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London Ambulance Shift During COVID-19 Second Wave

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Background

Being a paramedic is a dangerous job (Maguire et al., 2014; Maguire & Smith, 2013). Paramedics experience violence, workplace injuries and sleep disruption as well as high rates of mental stress and fatigue on a daily basis. To compound these issues, the COVID-19 pandemic has put even more strain on frontline paramedics and ambulance officers. Recently, Rengers, Day and Whitfield (2021) published a description of 12-hour ambulance shift during the second wave of COVID-19 in London. The article explored the experience of paramedics on the frontlines for historical prosperity. This article is a plain language synopsis of this peer reviewed work.

Compared to many parts of Canada, London is a densely populated area with high volume local, national and international transport. These two factors paired with the aerosol transmission of the virus fuelled the rapid spread of COVID-19 throughout London (BBC, 2021; Flynn et al., 2020; Trust for London, 2021). The already strained National Health Service (NHS) and London Ambulance Service (LAS) adapted to continue service during the pandemic. As the pandemic surged the LAS enlisted the help of the London Fire Brigade (LFB), Metropolitan Police Service (MPS) and returning LFB members in order to respond to patients.

Initially, inadequate personal protective equipment (PPE) for healthcare workers meant large numbers became infected and died from COVID-19. As the pandemic’s second wave struck, more suitable PPE was provided to health care workers. LAS paramedics use level two and three PPE to help reduce the risk of infection. Level two PPE, consisting of an apron, gloves and surgical face mask, is worn to assess every patient. Level three PPE is worn when performing aerosol generating procedures (intubation, suction etc.) and consists of a full-face reusable respirator, full sleeve surgical gown/ Tyvek suit, and double gloves. As personal-issue reusable respirators have become available, these are now worn when assessing COVID-19 suspected or positive patients.

In the LAS, category one (Cat 1) calls require a seven-minute response time. This level of call is enlisted for patients experiencing cardiac arrest, unresponsiveness, extended seizures or a high level of trauma. Category two (Cat 2) calls need an 18-minute response time. Cat 2 calls are for patients with altered level of consciousness (ALOC), difficulty breathing, chest or abdominal pain or a seizure that has stopped. Finally, category three (Cat 3) calls require a response time of less than two hours. Due to the strain on the healthcare system that COVID-19 has caused, some Cat 3 response times have been greater than eight hours (Perkins et al., 2020). This category is applied to patients who have fallen (mostly elderly) or are experiencing mental health issues or back pain (non-traumatic).

The shift

The LAS advanced life support (ALS) crew clock on at 0830 for their shift. The crew are immediately dispatched to a Cat 3 call that has already been held for six hours. The patient, a 37-year-old female, has a cough, so the crew are required to don Level three PPE. The patient is thoroughly assessed, deemed non-critical and left at home with self-care recommendations. The crew doff their PPE, clear the case and are immediately dispatched to a 53-year-old female patient with non-specific back/ flank pain. Although the patient has no reported COVID-19 symptoms, protocol dictates that the crew don Level two PPE in order to transport the patient to hospital. During transport dispatch broadcasts to all crews that multiple calls are currently on hold. To attend to these waiting patients faster, while at the hospital one officer triages the patient while another resets the ambulance.

After triaging the patient, doffing their PPE and clearing the case the crew are dispatched to 58-year-old female patient with a five-day history of abdominal pain and diarrhoea. Upon arrival at the scene the crew don Level two PPE in order to assess the patient. The decision to transport is made, and during the transport to hospital dispatch broadcasts to all crews that assistance is required due to increasing call frequencies. The patient is handed over to the hospital and the crew doff their PPE before clearing the case. The crew are immediately assigned Cat 1 to an actively seizing 96-year-old patient with a history of fever. Prior to attending the patient, the crew don Level two PPE. The patient is treated on scene and transported to hospital, however, is unable to be offloaded due to a bed shortage. This brief delay allows the crew to eat some food. One officer remains in PPE with the patient while the other removes themselves, doffs their PPE and decontaminates before eating as quickly as possible, so that the other officer also has the chance to eat.

Following handover, the crew are dispatched to a 57-year-old female in respiratory distress. The crew are required to don Level three PPE before entering the scene. On arrival the patient is confirmed as COVID-19 positive. The patient’s oxygen saturation is 70% on room air and their respiratory rate is tachypnoeic at 44 breaths per minute. The patient has a tachycardic heart rate of 120 beats per minute and is febrile with a temperature of 39 degrees Celsius. While the patient is obviously unwell, she is not the most severe COVID-19 patient the crew has attended this week. The crew provide the patient with high flow oxygen before transporting to hospital. Once the patient is handed over, due to her COVID-19 positive status, the ambulance and equipment undergo extensive decontamination. While decontaminating the vehicle the crew is all too well aware of the growing list of delayed calls and the pressure to become available.

Following the completion of decontamination, the crew are dispatched to a Cat 2 call. The 52-year-old male patient, confirmed as COVID-19 positive, is in respiratory distress. Prior to entering the scene, the crew don Level three PPE. The patient is thoroughly assessed, deemed non-critical and the decision is made to leave him at home in the care of family with health advice. As the patient is confirmed COVID-19 positive, another extensive decontamination is required of kits and vehicle before the crew can be dispatched to another patient. With decontamination and doffing complete the crew are immediately dispatched to another COVID-19 positive patient, a 32-year-old female in respiratory distress. The crew again don Level three PPE and administer the patient urgently required oxygen therapy. The patient is transported to hospital where the crew wait in line behind seven other ambulances. Hospital staff take blood samples and patient vital signs in the waiting ambulances. The crew remain in full Level three PPE for three hours due to bed shortages. A bed becomes available at 2130, and after a thorough ambulance and kit decontamination the crew arrive back at station almost two hours after their log off time.

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Conclusion

This is a description of a standard 12-hour shift experienced by London based paramedics during the COVID-19 second wave. COVID-19 has greatly affected the delivery of ambulance services in London and around the world. The impact has not only been on the patients, but also the paramedics delivering care. The day outlined in this article is intended to add to experiential data as well as to let other health care providers undergoing a similar experience know they aren’t alone.

The full article is available here https://ajp.paramedics.org/index.php/ajp/article/view/976

References

  1. Demography, London’s Population & Geography – Trust for London. 2021. Available at: www.trustforlondon.org.uk/data/geography-population/ [Accessed 27 June 2021].
  2. Flynn D, Moloney E, Bhattarai N, et al. COVID-19 pandemic in the United Kingdom. Health Policy Technol 2020;9:673-91. https://doi.org/10.1016/j.hlpt.2020.08.003
  3. Maguire B, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med 2013;28:376-82. https://doi. org/10.1017/s1049023x13003555
  4. Maguire B, O’Meara P, Brightwell R, O’Neill B, Fitzgerald G. Occupational injury risk among Australian paramedics: an analysis of national data. Med J Aust 2014;200:520. https:// doi.org/10.5694/mja14.10941
  5. Perkins A, Kelly S, Dumbleton H, Whitfield S. Pandemic pupils: COVID-19 and the impact on student paramedics. Australasian Journal of Paramedicine 2020;17. https://doi.org/10.33151/ajp.17.811
  6. Population density – population and migration – KS3 Geography Revision. BBC Bitesize [Internet]. Available at: www.bbc.co.uk/bitesize/guides/zkg82hv/revision/2 [Accessed 4 February 2021].
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