Graham

Age at interview: 40

Brief Outline:

Graham has been a research paramedic for six years. He is currently undertaking a PhD about stroke. Graham describes pre-hospital research as a developing area to which paramedics can contribute valuable insights and skills.

Background:

Graham is a research paramedic. He has a very understanding wife and two young daughters. His ethnic background is White British.

More about me...

Graham has been a research paramedic for six years and is now undertaking a PhD. After several years working as an operational paramedic, he started “looking for what else I could do, what else I could get involved in”. This led to a 12-month secondment to work on a randomised controlled trial. This was “a very steep learning curve” as he had had “very little or no research exposure” before. Graham explains that there are major differences between the paramedic world and the research world in terms of “language”, “time scales” and the “way of thinking”. He had no official induction or training on research, so learnt as he was going along. Having good mentors was key to this, although often these individuals were not paramedics by background. When the post finished, Graham was offered another and this continued as “an evolution of one thing which led to another”. During this time, he applied for an NIHR-funded Master’s programme; although his application was unsuccessful, the experience directed him to the areas he needed to strengthen further and he was awarded the funding on the second attempt. Building upon a study conducted through a university research team he had worked with, he was supported to start a PhD funded by the Stroke Association.

In his research paramedic role, Graham has worked on studies about head injuries and chest compressions for cardiac arrest. He has been involved in training frontline paramedics participating in the studies, collecting data, and following up patient outcomes and experiences. Graham has also presented findings at conferences, including from his PhD research. Throughout the time Graham has held research jobs and been undertaking his PhD, he has continued to work as a frontline paramedic. This has been “a juggling act”. His current weekly split is to spend four days on his doctorate and one day in the ambulance service. Continuing to gain frontline paramedic experience is important to Graham in terms of how he sees his identity, maintains his professional skills, and keeps his research relevant. He explains, “If I lose that side, then I lose the reason for doing what I’m doing, I lose the insight into the situation where I’m working”.

Graham describes pre-hospital and paramedic research as a developing area. He suggests that, because paramedics are a rapidly evolving profession and have not previously required university education, there has not been a strong basis to move into research. However, Graham feels passionately that paramedics have a lot to contribute and he is keen to raise awareness of this. For example, he emphasises that paramedics often have good observational and communication skills. They have unrivalled insight into the pre-hospital environment, which is different to the in-hospital environment. In some studies Graham has worked on, he has been a “bridge” between paramedics and academics, for example by using a researcher’s idea to “translate it and sell it to our [paramedic] colleagues” in order for the study to work in practice. 

Graham explains that, “[paramedics] see patients for such a short amount of time and we take them to hospital, or wherever, and then very rarely do we actually find out what happened to them”. Research can give paramedics “insight into what impact your actions, your words, your mannerisms have. It makes you reflect and think about what could I do differently next time, how would I do it better?” but also “the value […] in what we do”. Owing to the nature of emergency situations, Graham has found that many studies involving paramedics require alternative models of consent (“implied or shorted […] but then followed up later”). Some studies entail cluster randomisation, where an ambulance station is randomised to an intervention or control arm rather than individual patients. Graham finds that most paramedics “value the opportunity” to be part of research but some have a preference for the intervention arm owing to the belief that this is an improvement. However, he highlights that the control arm is important because the research is being carried out to produce the evidence base. Graham gives some examples of where standard practices taught to paramedics have been changed or stopped in recent years in light of research.

Graham isn’t sure what is next for him once he completes his PhD but he is keen to explore “hybrid” clinical academic roles. He would like to see paramedic research grow and for there to be a cohort of academic paramedics who can then “help the next generation of researchers to come through”. Graham’s advice to paramedics interested in pursuing research roles is to find people who can offer guidance and mentorship “through the maze” (including about funding). His experience of working in a multidisciplinary research group is that paramedics have valuable insights and can gain from opportunities to “collaborate with people, learn from them, [and] build the contacts” to further research.

Graham talked about the importance of paramedic practice being based on evidence, including the outcomes for patients once in hospital.

For us as paramedic’s, research is quite a new thing. Pre-hospital research in general is quite a new thing, and research led by or involved paramedics is, is a relatively new thing. 10 or 15 years ago it, it really wasn’t happening, so it’s, it’s quite a recent development. So going out and talking to the paramedics, getting them involved, getting them interested, that’s been a bit part of a lot of these studies, now I’m doing a lot more in the background with the data and collecting data and collecting outcome data and linking up our data with patient outcomes, and certainly in my own work there’s been a big element of linking up the pre-hospital data with the in-hospital, ‘cos often we, as I say, we don’t know what happens to the patient, we don’t know the final diagnosis, we don’t know the outcomes. But that’s what we need to actually inform our practice and trying to find those and build those bridges and build those links in, is what allows us to change and judge the effectiveness of what we do. So trying to work in that sort of arena has been a big part of what I’m doing at the minute. 

