Paramedics have similar aims within their various job roles—to provide emergency medical assistance that preserves a patient's life until definitive care is available. Because of the global need for emergency medical care, paramedics are known to be able to work almost anywhere in the world. Prior to the opportunity of an international placement, I was unaware of just how versatile this role could be and how different practices could be across countries and environments. The opportunity to experience international paramedicine not only offers a unique paramedic education, but also adventures abroad and the chance of new experiences.
As a third (final) year student on the BSc Paramedic Science course at St George's University of London, the prospect of an elective placement was unique and sure to be an incredible once-in-a-lifetime experience. The criteria allowed students to organise any type of placement, anywhere, providing it would offer a new and different learning experience. I immediately knew I was going to take this opportunity to learn about how prehospital care differed in an international setting. After careful consideration of all potential placements, language, insurance, similarity of scope of practice and feasibility, I chose South Africa and was off on a 3-week journey with five other final year students from St George's University.
Student placement in Johannesburg
The placement consisted of working alongside a leading private ambulance service within the city of Johannesburg, as well as shifts within a government-run hospital emergency department. I was able to complete 120 hours of work, and encounter a vast range of patients, as well as become exposed to situations I would potentially never see, even working in the metropolitan city of London UK.
Working with the service, my time was spent mostly on their response vehicles (RVs) with some time on the ‘bus’ (ambulance). To enhance our exposure to emergency medicine in South Africa, I spent a few shifts in the emergency department (ED) of one of the main government hospitals in Johannesburg. Despite being a leading hospital in the city, however, it had limited resources, equipment and staff.
Working in Johannesburg provided exposure to a vast range of calls and patients—several of which I had yet to experience working with the London Ambulance Service (LAS) and some which are considered common calls for an ambulance to attend no matter where in the world you work. The variety of patients I attended, included motor vehicle accidents (MVAs), stabbings, major head injuries, assaults, chest pain and seizures. In the next section, I present two case studies of patient scenarios I attended to while on placement.
Case study 1: car hijacking
While working on an RV from the private ambulance service, we were dispatched to a gunshot wound; we had no other information relating to the patient's age or state of injuries. En route, we passed an incident where there was a crashed car, and another ambulance service whose staff were beginning to provide treatment to a patient with a gunshot wound. Because of the similarity of the call description, we were unsure if this was our call; however, we followed our satnav and proceeded another 500 m down the road. Upon arrival at the second incident, we were confronted with a chaotic scene of abandoned vehicles, multiple casualties, unknown location of the assailants, a couple of emergency service vehicles and a group of more than 50 spectators.
As a result of the lack of scene management and the large amount of resources from varying medical providers, as well as other local security agencies blocking access to the patients, our mentor was unable to get very close to the scene. Both myself and a fellow student were sent from the car to go and assist the other emergency medical staff while our mentor secured the scene and parked the RV. There were two patients, both of whom were police officers with gunshot wounds. We proceeded to treat the more seriously injured patient, joining colleagues who were first on scene. Our patient had a gunshot wound to the lateral posterior aspect of his pelvis, with the exit wound in his junctional zone. Rapid management of the patient's time-critical injuries was undertaken; through haemorrhage control, intravenous (IV) access was gained. Ketamine and IV fluids were administered; the entry wound covered with a transparent dressing; and the patient immobilised on a spinal board. We then loaded the patient into an ambulance and proceeded to convey him to a local level 2 trauma centre.
Patient conveyance presented with additional challenges and attempting to reverse out the scene caused unforeseen delays. Although this job was of high acuity, the management of the patient provided by a multi-agency team was impressive—even more so in light of the surrounding situation and scene, which was still volatile. The location of the offender who had caused the injuries was unknown and there was a vast number of spectators who had the potential to be involved—this was an ongoing incident which we later discovered caused further destruction through the city of Johannesburg. However, it did highlight the importance of whole-scene management and how easily everyone can become task-focused, leaving aspects of the situation such as patient extrication and scene evacuation unmanaged.
One of the biggest differences in terms of patient management on placement in contrast with our experience was that in a similar situation in the UK, we would not even gain access to the patient until the police had assured the safety of the medical professionals in attendance.
Case study 2: intoxicated or head injury?
A patient was brought to the government hospital ED from a local township by ambulance during the early hours of the morning. At the time of admission, the patient was intoxicated by alcohol and stated that he may have been involved in an assault. The patient was combative throughout his time in the ED, and by 9 am, he had not received any treatment or pain relief as he was agitated, refusing treatment and the staff was having difficulty managing his behaviour.
