Bob Dobson on the Principles and Philosophy of Paramedic Service in UK
Bob Dobson spent 34 years in the London Ambulance Service (LAS) where he was a founding member of the LAS team setting up the National Paramedic course. He was responsible for training the first 180 paramedics in London.
Bob has attended many of the major incidents in and around London over the last 30 years with both operational and tactical command roles.
He was the Secretary of the Disaster and Military Section of ESTES (European Society of Trauma and Emergency Surgery) and is a Board member and lecturer for MRMI (Medical Response to Major Incidents).
We met Mr. Dobson during one of his courses in June 2016 in Kyiv, Ukraine.
Bob, you were one of the individuals who founded the paramedic service in the UK. It is important to know your experience. How did you manage to do that?
It started because we had people on ambulances and our public didn't understand what they did or what the skill level was.
We people back then were often called Ambulancemen or Ambulancewomen, we needed a term that was non sexist and which gave them a good idea of who was actually going to come and rescue them should they ever require the emergency Ambulance.
There were various systems and skill levels of Ambulance staff around the world. Former Eastern block countries had Doctors on every Ambulance, in the West the preference was for the Doctors to be doing other duties and the Ambulances to be covered by Ambulance workers. We looked at many different systems from many countries and the skill levels varied greatly. The country that interested us at that time was the USA.
From the Vietnam war the Americans came back and they used a new term called “paramedic”. The Paramedics were doing skills in the front line of the war that had only previously been done by Doctors. We looked at America and in effect “stole” their ideas and all their information. We decided that we would go the same way as Paramedics in the USA and we would also develop the slightly lesser role of Emergency Medical Technicians (EMT).
When we looked at finances of how much it would cost to have a doctor on an ambulance up against a paramedic it was far cheaper to have a Paramedic. We needed our doctors in other areas.
How much time did it take for you to set up the system?
It was round about 1998 and it took a long time. It would take at least 4 years, because when we devised the system we already had people, who were trained into a certain level. We transferred their skills over to the paramedic course and then we did a short course, which was known as the Exemption Course. This course recognized peoples previous skills and knowledge and fast tracked them to the Paramedic Status.
Now paramedics have to do 3 years at university, but the entry for university is very-very difficult. If you haven't got your advanced level qualifications from school, you are not accepted into the university. It is like any application to University, only the best are accepted. If you are lucky and you are accepted, then you will be offered a place on the Paramedic Degree course.
Do paramedics take some kind of refresher courses?
All the time. There is a system when something comes which is new then it is a requirement for all Paramedics to learn it to maintain their position and status. There is also constant requirements to do refresher training, we call this Continuous Professional Development (CPD).
Every Paramedic is registered. It is a legal title. If somebody says: “I'm a paramedic” and they are not a Paramedic then it is against the Law, and in fact they can be arrested.
There is also the Government Awarding Body called the Health and Care Professions Council (HCPC). They would randomly select a paramedic from the register and request evidence of how they have developed through the last year”. You have no choice and you have to produce your documents to the HCPC to say: “This is what I've done to make sure that I can keep my status”. And that can happen to anybody at anytime. The other thing, that is probably worth saying, is that if you are a paramedic in London it is exactly the same as if you are a paramedic in Glasgow in Scotland, or in Cardiff in Wales, or Belfast in Northern Ireland. The status is exactly the same.
There may be some differences. In London we have a metro system, so the paramedics in London have to train to rescue in a metro system, but we don't have mountains. In Scotland they have mountains, but they don't have a metro system. The paramedics will be exactly the same to a point, but they also focus on things specific for that area.
Who works on ambulances in the UK now?
There are no doctors in the United Kingdom who work on ambulances. All the front line emergency ambulances must have at least 1Paramedic on board. They will work alongside either an EMT or a Student Paramedic. A very small team of Doctors are often in FAST cars or they are in helicopters.
The idea is that paramedics can do over 90% of all emergencies, but some emergencies become very-very difficult.
For example: a person might be trapped, they may have a head injury, they may not have protected airway. The paramedics are trying to intubate, but when somebody is unconscious and there is a gag reflex, there is a need paralyze the patient. Paramedics in the UK cannot paralyze a patient so the doctors will come out on helicopters or fast cars and do the skills that are beyond the Paramedics skill level.
