This post was originally posted on PHARM MED

Dave Seel, Paramedic, MD Medical Rescue Ltd, 17 years in NHS (Merseyside) front line 999 ambulance, subsequently 9 years specializing in Industrial Medicine and Rescue in the Power Generation sector. Dave also spent a number of years in the Medical Devices sector bringing new technology into pre hospital deployment. Dave established Medical Rescue, recognizing the need for advanced Medical skills in addition to rescue disciplines in the Industrial sector. Dave is a PHTLS Paramedic, IOSH accredited, and has won national awards presented in the House of Commons. Dave is a lifelong Liverpool FC supporter.

Mark Turner, Paramedic. Began work as Economist managing Hedge Funds throughout Latin America. Studied Emergencv Medicine at the University of Iowa (USA) and Birmingham City University (UK). Mark works with the Hampshire (Coroner’s) DRD group specializing in Substance Abuse in the pre hospital environment and is a volunteer Lifeboat Paramedic. Mark has worked in the Offshore Shipping Industry and in Remote Area Medicine, is a member of the UK Govt International Emergency Trauma Register, IOSH accredited, Offshore registered, PHTLS, ALS and FAST Ultrasound. Mark is currently one of the Rescue Team Paramedics for Medical Rescue. Mark drinks Guinness and plays Polo.

Introduction

The role of Paramedic, from its beginning as entirely Ambulance based (and solely NHS as employer) has produced numerous specialty grades in recent years; some of which are represented by the College of Paramedics, others, as yet, not.

For example; the roles of CCP, ECP/PP, Military Paramedic, HEMS & Coastguard Paramedics, HART Paramedics and Offshore Paramedics are well recognized and established specialized disiplines, often with their own separate, University based courses to “top up” on the existing Paramedic BSc.

Some specialties; such as Remote Area and ED Paramedics are less well understood and represented.

It is the purpose of the authors to describe the role of the Industrial Paramedic; Why the skillset of this role is unique in comparison with those mentioned above and to debate the case for recognition and specific training for this specialty.

Narrative

The first question facing the Industrial Paramedic, and indeed – within this discussion document, is; what is Medical and specific about the skills set you may have claimed to identified?

Medically, the Industrial Paramedic must be able to extract the patient, but clearly an advanced level of trauma skills must be necessary, practiced rapid diagnosis and treatment (Industrial Paramedics work to PHTLS “platinum 10” standards) although much of the work undertaken is actually minor injuries and illness.

This, arguably, requires a broader skills set than some or all of our colleagues in other fields of Rescue/Paramedicine?

The UK HSE reports the following Industrial injuries in the UK; (based on last available data 2014);

“155 workers killed annually – equating to three per week”

“22,500 workers seriously injured per annum – one every 22 minutes”

“79,000 workers unavailable to work for between 3 and 7 days”

“16,000 people leave the workforce annually never to return due to harm at work”

Overall the cost to UK society and industry is £14 Billion per annum.

(source : HSE)

It is arguable that much of this cost is shared between productive industry and the NHS?

Furthermore, the HSE risk management guidelines state that facilities are required to “mitigate the risk they have created” and therefore may not entirely rely upon the statutory services.

The importance of the Industrial Paramedic may be described the following paragraphs and associated arguments.

We argue that the Industrial Paramedic has FIVE unique responsibilities, skills and identifiers;

Economic; the cost (as described above) to the Industrial economy, the broader economy and the NHS.

We believe this case has been made using HSE statistics and requires no further comment.

Efficiency; to improve industrial practice with the input of Medical and H&S professions – furthermore, to improve that same review by the medical/rescue data achieved from active response, be it minor injury or major emergency.

Health and Safety is an integral part of this – Industrial Paramedics must have an IOSH (Institute of Occupational Safety and Health) accreditation, in order to effectively mitigate risk, produce rescue plans and work effectively with our Health and Safety colleagues.

Coalition; working with local NHS public health  HCPs to report and treat outbreaks of viral or bacterial illness; For example – an influenza outbreak on an industrial site may burden not only the client in days of work lost , but the local NHS (in particular many of the workers may be resident in another NHS trust, therefore relocating costs locally and unexpectedly.

On many sites, the Paramedic team are responsible for annual influenza inoculation as part of a pro active policy to reduce non-incident related lost time.

Often, the industrial environment poses serious and aggressive environmental and biological risks –workers may need to descend into deep underground chambers containing, for example, decomposing shellfish, diesel fuel and human waste – in each case the Industrial Paramedic must, besides recording the Industry Standard gas tests, advise the workers and managers of appropriate precautions and subsequent “markers” for eye and respiratory infections (this may coincide with annual influenza and often be confused with the same – therefore workers are sent home with advice cards and the telephone number of the attending Industrial Paramedic for the guidance of local ED teams).

In addition to trauma response, health screening (for suitability for a given task, such as confined space working or driving heavy machinery) provides a necessary risk management tool with the additional benefit of often discovering issues which may be reported to the worker’s own GP for further investigation.

The minor injuries role in the Industrial Sector is an equally essential one.The prevention of LTIs (Lost Time Incidents) and further pressure on local walk in centres and EDs – especially given that a major “outage” in the sector may involve around 400 staff on average (often many more).Treatment and advice on site saves time and money and patient outcomes – particularly as travel times to local NHS facilities are often long, and shift workers may present at busy times, or otherwise ignore injuries if no on site treatment was available.