Graham described research as a “different world” to the one he knew as a frontline paramedic, and this took a lot of adjusting to.

It’s a totally different world. And it’s a totally different, it’s a different language, it’s a different time scales, it’s a different way of thinking. The paramedic, paramedic practice is very immediate, very hands on, very one patient, what’s in front of me, what do I do, what do I deal with it, how, you know, what do I do for this one patient? Take them to hospital. Hand them over. Onto the next one. It, you know, it’s, it’s short, defined chunks of time which, as I say, can be quite charged, not always, but it, it’s very defined points of time. Research is a whole different ball game. There’s a totally different language, there’s a whole different set of laws and regulations, ethics underpinning it, which is, is brand new to us unless you’ve been exposed to it, and actually, thankfully new paramedics are getting some exposure. But when you’re, the paramedic students that I’ve dealt with are concentrating on learning how to deal with the patient – the ethics and the research is a sort of secondary concern to them. But for us, when you get into this, it is a new, it’s a new world and it’s a steep learning curve which is where having that mentorship and those people to guide you through that is very important. But once you get, once you get involved in it then you start to get the hang of it. But you also then start to ask more questions and start to look into things more.

Graham didn’t have any official training when he started as a research paramedic, but he had good mentors who also supported him in pursuing a doctorate.

[Laughs] I went from working my shifts to Monday morning starting in research and ‘right, here you go’. And sort of learnt a lot as I was going, but that’s, I was lucky to have people that looked after me and guided me through that sort of process. And that’s why I think we need more paramedic sort of academics who can then help people to make that jump and get involved and give them an opportunity to get involved in research in a sort of safe and protected way.

I think I’ve been very lucky. I’ve had some very good mentors. Primarily from outside of the paramedic profession. They’ve, I think, shown me that research-, shown me what difference research can make, shown me how-, if I’m going to get involved in it, how I can get involved and who I need to talk to, what I need to do. Because really, I came into this blind with, with no plan, no career plan, no-, it was something interesting and new and I didn’t know where it would lead or what it could lead to. They’ve sort of really taken me under their wing and supported both with development academically for research but also encouraged me to keep involved clinically, and shown me that, through what they’re doing, that this is possible to actually do, and the sort of influence that they have and how they can change things, and hopefully make things better. What you can aim for. So and because of-, there is certain people within our profession who’ve helped and acted in that way as well but, as I say, they are very few and far between. But it’s, [sigh] I think they’ve been, [sigh] they’ve been very valuable, it’s difficult to sort of put into words how valuable they have been. But I really don’t think I’d be doing what I’m doing now, which will hopefully lead onto better things, without, without their sort of guidance and protection and [laugh] mentoring.

Graham described how consent tended to work in paramedic studies.

Consent is a tricky issue for us. The traditional model of consent is based on patients being in hospital, having time to consider the study, you know, read a patient leaflet, I understand and things, you’ve got 24 hours or more to consider it. That doesn’t work for us [laughs]. We don’t give people 24 hours to think about what we’re going to do. So, and I think this is one of the reasons why pre-hospital research is a fairly relative, is a relatively new thing because the models of consent didn’t really exist until relatively recently to let us do that type of research. So, for us, consent is often a delayed-, it’s either a very shortened consent, so in our situation a very short, “We’re doing this, this is the situation, are you happy to be involved? Yes or No.” And then we go down whatever route, and we follow that patient up later on and take a more informed consent. So often the consent is either implied or shortened in our setting, in the emergency setting, but then followed up later on with a more informed consent. And it’s often the option to either have the data, the patients’ data, included or excluded from the study. Some of the situations we work in, such as the cardiac arrests and some of the stroke research we’re doing now, informed consent is impossible. Due to the nature of the conditions we’re studying, at the time. So then there’s other forms of consent in terms of delayed consent or family consent, or there’s various models that have been looked at. But they, they’re again recent developments. So it depends on the study, it depends on the condition, it depends on the patient that we’re talking about. But we do-, they’re all set up to give the patients the options to be included or excluded or to have their data included or excluded. But we have to adapt them to the situation we’re talking about.

Graham felt it was beneficial to continue working as a paramedic whilst he was undertaking his PhD, even though it could be a “juggle” at times.