The patient had multiple visible maxillofacial injuries and wounds to his scalp. However, there was minimal history of how the injuries were sustained. Myself and a fellow student gained IV access with translation help from a local student, while the doctor prepared a suturing kit. With a bag of saline running through and a dose of propofol, the doctor began to suture the wounds to the scalp. During suturing, it was discovered that the patient had obviously present skull fractures. After completing the sutures to the patient's scalp, it was at this point that the doctor ordered for the patient to be added to the morning's computed tomography (CT) list. Shortly after, the patient was given another dose of propofol, which had a very rapid effect, causing him to need some oxygen therapy and close monitoring. Rapidly, the facial wounds were assessed, where the nasal bone was seen to be visible and the doctor closed all wounds. Later that morning, the patient was sent to CT, where the results showed three depressed skull fractures. The patient received monitoring while he awaited further assessment and treatment.
During this time, he began to experience haematemesis and increased confusion. The patient may initially have had indications of being severely intoxicated, with obvious indications such as the strong smell of alcohol; but this particular experience highlighted how diagnostic overshadowing and a patient's presentation while intoxicated can affect their clinical assessment and treatment.
Contrasting with previous anecdotal experience in the UK, a patient with this history of presenting complaint, mechanism and injuries would be treated in a Resus (area of the ED for the most time-critically unwell patients) of a major trauma centre where maxillofacial specialists are available.
Transcultural awareness
Prior to this elective placement, I was aware there would be some international differences, mainly as a result of varying community needs and different healthcare systems.
One of the key differences I noted was in major contrast to the UK was the number of ambulance service providers. In the UK, we are fortunate to have the National Health Service (NHS), which is a publicly funded national healthcare system providing free health care to anyone who needs it. In the prehospital setting, this allows for standardised regional ambulance services to respond to all emergency calls, with minimal use of private ambulance services.
Similarly to the NHS, South Africa also has a government healthcare system and ambulance service; however, we soon became aware of how this is an understaffed and underfunded service with minimal available resources. The contrast continued with the uniformed patient fee schedule, where a patient's health care is chargeable and categorised dependent on their income, private healthcare cover and referral type.
This aspect of health care in South Africa was one that all of the UK students took time to adapt to as we were required to ask our patients about their medical aid (similar to insurance) and cover levels, prior to even assessing or treating their medical needs. The type of cover they had also impacted upon which hospital (private or government) we could take them to. This adds a dimension to the work of a prehospital clinician. It also often seemed to increase the time on scene while searching for the medical aid number to find out if we could take the patient; whether their cover included transport; and to which hospital we were able to take them. It often felt quite strange having to hand over a patient to a government ambulance purely owing to the level of cover their insurance provided.
The number of different ambulance services, both private and the government, was a huge shock when compared with those available in the UK. Within the cities of Johannesburg and Pretoria, a vast number of companies provide emergency medical care, some having only one or two RVs.
When attending to a call, it was quite common for there to be multiple ambulance services and lengthy discussions about who is responsible for the patient and who will convey. It is also common for a recovery truck to be on scene prior to any ambulance, fire or police response when attending MVAs, which adds to the complications of scene management.
As expected, there were also many differences with the equipment carried by prehospital clinicians. This varied greatly from little things, like the style of their cannulas and their gloves/personal protective equipment (PPE), to the size of their ambulances. There were many different bits of kit to adapt to, yet also many components that were the same as ours in the UK. Adapting to using cannulas that were the same as intramuscular needles in the UK was very useful as it really tested our technique. A further contrast was with their defibrillators and monitoring: the ambulances had a much simpler monitor than the RVs, and even though the RVs have the same model of defibrillator (LIFEPAK®15), we were surprised by the use of paddles as opposed to pads for defibrillating a patient.
The South African paramedics and emergency care practitioners (ECPs) also had a much larger variety of drugs within their scope. Sometimes, however, they had less autonomy in those they could give. A key example of this is with morphine; within the UK, there is very strict drug control of morphine and a paramedic can only carry 20 mg, which is assigned to the paramedic at the beginning of the shift and signed back in at the end. In contrast, the South African paramedics and ECPs have their morphine assigned to the vehicle, often carrying quadruple the amount permitted for a UK paramedic. There are also many drugs licensed and carried by paramedics in South Africa (e.g. magnesium sulphate, ketamine, rapid sequence intubation (RSI) medications, vast quantities of morphine) that will hopefully be transferred across to UK prehospital care, allowing further options for prehospital management (though scope of practice also differs across countries).