Co-operation; the 8 minute target for NHS “red calls” for the most serious medical or trauma response is always difficult and under review (citation);

In particular, within the Industrial Sector, and power generation in particular, it is highly unlikely that most NHS trusts can achieve this target, given the often remote locations of the facilities outside urban conurbations.Even if an Advanced Paramedic crew arrives on scene; the difficulties of the Rescue environment, their lack of task-specific equipment, may of course render them useless?

The UK power generation “cluster” in Kent (UK) for example, deserves discussion;

Distance to the nearest UK Major Trauma Unit ; 1hr 12min to St Georges Hospital (MTC) 44.3 miles (road).

Distance to nearest ED – 26 minutes each way,  14.3 miles, minus traffic (using commercially available maps and online services to determine this response – again by road).

Distance to HEMS helipad;  81m by road if weather against flying – estimated at 1hr 18m.

Flying (McDonnel MD Explorer at max speed of 161mph according to manufacturer) would still take perhaps 30 minutes to receive Critical Care assistance and rapid retrieval of the patient (if available?).

Average response for local 999 Ambulance Trust (SECAMB) for the reporting period 2013/2014 was 73.9% for RED 1 calls, against national target of 75% (source SECAMB).

An examination of the journey times within the Isle of Grain cluster, and distances, suggest there would be difficulty responding within the guidance times for either individual, or perhaps mass casualty, incidents?

Capability ; whether in Power Generation, Water Utilities, Nuclear Plants or Port Facilities or the myriad other industrial sites the modern economy relies upon, the Industrial Paramedic must have an advanced Rescue skills portfolio.

HART teams and Fire and Rescue Services may not have the operational or specific specialties in order to deal with some Industrial emergencies.

A working knowledge of the industry – power generation? Underground work? Utilities? Is certainly desirable, and moreover, knowledge of the individual site and the high risk work to be undertaken is essential.

Local HART and Fire & Rescue teams may or may not have trained on their local high risk industrial sites, but are highly unlikely to have trained for the site and industry specific risks.For example; power generation sites use hydrogen gas to cool the generators, and large quantities of Hydrochloric and Sulphuric acids in water treatment.Each of these substances present a high risk over and above the activities taking place at a given time in the operation and maintenance schedules.

The Industrial Paramedic will not only be COSHH accredited, but must be aware of (and document) the location of COSHH substances on site, delivery dates and times, current storage status and quantities and the movement of temporary risk items (think, welding gases during maintenance work).Before high risk activities take place, a rigorous risk assessment takes place, involving on site management, health and safety, but usually led by the Paramedic team.Rescue plans must be submitted, tested and agreed by all concerned before permits to work are issued.In many gases gas tests must be undertaken by the Paramedic team, often using BA (Breathing Apparatus) – a skill common to HART and Fire crews, but rare elsewhere.

Thereafter the task must be closely monitored – for example in a metal confined space – how many workers inside? (how much CO2 being produced?), external and internal temperatures, continual gas monitoring, emergency back up lighting and EBS (Emergency Breathing Sets) for each worker.How long can the workers be in the space without a break? Has suitable hydration facilities been put in place? Have the workers been health screened for confined spaces?

The next step is detailed practice and critique of emergency extraction and follow on medical care for one or more workers in the event of an incident.

Equipment (and medical kit) must be tested and placed as near as possible.Questions such as the type of stretcher (often a “Troll” or “Paraguard) for appropriate access must be discussed and tested (local HART or Fire Rescue may not carry the this equipment or have trained on site?)As we have seen from the distances, the time to assess the emergency, response times and the local expertise needed – in the event of a time critical access and medical response – much or all of the “golden hour” has already been expended.

Confined spaces, are defined in the regulations (source HSE) as;

“A confined space is a place which is substantially enclosed (though not always entirely), and where serious injury can occur from hazardous substances or conditions within the space or nearby (e.g. lack of oxygen)”

Work at height, is also clearly defined in the regulations (source HSE);

“Work at height means work in any place where, if there were no precautions in place, a person could fall a distance liable to cause personal injury”

Clearly, the Industrial Paramedic must have advanced access skills in confined space as well as working at height – often referred to as “high angle”.

In many cases, the task may demand both disciplines; the confined space may be 25m or more above ground, creating a dual hazard to be planned for and executed safely in event of an emergency extraction.

Economic, Efficiency, Cooperation, Coalition and Capability (EECCC) may therefore be a common identifier and acronym for the competencies of the Industrial Paramedic?

Conclusion                                                

Although it may be debated that the role of Industrial Paramedic is simply an amalgam of Critical Care Paramedic, ECP/Practitioner  and HART Paramedic, it is our contention that the other varied and essential skills implied in this role have been successfully argued in the Narrative.

As with other specialist grades, the role would be subject to “skills fade” if not in continuous practice and ongoing CPD.

The adjuncts to this grade must be taken into account and understood; Health & Safety, knowledge of industry standards, protocols, guidelines and legislation.

The essential advisory participation of the Industrial Paramedic – particularly in Health and Safety and onsite Occupational Health.

As the statutory services retrench into the traditional 999 role under funding stress, we should expect  ever increased participation of specialized grades in Industry, though primarily in the Private Sector in cooperation with local NHS trust assets and regional Fire and Rescue Services.

It is the conclusion of the authors that Industrial Paramedics, with their unique skills ought to be recognized as a pre hospital specialty and represented alongside other grades (in particular Offshore Paramedics) within the College of Paramedics.

 

Mark Turner

Dave Seel

9^th February 2016

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