What does a typical week look like?
40% is primary care and 60% is on the community car or rapid Response Vehicle (RV) for WAST.
There isn't necessarily a strict definition for what the other 60% looks like so I like to refer to it as a community car because we're not necessarily going to emergencies and things, we're going to really the same kind of patients that we are seeing in the surgeries. So we're going to our often elderly patients with chronic healthcare problems or multiple comorbidity patients, it's seeing that same patient demographic sometimes a little bit later down the line in regards to disease progression or their acute deterioration. With WAST, my management is often very similar, trying to manage them with medications that we carry, and occasionally they will need to go into hospital in the same way as they would if we were in the surgery.
I do two roles really in HPI, I do home visiting occasionally if the team are low on staff simply because they know that as a paramedic it's quite easy to move into that role. But the majority of my time I spend on what's called the same day service, that is any patient who needs an appointment on the day will come through to one of the Advanced Clinical Practitioners. It might be myself as an APP, or one of the Advanced Nurse Practitioners. The way HPI works, every patient that comes through is triaged. So I put it on my list for a phone call or might think, ‘well actually, I know this is going to need a face to face consultation’. I'll have 20 minute slots throughout the day, soon that's going down to 15 minutes. About fifty percent of the time I'll have a chat with the patient and bring them in for a face-to-face appointment later in the morning or in the afternoon. If it's something fairly basic or minor they're able to send photographs or we're able to use a video call. My mornings and afternoons look pretty much the same.
What does it mean to you to work in primary care ?
Our job as an APP is a little bit isolating. Working on the car I don't really get a huge amount of time with colleagues, just sort of asking “ how's your day?” and normal colleague interaction. One of the things that I feel that I get out of this role in in primary care is that interaction with other colleagues and working in a building where I've got my colleagues around me and if I go for a cup of tea, which is normally squeezed in between a couple of patients, I might bump into a colleague and have a chat. I like the interaction of the surgery.
What is special about your profession in primary care?
I think initially I did wonder what do we what we bring as paramedics? One of the GPs says from her point of view she loves the fact that if we have a really poorly patient, she can get us. Some of the GPs, it's been a while since they've worked in a hospital situation or in A and E.
I've got those areas of practice that I feel very comfortable with, like chest pains which are a really common presentation. So when those kind of patients come into the surgery, they are the patients I like to have on my list because I might deal with it slightly differently to somebody who's not so familiar with that, and I suppose I'm probably a little bit more comfortable exploring other causes of the chest pain rather than simply assuming the heart attack until proven otherwise.
What has been your greatest area of learning from primary care?
I think the way in which the system works and that has been so helpful, coming back to WAST. Us paramedics, we don't do hospital rotations, we do a few days here and there so we really don't really learn the way in which the healthcare system works. I'll use an example, something like a DVT. If I was on the ambulance prior to having been in primary care, he's going to hospital and that's all I knew. Whereas now, if you got a DVT, whether I'm on the ambulance or in primary care I now know we've got a specialist DVT nurse on call who I can contact, have a chat with, get their advice, book a specific appointment for that patient. And I'm not clogging up A&E, the patients are not having to go through the process of being triaged again. There's a whole host of examples where I have an understanding of how the system works, I'm able to contact the appropriate person, refer the patient, but also get advice from the appropriate person. I'm quite comfortable now calling up an ENT and speaking to the registrar now. I would never have done that as a paramedic before primary care, it would have been ‘there's something wrong, and you go in’.
Can you describe the role of supervision in your development as an APP in primary care?
It's invaluable. As a paramedic coming into primary care, you have to have supervision. I don't really feel that I would have stuck it out had I not had a port of call, a designated person. It's obviously been a couple of years now, and I don't need as much direct supervision but there is a go-to GP, a duty doctor and I've got pretty good rapport with them.
What plans do you have to develop the role?
I'm just finishing my prescribing qualification now. I really want to consolidate my primary care knowledge, become comfortable in my area of prescribing, that is my goal over the next 6 to 12 months. And then I'm really keen to see the paramedic profession evolving, and be involved in in the development of paramedics coming through into primary care.
What are the 3 key skills essential to your role?
- For the primary care role, time management is number one!
- You've got to have a bit of a thirst for knowledge, you can't cruise because the role of a primary care clinician is so broad, you just have to continually read and I don't think that's ever going to stop. I think even 20 years down the line, I'm still going to be reading up on something every day!
- Accepting and knowing your limitations. When I started in practice, it was quite overwhelming to have the patient come in for example, with a rash. I could assess the patient, and quite quickly get to the get to the point of ‘okay, I've got a well patient’. But I would have this problem where I haven't got a name for this rash. I've realised over time it’s fine just to accept your limitations. Go, ‘I've got no concerns, I'm going to have a quick chat with a colleague’, or ‘let's see if we can book you in next week with one with your own GP’. And that is okay. Your non-emergency rashes and things like that is still a big area of development but I'm starting to like them now because there's loads of resources. Dermatology websites are really visual, those kind of resources have been really, really helpful. As paramedic we love our algorithms, it's always nice to have that backup, a bit of guidance.
What advice would you give to somebody interested in becoming an APP or paramedic in primary care?
Just jump in, go for it, be confident in your decision making. Be confident when you are seeing a patient that you do know how to assess this from paramedic point of view, if the patient is unwell or not. But just be totally aware of your limitations and know when to when to seek advice.
Stats/facts
- Josh works in a rotational role, he is employed by Welsh Ambulance Service.
- 60% – Josh spends 60% of working hours on a rapid response vehicle providing advanced care in the community for WAST.
- 40% - The remaining 40% of working hours are spent in primary care
