An increase in capability and community expectation coupled with an increase in demand has placed both external and internal pressures on paramedics with discernible similarities between Australia and the UK (Armitage, 2010; Mahtani et al, 2018). Where paramedic performance is measured, paramedic wellbeing has been less considered (Gayton and Lovell, 2012). Ongoing caseloads, daily exposure to human suffering and continual shift extensions or missed meals can cause a physical and emotional toll (Armitage, 2010; Gayton and Lovell, 2012; Mahtani et al, 2018).
A recent review of paramedicine personnel determined that paramedic stress and burnout are among the highest within the emergency service network when compared with police and fire (Maguire et al, 2014; Varker et al, 2018). Further data conclude that ongoing exposure to traumatic events coupled with broken rest can lead to psychological impairment (Bradford, 2002; McFarlane, 2010).
Although resilience in paramedic staff is a testament to the profession's character, the increasing operational demand, lack of apparent regard for operational fatigue management, and ongoing traumatic exposure will likely negatively impact paramedics' capacity to respond with ideal performance (O'Meara and Boyle, 2008; Scully, 2011; Woollard, 2015). The question arises of how to measure these intrinsic factors in paramedics, which might be contributing to fatigue, decreased resilience, and burnout.
The demands of paramedic job performance are influenced by a multitude of factors, many which have not received extensive attention in the literature. What is known is that the demands of this role can be physical, emotional (Blau et al, 2012) and cognitive (LeBlanc et al, 2005), with high rates of injury and many markers of poor health present in paramedics (Sterud et al, 2006; Studnek et al, 2010; Maguire et al, 2014). An as yet underexplored area are the links between job performance, physiological response and resilience. There is also growing evidence that paramedics risk developing work-related health problems such as post-traumatic stress disorder (PTSD) (Sterud et al, 2006; LeBlanc et al, 2011; Halpern et al, 2012) and may not have longevity in their career compared with other health occupations (Rodgers, 1998a; 1998b). This was the impetus for the ‘Fit for Duty’ research project recently completed by the lead author (SM) studying New South Wales (NSW) Ambulance paramedics in this region of Australia.
Research in situ
Paramedic care to the population of 7.8 million people in NSW is delivered by the state government organisation: NSW Ambulance. In the 2015/16 reporting period, the service responded to 1 115 635 requests for service. This was an average of 3048 responses per day (NSW Ambulance, 2016). The service employs over 4500 staff, most of whom are paramedics reporting to work in either of the two distinct geographic rostering areas: metropolitan and regional. Although this research focused on an Australian cohort, the authors acknowledge the distinct operational and clinical similarities within paramedicine in the UK, New Zealand and Australia.
Given the present research on paramedic health, researchers were interested in exploring the following two questions:
Results for the first question were derived from a self-reported survey of NSW Ambulance paramedics (n=747) exploring how they viewed their health status. These results were compared to normative data from the Australian population and have recently been published in the Irish Journal of Paramedicine (MacQuarrie et al, 2018).
Methodology
In developing a methodology to address the second question (does health status affect being a paramedic?), researchers employed a unique approach to studying paramedics' (n=32) physiological responses to emergency calls. Smart textiles (the Hexoskin biometric shirt) were employed to monitor performance (Figure 1).
This examination of the demands of paramedic job performance served to establish a descriptive profile of occupational task performance. Paramedics' heart rate and respiratory rate were continuously recorded before, during and after emergency calls. Self-reported measures of blood pressure and rate of perceived exertion were also recorded. Researchers conducted maximal cardiorespiratory fitness testing on 14 of the 32 paramedics to establish VO2 max and heart rate max.
In a novel approach to researching paramedics, a tri-axial accelerometer recorded levels of occupational physical activity (OPA) (expressed as g-force) during emergency calls (including cardiac arrest calls) and throughout shifts. These data were correlated with calls attended to establish trends and examine linkages to variables (e.g. age, gender, level of certification, body mass index (BMI), shift type (day or night), priority code, and chief complaint using Vivosense software (Figure 2).
Over a 6-month period, these paramedics in metropolitan and regional postings completed over 230 shifts, responding to almost 1000 emergency calls. With part of this project aiming to define the context of paramedic job performance, the data revealed interesting findings not yet explored in previous research on paramedics in situ. Comprehensive findings will be reported on in future articles. For the moment, technology to measure paramedic physiological performance has met a growing willingness to explore paramedic wellness and resilience.
Our modelling identified trends in paramedics that elicit significant physiological changes and an accounting of the occupational physical activity levels. Paramedics on shift may not be as consistently physically active as previously thought, but are still subjected to intermittent physical demands that are significant (for example, CPR performance). It appears that posting, BMI and call type will influence physiology. Importantly, cardiorespiratory fitness appears to have a significant attenuating effect during shifts and calls.
Conclusion
While the operational demands on paramedics are likely to follow contemporary trends and continue increasing, paramedics will continue to respond accordingly to meet this challenge. However, the increase in operational demand, coupled with the ongoing development of advanced prehospital clinical skills places operational paramedics under significant stressors. The intrinsic factors experienced by paramedics are likely contributing factors to fatigue, low resilience and burnout. It is therefore imperative that we understand how paramedics respond physically and cognitively to deal with the demands of the job.
This project has a team comprised of paramedics, paramedic researchers, ambulance service management and exercise physiologists. To fully explore, understand, and inform these findings will take the willingness of these parties in remaining committed to improving paramedic health. Paramedic services and paramedics need to value the health of the paramedic provider and future research must be supported to continue exploration of this complex issue and what it will mean for the future profession and workforce.