It works good in other ways, because the doctors don't run to every different call where there skill level is often not required, which often results in a waste of their precious time. When the doctors get called, they know its going to be very-very serious. They become highly skilled and often go on to be the top trauma doctors.
What number do you call to ask for help and how does the dispatch centre work?
What happens is if you are in England you dial 999, but you if dial 911 or 112, which is American and European numbers, it automatically goes through to 999 system. While receiving the call, if it is appropriate to mobilize the Police and Fire Brigade, this is done via computer. The information is sent immediately to the Police and Fire Command Centres. It's done in a nanosecond.
All the ambulances are on data track, so we can see what speed they are doing, what direction they are going and everything about them on a big screen. The computer will scan out the first ambulance and it will be automatically sent.
How much time does it take for ambulance to get on the scene?
It should be within 5 minutes for the serious ones. Maximum 8 minutes in the cities and then in the rural areas it should be about 15 minutes. The time starts from the moment the call is answered in the command center. When the call comes in, the address of the caller automatically comes up on the screen, if the call is made from a land line. Mobile phones are more difficult to find their location. The address and map reference goes to the allocated vehicle which has a computer in the Cab (front) of the vehicle. It shows the map and the route to scene. It works like a satnav and takes you to the exact location, within metres.
Sometimes it happens that the Ambulance is very close to the scene, It is not uncommon to find that people who have rung for the ambulance are still on the phone when the Paramedics walk in. Sometimes we arrive at the address so quickly that we don’t always know what has happened as the member of the public making the call, hasn’t given the information to the command center.
London has something like 1,000 vehicles of different types. Normally 2 people work on one Ambulance, but we have a lot that work singularly in cars, on motorbikes and on cycles.
We have a student paramedic or an EMT with a paramedic. Sometimes you can see three people on the ambulance. The reason for that is maybe that is a student-paramedic that comes from the university, needs to have experience outside their classroom, so they go on observer days or practice placement days.
Do people who work at dispatch need to have specific training?
They need a small amount of training, but we also have a special incident desk, where people at that desk can speak with paramedics and on occasions, doctors. We call this the special incident desk. People working on the desk are looking out for the most serious emergency calls. They often ring the person back, if they need some extra information. The Desk will mobilize the helicopters, motor cycles or other specialist vehicles.
Most of the people are trained to be dispatchers or receivers of the calls. But that is a special course that they do. It's not high level medical. You don't need to be a doctor. They just want to know where you are and what you think has happened.
How do different services cooperate in major incidents?
If there is a big major incident in London immediately the ambulance headquarters will send a team to a special room at the police headquarters at New Scotland Yard, and immediately the fire brigade will send a special team to the police headquarters as well. They will be the liaisons.
If the incident is of national or International interest then Cobra is mobilized. “Cobra” is like the regional command center. It's all of the commanders and even the Prime Minister. So they can make national decisions. These individuals are the head of the army, the head of the health service, the chief of the police, the chief of the fire brigade. They will go in to a Cobra area. You cannot go any higher in status.
How do they train to cooperate better?
We are constantly practicing. When I'm dealing with the police, the assistant chief, we know each other on a first name basis because we’ve practiced together so many times. We had 30 years of Irish terrorism which meant that we had bombs in London every week.
We work out the tactics of the other side [bad people], if you want. So we can function the best.
We know we don't always have all of the answers. We search the world to find out if anybody has got the solution. If you take the chemical incidents back in 1999, we were very bad with them, and we went to Sweden who had a much better system of dealing with Chemicals than us. On an international stage we are happy to share best practice or ideas with everybody else. If you want something from us we are happy to share with you.
One of the reasons for courses like this [MACSIM] we are learning about you and you are learning about us. We are opening up ideas.
When you have people from 12 countries, you learn things from them because we are all trying to do the same thing - we are all trying to save lives. There are no secrets. We want to work together so we can understand what the gold standards are across the world.
Do you believe that the main principles can still be the same for all the countries?
