Secondary Roles of a Paramedic
Paramedics as first responders to emergency scenes have the much-needed role of stabilisation, treatment and transport of the ill or injured. As vital as this primary role is, it can be only one of many the paramedic plays. These secondary roles of a paramedic shall be discussed in this essay, namely the general roles and responsibilities, well-being of the paramedic, the importance of paramedic documentation, medico-legal and ethical considerations paramedics must be mindful of, and the move towards evidence-based practice in emergency medicine.
The first topic to be discussed is the roles and responsibilities of a paramedic, those responsibilities being involvement in the community in the form of teaching injury prevention, and teaching first aid and CPR, development of the personal and professional self, and support of citizen involvement in emergency services and primary care efforts. This brings one to the secondary role of education, whether to the civilian community or that of emergency medical practitioners. It has been considered beneficial to the public for paramedics as healthcare practitioners to become involved with education in the form of community health projects. A worthwhile example of this can be found in a seniors’ apartment building in Hamilton, Ontario, where Emergency Medical Services educated the elderly residents on the prevention of hypertension and diabetes (Agarwal G, Angeles RN, McDonough B, McLeod B, Marzanek F, Pirrie M, Dolovich L.; 2015; 8 113). This approach proved quite successful in its setting, indicating the program as a feasible means to prevent morbidity from these conditions and resultant EMS calls to treat such. Thus, it can be seen that the efforts paramedics made to educate civilians on preventative care were able to better the population, therefore affirming the role of paramedics as teachers.
Another aspect on the topic of education is the responsibility of paramedics to refine their own education system, namely with the aim of fine-tuning paramedic training programmes to reduce the number of patients inappropriately transported to hospital (M Woollard; 2015). This works to redefine the role of the paramedic practitioner, offering a more structured clinical career for ambulance professionals where there may not have been one before. In turn, this creates qualified paramedics better equipped to assess the situations presented to them and delay or filter out truly unnecessary cases, cutting down on overloading of emergency services and personnel with patients that do not require the level of care an ambulance crew provides.
This then serves a vital role, as an overflow of work, especially that concerning the lives of other people, can cause negative effects on one’s well-being. Stressful situations are part and parcel of working in emergency medicine, though a high level of exposure can easily lead to an often-unnoticed decline in mental health in even the most experienced paramedic. Instead of debriefing with their team, many paramedics have allowed themselves to ruminate on potentially traumatic events, an activity closely associated with the development of PTSD (Hu, E., Koucky, E. M., Brown, W. J., Bruce, S. E., & Sheline, Y. I; 2014; 29 10). Not wanting to compromise their job or simply being unaware of the symptoms, these issues are often never brought up for resolution and subsequently allowed to develop further. Such a decline in a paramedic’s health is detrimental to their practice, especially since the development of PTSD can have consequences spanning several years even after the original problem has resolved (Smith, E.C., Burkle, F. M.; 2019; 34 56-61).
Additionally, every paramedic is bound to experience not only scenes of violence towards others, but violence towards themselves. This can stem from many sources but has been shown to come primarily from the patients themselves (Bigham, BL; Jensen, JL, Tavares, W; Drennan, JR; Saleem, H; Dainty, KN; Munro, G; 2014). Naturally, the paramedic is at risk of harm to themselves in such cases in the form of injury and infection. It is thus a necessary role the paramedic plays as a proponent of proper hygiene and an alert observer of the situation around themselves and their partners to prevent potentially irreversible consequences. From this one can understand the tension a paramedic feels when en route to a new call, with so many dangers to gather stress from.
Paramedics may deal with this stress via use of particularly morbid humour, which has actually shown more positive results in terms of reducing emotional tension and maintaining their own resilience. As said in a study done in 2018, “paramedics used humour to de-escalate emotional tension that arose during a mental health call and also used humour among themselves as a form of resilience.” (Rolfe, U; 2018). As disturbing as the general public may find such a coping mechanism, it has shown far better results in terms of dealing with the mental stresses found in the field than other popular vices like alcohol. One can see the importance of maintaining a healthy state of mind in the world of emergency medical care then, as a mentally unstable paramedic cannot be relied upon to perform to their best, which can result in cases of patient negligence.
As a paramedic, such cases are highly detrimental to one’s career - nobody wants to receive care from a paramedic known to have mistreated or abandoned a patient during an emergency. But at what point can one prove negligence during a high-stress situation with many injured people and potentially confusing priorities, such as a multiple vehicle collision? Here one finds the paramedic’s role as defendant to their own case, and an important component in the cases of others. They may find themselves in a courtroom not only on charges of negligence, but also possibly to aid in identification of a suspect in a crime, or to provide knowledge of the condition of an abuse victim. It is vital to have comprehensive knowledge of the medico-legal system to prevent unjust ruling, or to aid in successful closure of a case (Pozgar, GD; 2019).
