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Whilst rural paramedics are concerned with a whole of community response,

urban paramedics mention community response relating to the types of cases

they attend in the community. The types of cases urban paramedics mainly

have concern for are chronic care, social care, and mental health care. A

common theme is that urban paramedics feel under trained in each of these

community-based areas.

A focus on attendance to community members requiring chronic and social

care is common to all urban paramedics in this study, and appears

exacerbated by difficulties accessing urban General Practitioners (GPs).

Urban paramedics reported various situations. Patients who have problems

with medication; have recently seen their general practitioner but are unclear

on treatment regimes; people who are unsure of how to manage elderly

relatives at home; elderly people who may just need a lift after falling to the

floor; or even those that simply want a chat because they are lonely. One

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“We are seeing a lot more social side of things, mental health, people who cannot access...local GP type work, where people cannot access a local GP for a week or more.” (Urban

Paramedic)

“A lot of the GPs down here have their books closed now, it can take anything up to a couple of weeks to get in to see a GP, they don’t want to wait that long so they will ring us, with a view to getting into hospital quicker...the books are closed on town doctors as much as they are in country areas. There might be a lack of a GP in a country area, but there is a lack of GPs in the city because they are not available. Effectively the same thing.” (Urban Paramedic)

All these community members require some form of health care; however,

urban paramedics feel that they are not currently equipped to manage these

types of care.

“I do not think we train for any chronic area…wound management, catheters, small things, we just do not focus at all on it. We are probably getting to the point where we probably should.”(Urban Paramedic)

This focus on chronic and social care by urban paramedics during interviews

was accompanied by a degree of frustration. The following phrases were used

by urban paramedics:

- They (patients) can’t get any other help; - just going(to the patient) for (to give) advice; - no chronic training;

- pick it up (training) by experience;

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- not the right path to take (in reference to a focus on critical care);

- (patients) can’t access a GP for a week or more.

There was also lack of satisfaction gained from attending such cases.

“Geez…..I am shocked at the number of non-ambulance cases that we attend. That was probably because I knew nothing about ambulance before I joined. There was a momentous day on the garage where I first go to touch an ambulance! When I actually went on road, I was a third for two weeks and in that time I thought that because I was a third that is why we were going to all the crap work! ...I thought because I was new they must only be going to not emergencies...and that just never really changed...until I went off to branch [rural] stations.”

(Urban Paramedic)

Further to this was that the urban paramedics interviewed believed that new

paramedic recruits do not realize that the majority of work is chronic.

“Like it’s very frustrating…and so I think that number one we need to recognise that our role has definitely changed and there needs to be a decision as to whether we are going to insist we are truly an emergency service, and they are going to have to find alternative ways of looking after all of the non emergency things we go to or they are going to have to realise that our work has changed dramatically and train us

accordingly...and that’s also going to help with recruitment because they’re not going to be putting as much emphasis on perhaps recruiting people who will make

excellent…paramedics...like you know your helicopter paramedics who love your Cat 1s(emergency calls) and big traumas and that sort, that’s the sort of person they look for when they recruit. Those people often do not last long because they just get so bored with the crap work.” (Urban Paramedic)

A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland

158 The emotive description of non-emergency work as ‘crap’ work in these two

quotes offers further reinforcement to the frustration and lack of satisfaction

that paramedics feel when confronted by these cases they feel ill prepared to

manage.

In addition to chronic and social work, the issue of mental health is one of

particular concern for urban paramedics in this study, and attendance to

psychiatric cases is certainly among the most common of cases attended in

urban areas (Appendices M & N). Mental health problems that confront

paramedics present in forms such as general psychiatric patients; overdoses;

attempted suicide and suicide of other types; depression; anxiety;

homelessness; and general inability to cope with the demands of society.

Despite frequent attendance at such cases, and reiterating concerns with

social and chronic care, urban paramedics in this study all mention a lack of

preparedness to be able to manage the care of patients with mental health

problems.

“The extra skills and knowledge (critical care) I haven’t really applied yet, and I find that I’m still going to people who have a fascination with their bipolar at 2 oclock in the morning, and I really don’t really know what bipolar is!” (Urban Paramedic)

A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland

159 Like the limited access to GPs in social and chronic care, this is compounded

by what paramedics note is a lack of community based care for the mentally

ill; the only option for the paramedic is to transport the patient to hospital.

“Mental health people (patients) who cannot access mental health services…its broadening into the more generalised (ambulance) work.” (Urban Paramedic)

“I think I had one lecture on mental health, and we do a huge amount of work where we go to people with mental health issues who are having exacerbations at night….the only thing we can do is cart them off to the emergency department and dump them where they are not going to see anybody until the morning.” (Urban Paramedic)

Both sites examined in this case study have in place guidelines that deal with

mental health. However, these guidelines are limiting to the paramedic in

terms of patient management. Whilst the “Mental Status Assessment” allows

for the paramedic to assess a patient’s mental status based on the nine

categories of appearance; behaviour; speech; mood; response; perceptions;

though content; thought flow; and concentration, it does not offer guidance

on how to manage the patient (Rural Ambulance Victoria 2008b).

Similarly the “Agitated Patient” guideline is aimed at management of clinical

causes such as hypoglycaemia or drug overdose; verbal de-escalation of a

confronting situation; or sedation where the patient is a risk to themselves or

A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland

160 by the use of sedation or police assistance (Victorian Government

Department of Human Services 2002pp. 1-26).

Part of the differences between rural and urban paramedics is that while urban

paramedics are quite vocal in their expressions regarding the chronic, social,

and mental health cases they attend, there is no mention of such by rural

paramedics. Certainly, within Australia a postgraduate qualification in rural

and remote paramedic practice at James Cook University has components

based in social and chronic care (Raven, Tippett et al. 2006: 4) and so this

type of care has been deemed important in a rural community. When earlier

discussing community education in section 5.2.1 (p. 142), it was revealed that

community support provides the confidence necessary for health workers to

provide evidence based education (Rogers, Dunn et al. 2008: 42), perhaps it

is because of this same community support that rural paramedics are able to

mange the social, chronic, and mental health care cases as part of their normal

role. Further investigation is required to help gather evidence in this regard.

5.2.5 Summary

Rural paramedic practice is different to urban paramedic practice in that rural

paramedics are involved in a whole of community response rather being

limited to a dispatch response to emergency cases. My findings show that

rural paramedics demonstrate this whole of community response by

A comparison of the practice of rural and urban paramedics: bridging the gap between education, training, and practice. Peter Mulholland

161 practitioners, and 3) becoming part of a community social fabric. Rather than

a whole of community approach, urban paramedics are concerned with the

types of cases attended, and specifically these include the mental health,

chronic care, and social types of cases that urban paramedics feel deserve

further attention in paramedic education and training.

5.3 An inter-professional team member versus an