Paramedics in South Africa have increased responsibility for the entire scene in contrast to paramedics in the UK. A paramedic would be responsible for the management of not only the patient, but the entire situation. For example, securing the road at an MVA would generally be managed by the police in the UK; in South Africa, the paramedic would place out cones, divert the traffic, and also be responsible for the helicopter landing if required.
The opportunity of an elective placement has facilitated our transcultural awareness of prehospital and emergency medicine. I would highly recommend exposure to international prehospital medicine as it has many benefits.
This placement has enhanced the importance of communication as I was in the minority who only spoke one of the 11 official languages in South Africa. This allowed me to experience the position of quite a few of the patients we treat in London and also facilitated the use of alternative communication methods; for example, the use of images for communication and the emphasis on non-verbal communication. These new perspectives on communication have provided encouragement to all of us to transfer this broader knowledge to our future practice in London.
This experience has also increased my confidence and abilities in trauma management and scene safety. This was further supported by the calmness demonstrated by the mentors in South Africa in the stressful situations encountered. The higher occurrence of major trauma and serious incidents in South Africa facilitates an increased level of confidence in their paramedics in those situations. This is something I hope to translate to my practice as a paramedic in the UK.
In the following section, four of the five students who accompanied me on the elective placement described in this article share their personal perspectives of the experience.
Fellow student perspectives
Natalie Cole
‘The invaluable opportunity to arrange an elective placement in Johannesburg South Africa working with a private ambulance company and to contrast work in an ED in a Government hospital has been an excellent experience. It is safe to say that each day I was pushed to my limits and exposed to relentless emergencies that were treated as regular calls to attend to, which were of a completely different calibre in terms of their management and urgency to those I experience in the UK. These varied from stabbings, shootings, road traffic collisions and car hijacking through to panic attacks and chest pain. Working with a private ambulance company in such a hostile and challenging environment really has increased my clinical competence as a student paramedic. I wanted to amplify my skills and knowledge gained over my 3 years at university to enhance my experiences as a newly qualified paramedic and can say it was hands down the most exhilarating yet terrifying placement to be on. ‘
Karishma Purmessur
‘Having chosen to go to South Africa for my elective placement, I was initially nervous but knew that the experience would be beneficial for my clinical practice. I chose South Africa to step outside my comfort zone and push myself to be more confident in high acuity cases. My placement in Johannesburg gave me an insight into how the healthcare system not only differs from that in the UK but also varies within the country between government and private hospitals. I saw a range of trauma jobs including road traffic accidents, stabbings and gunshot wounds, which I was able to get hands on experience in treating, which has been invaluable. I believe this elective placement has given me the ability to handle stressful cases with more ease and made me more confident while out on placement in London and eventually as a newly qualified paramedic.’
Richard Teare
‘During my time in South Africa, I had a unique opportunity to experience health care from a private company setup, where the patient's insurance, or lack thereof, depicts which hospital that patient is transported to. There were numerous opportunities to experience high mechanisms of trauma including multi-casualty road traffic collisions, multiple gunshot wounds, stabbings and falls from height. Demographics of the patients ranged from the rich, who had everything, to those with nothing in the townships, usually all in the same town. This degree of variety in a country with simply jaw-dropping beauty was an attack on the senses. Some aspects were remarkably similar, however, such as each clinician's desire to provide the highest possible level of care to every patient they encounter with a heart-warming level of passion and a reminder that clinicians all over the world are fiercely proud of what we do.’
Grace Harris
‘The importance of learning from clinicians who work in varied fields cannot be underestimated. The high level of training the paramedics receive in South Africa showed me just how far the profession has the potential to go. Having also spent some shifts in a government ED, where supplies were short and I had to adapt my practice to using the equipment available, this further showed the country's difference in wealth. The work the paramedics in South Africa do is both dangerous and inspiring. My appreciation for the NHS has doubled since this experience. If you have the opportunity, either as a student or as a paramedic, I can't recommend more highly the value there is in experiencing your profession outside the comfort zone that is home.’
Future directions
I am looking forward to arranging a similar placement for future students and aim to create an exchange programme for paramedics to experience international paramedic practice. Hopefully in the future, I will be able to spend time working in South Africa as a paramedic.