’.

In a study conducted by Kilner (2004), results showed that IHCD-trained paramedics recognised the need for evidence-based practice (EBP), research and having their own body of knowledge. But it is feasible to argue that its absence from the IHCD curriculum proved a significant barrier to them achieving it (McClelland, 2013). Wood (2012) argues that for pre-hospital research questions to have meaning and relevance, the clinician generating and conducting the research should be primarily embedded within the pre-hospital setting. However, this is not the case. Wood continues by suggesting an ironic truth: that the majority of pre-

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hospital research is conducted by predominantly in-hospital doctors of medicine. In contrast, those embedded within the pre-hospital setting (paramedics) have traditionally not possessed the knowledge or had the means to conduct research. The result being that pre-hospital emergency care appears to lack robust evidence and is based on scanty science (McClelland, 2013).

It is not the evidence behind the in-hospital procedures utilised in the pre-hospital setting that is questionable, but the context in which they are performed. Paramedic practice is conducted in ‘a context rife with chaotic, dangerous, and often uncontrollable elements with which hospital-based practitioners need not contend’ (Nelson, 1997: 162). A lack of evidence confirming the use of in-hospital guidelines in the pre-hospital environment does not necessarily render them completely redundant, but it may result in a dilution of their relevance. The SAR environment and the demographic of SAR casualties are different again to those of the patients seen by an ambulance paramedic (Dykes et al, 2009; Howes et al, 2011). Arguably this could cause a further (although lesser) dilution of relevance when ambulance service guidelines are used by the SAR paramedic.

The progression to higher education addresses this by empowering paramedics with the tools necessary to generate their own questions and perform their own research (Siriwardena et al, 2010; Wood, 2012;

McClelland, 2013). SAR paramedics can now mirror their colleagues in the ambulance service and start to produce their own body of knowledge, something argued by many as essential for the very definition of their profession (Armitage, 2010). This transition from knowledge users to knowledge creators will ensure their practice is founded on a more relevant evidence base (Siriwardena et al, 2010). SAR paramedics no longer have to make do with improvising guidelines of arguably diluted relevance. They are equipped to produce their own body of evidence, specific to their practice. This will ensure they adhere to EBP principles by conscientiously, explicitly and judiciously using current best evidence for their practice to facilitate making the best decisions about the care of their casualties in the circumstances they find themselves in (Sackett et al, 1996).

This ideology of SAR paramedics taking ownership of their practice can be extended beyond that of research and generating their own body of knowledge. Having already conquered the skies, it is the world of academia and governance that are the current limits for the SAR helicopter paramedic. With SAR paramedics now progressing to academic level 6 in England, Wales and Northern Ireland, there are already level 7 modules, specifically aimed at SAR paramedics in the pipeline.

ConclusionsFor SAR paramedics it is themselves that have the greatest potential to advance their own profession. An opportunity now exists to advance the practice clinically as well as strategically with the development of skills in advance airway management and greater analgesics. The future is a blank canvass; the profession is the master of its own destiny. No longer does the SAR paramedic profession have to be content with being the guests of others in the SAR medical world, it can strive to become the hosts.

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