It was good to be honest, I enjoyed it. ‘Cos I got to do a bit of everything and you don’t-, when you do something all the time, if you’re doing clinical all the time, then you can get burnt out, you can, you know, it can get to you after a while. If you’re doing academia all the time, if you’re studying all the time, that then also takes its own toll but in a different way. Being able to do a bit of both, gives you a relief, you know, when you, when you’ve had a bad day clinically you’ve then got a research day the next day, which gives you a chance to recover. When you’ve had your head buried in the books for a week and you can’t see what you’re doing and can’t think straight, to actually go out and get hands on with some patients and then have to deal with something on that side gives you a relief in a different way and to think about it, and perhaps re-invigorate why you need to go back and do the learning. And I think the two complement each other, if it is a difficult juggling role.

Mm. Mm. Yeah.

But I think that’s something we, we need to develop. We need to develop-, if we want people to go down this route, we need more hybrid type roles, we need this clinical academic role, and that’s something I think we’re only just really sort of exploring.

Through research, Graham has been able to connect up data on paramedic practice with patient experiences. This has potential for future patient benefit and builds the professional evidence base.

It [connecting up data on paramedic practice with patient experiences] makes you think about what you’re doing in a different sense, and it makes you realise what the impact of what you do has in a different sense. ‘Cos we see people for a very short period of time and that could be quite a charged, emotional, intense short period of time and often you’re sort of relying on going back to training, back to your protocols to, very concentrating on, “I’m doing this, I'm doing this, I’m doing this, I’m doing this, I’m going to get them to here,” and then it’s over. And you’re on to the next patient, you’re on to the next job, you do whatever else. And it’s, for you it becomes, you know, another job on another day on another shift. For that patient, that’s a life changing experience potentially and for their family it can be-, their family, their friends, the bystanders, whoever was involved in the situation, it can be a huge event. So actually to be able to get that insight into what impact your actions, your words, your, your mannerisms have. It makes you reflect and think about what could I do differently next time, how would I do it better? What, what would I say or what would I do that would improve this experience, that would make us come across better, that would, you know, your- these experiences don’t all have good outcomes but we can make them better or we can make them worse. But without, without that feedback, without completing the loop, it’s often very difficult to get the insight into what you could have done better. And I think that’s one of the things where research can help, and that’s one of the things where I’ve certainly learnt from having that patient contact and going out and talking to people. 

But I suppose on the flip side of that, it’s also showing some of the good that we can do. And again we don’t often-, it’s not just negative feedback, it’s positive feedback we often lack, ‘cos we do what we do, we hand them over to the hospital and the hospital takes the patient on what, on what could be a short or a long journey [laugh]. And they have whatever outcome they have, but sometimes that can be a very good outcome, sometimes we can have a very positive impact in a situation and it’s nice to hear that as well. And that again can reinforce some of the good areas of practice. And just show the values sometimes in what we do.

Graham would like to continue on a clinical-academic pathway, but was unsure about how to make this work in practice.

I know what I would like to do, how I actually go about making that happen is a different matter. I would like to carry on down the clinical-academic type route I think. The, the experience I’ve had, the contacts I’m making, the-, I think I can-, I’d like to think I can use that to make a difference going forward. I’d like to think having a foot in the ambulance service and a foot in academia allows me to link up people, put people in touch, make things happen, help studies get through, develop more research and also bring more sort of-. Research isn’t for everybody and it’s certainly not, not every paramedic [laugh] is going to be interested and not every paramedic is going to see it as a career like I’m trying to do, but there is people out there who would like to go down that and hopefully I can ease the path for them a little bit and let them learn from the mistakes and the time that I’ve had.

And, you know, help them develop the ideas that they have got. So I’d like to see myself continue going down this route, but that relies on finding a role within the ambulance service and a research or academic role that I can combine to make that happen. And that’s something I’m exploring at the minute.

Graham was grateful for the mentorship he had received. He anticipated that, as paramedic research developed, there would be a cohort of mentors from his own profession.

But also- the big RCT’s that I’ve been involved in, the big studies that has sort of brought me to the position and that have taught me a lot, have all been led by academic emergency medicine doctors or stroke doctors or critical care doctors, you know, academic physicians that have seen opportunities to develop research, and often take from the hospital setting and take the pre-hospital setting, and they’ve mentored people like myself, they’ve developed people like myself. But within the paramedic profession, we have a few senior clinical-, sort of clinical academics that have the, the contacts, the knowledge, the background to do that, but they are very few and far between. And that makes it difficult, so in terms of support we’re, we tend to look outside of our own profession to get people to develop us, and I certainly wouldn’t be doing what I was- what I’m doing now if people hadn’t taken me [laugh] under their wing and sort of helped me and guided me and looked after me to get me to this point. But as things are changing, as we do develop our own academics and our own clinicians and our own research experience, hopefully then we can sort of help the next generation of researchers to come through and sort of set the path and help them and guide them.