Thus, we see the importance of medico-legal considerations in a paramedic’s life, to which ethical considerations are closely associated. Here one finds many grey areas, where what may be the ethically “right” decision is in the hands of the paramedic. They often must face the quandary of when it may be necessary to withdraw from a dangerous situation, when to restrain a possibly mentally disturbed patient, or when to declare a patient brain dead. It is these “end-of-life” decisions one may find especially cumbersome to one’s morals, and where a trained paramedic’s sense of ethics become imperative to ensure the best outcome with minimal suffering from all parties involved (Wiese, CHR; Taghavi, M; Meyer, N; Lassen, C; 2012). Here they take on the responsibility of decision-maker, choosing between difficult decisions like loss of limb or even life and death.
An additional ethical conundrum, and one that can often result in frustration, is recognising and reporting child abuse cases. There is arguably no better person to recognise the signs of abuse on a child, but whether to report it as such is a difficult subject one has to be thoroughly educated on before considering it (Becker, TK; Gausche-Hill, M; Aswegan, AL; Baker, EF; Bookman, KJ; Bradley, RN; De Lorenzo, RA; Schoenwetter, DJ; 2013; 28(5) 1-10). One would have to take into account the physical and mental condition of the child, as well as that of the parents or guardian caring for the child, with more subtle signs like defensive behaviour or signs of aggression. Only after a careful examination can a paramedic consider filing for child abuse. This also ties in with the legal side of things, as filing a case of child abuse can often result in a lengthy court case with the reporting paramedic in the centre, linking back to the paramedic’s role as a case asset.
Of course, with such weighty decisions come paperwork. That legal aspect of proper documentation is highly important, as it is very easy to be taken to court on grounds of omitting a critical detail that may have changed the outcome of a patient’s life, potentially injuring both one’s own reputation and that of one’s department. This is obviously important in the line of public service, where one deals with hundreds of people and protocol, so the role of documenter is necessary in emergency medicine. Mosby’s Paramedic Textbook states four main reasons for documenting patient care - to: “Demonstrate the continuity of the patient care provided, create a legal record of the patient care provided, assist in financial reimbursement and cost recovery for patient care services and equipment and supplies, and assist in quality improvement studies and EMS research” (Sanders, MJ; Lewis, LM; McKenna, KD; Quick, G; 2012).
An interesting blend between the ethical and the documented is the do not resuscitate or DNR order. The document itself is very important as evidence of careful, informed consideration before ceasing patient care, which affirms a paramedic’s role of documenter. Additionally, a DNR order is also a weight on the conscious, as it can often be difficult to allow a patient to pass away while under one’s care. This is where the trained paramedic’s sense of ethics comes in useful to ease the weight on the conscious and help friends and family of the patient to come to terms with their loss. Furthermore, one has to be careful when to implement a DNR order, as it has been found that issuing one early can have an impact on the level of patient care and outcomes following successful resuscitation (Richardson, DK; Zive, D; Daya, M; Newgard, CD; 2013; 84(4) 483-487).
The most common example of documentation every paramedic encounters is the Patient Care Report, or PCR. As commonplace as these documents are in the lives of paramedics, they have been shown to be reliable sources of data for research in prehospital cases of myocardial infarction (Coventry, LL; Bremner, AP; Williams, TA; Jacobs, JG; Finn, J; 2014), and potentially other afflictions in future. This supports the importance of paramedics in documenting their patient care process, allowing for a comprehensive database of patient care both as a useful medical record for efficient treatment of the same patient in the future and as practical evidence of procedures working effectively in real situations.
Furthermore, the presence of documented cases allows for paramedics to use evidence-based practice, which has shown to be an important migration from the older processes that were based on traditional methods medical practitioners had always used before then (Hoffmann, T; Bennett, S; Del Mar, C; 2013; 6). Historically, practitioners would follow procedures they had been taught, unwilling to test and change methods that could potentially be improved. Foreseeably, this made no change in their patient survival rates. As the practice of medicine evolved however, so testing the system became more pertinent as advances in medicine demanded new protocols. From here one can see the paramedic’s role of improver, constantly refining and redefining their guidelines and protocols with gathered evidence. However, as with all changes in a system used by so many people, there have been some barriers to the adoption of evidence-based practice, including “difficulty in generalising results of studies across diverse EMS systems” and “perceived lack of evidence” (Youngquist, ST; Gausche-Hill, M; Squire, BT; Koenig, WJ; 2010). This, however, is an issue that is solved naturally over time as the cumulatively positive results become clear.
Thus, one sees the multiple secondary roles and responsibilities of a paramedic – as an educator and fine-tuner of education, an advocate for safety, an example of sound body and mind, a helpful source of evidence in legal cases, a decision-maker in times when others may not have the strength of mind, a documenter of important and useful information, and a refiner of an evidence-based system. Each aspect is as important as the last, and adds to the adaptability, intelligence and resilience that makes paramedics the unsung heroes they are.
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