Hospitals in some countries they have trauma centers, which are multi skilled with capabilities of treating every possible type of trauma and often specialize in burns or neurosurgery, for example. Other countries do not have Trauma Centers or Emergency Departments they use different systems. The Ambulances may also be different with Paramedics or Doctors, but no matter what system you have the principles of saving lives is basically the same. It's about how you can put it all together to maximize the way that you treat the patients.
In the United Kingdom we are very good at inter-agency training Police-Fire- Medics- Coast guard- voluntary services etc. We often find in some countries the fire brigade don’t talk with the police or the ambulance people, the medical people don't talk with the fire brigade. And they never train together. At courses like the one we are attending now [MACSIM] we put them in the same room together. The benefits of understanding the requirements of the other services, is enormous !! and this type of course gives big opportunities for people to communicate without someones life being in the balance. The time to practice is not when you arrive on the scene of an incident/accident when someone is seriously injured and their only hope of survival is in the hands of the emergency services.
What is the key to a successful response to a Major Incident?
Simplicity. If you make it too complicated, you make great big plans nobody ever reads that great big book when the incident happens. If you keep it simple then you will be able to function better.
What problems can occur with communication during disasters?
We never use Internet or mobile phone in real incidents, because the system becomes overloaded. So we have to have secure radios.
The other advantage with the radio is it is easier to record conversations. So afterwards we can hear and listen to what everybody said at every point. Who made the request? When did the request go through? etc Everything is digitally recorded. If you go on mobile phone is much more difficult to get that evidence.
Describe your own experience working in real life major incidents. Which of them do you remember the most?
Probably the biggest one I remember was the three train crash in London [Clapham Junction rail crash]. We had 39 dead, hundreds and hundreds injured because it was a 9 o'clock incident when people were going to work. That was probably the biggest and it is one of the famous ones.
Some times are memorable for different reasons. I went to lots and lots of bombs in London. People say, “How many did you go to?” So many, I cannot tell you.
Speaking about Ukraine how do you see the situation here? Can a paramedic service be created in Ukraine?
You have to take one step at a time. It is all about systems that have been designed over many-many decades. I think what you have to realize is that you are trying to do things in 2 decades that we took 5 decades to do. That's a big massive step.
What we started back in the 1990s we are now reaping the benefits of. We cannot do this overnight. The standard of the vehicles, the standard of the training of the staff, the technology that we use is star-trek now compared to when I started on ambulance service.
When I look just at ambulance vehicles here, they are no way near the standard of vehicles that we have. The technology just isn't there. But you cannot suddenly produce that. It's going be done in time and it's got be done in a way that everybody is pulling in the same direction and is “on side”.
When we started paramedics, we had the unions which were very against paramedics in the very first instance, because they felt that paramedics were a little too advanced from them. Then they started to realize that it was not such a bad idea.
Now paramedics in the UK are very-very respected and sought after. If it is cardiac arrest in England on the ground anywhere you will want a paramedic, you will not want a family doctor. And the family doctors if we are around they are very happy that we are there. That's just how it is.
Sometimes, I'm not sure, it seems like everybody here (In Ukraine) has to be a doctor or you don't exist.
Where we are it seems that everybody is part of the chain and everybody in the chain is respected from the first responder on the scene, from member of the public who starts doing treatment on somebody, we respect everyone right away, to the surgeons, to the Physiotherapist, to the occupational therapist. That's why the chain is very strong.
Your doctors are very strong, but if the treatment before the patient gets to Hospital is not strong then people are not going to survive. You can be the most intelligent person, but without the right equipment you cannot give the best treatment. That’s a key point of budgets and skill balance comes in.
If you make the entry into the system fairly difficult, you will take people who really want to be there. When they get there they are enthusiastic to become for example a paramedic or a physiotherapist or anything in the health care system. They are very enthusiastic about being part of the health care system.
I see lots of young people here, I see lots of highly intelligent people, I'm impressed with the way that your brains work, for example, how easily you switch languages. You are clever and motivated, but it’s about how you channel yourselves and how you try to develop in the right way.
There are countries that can help you with that. You must search for best practice and best ideas. That's what we did with America the early days. And that's what a lot of countries across Europe and Asia are doing now. We are currently undertaking the Macsim international course, which you can use the tools within the course to develop or test your systems in the Ukraine. The objective will always be to strive for better ways and never stop learning.