A decision by the National Ambulance Service to freeze the training of new advanced paramedics is delaying patient care and endangering lives, frontline workers have claimed, Michael McHale reports
For medical professionals, watching the death of a patient is undeniably difficult. Knowing that more could have been done to save that life can be devastating.
In recent weeks Irish Medical Times has been told of alleged instances where potentially life-saving care was either not provided in time, or at all, to those most in need of it.
Healthcare workers have shared stories of colleagues on the frontlines of emergency medicine witnessing patients suffer when the professionals needed to provide critical advanced care weren’t available to treat them in a timely manner.
In one alleged case, a patient who called 999 with a complaint of chest tightness ended up dying of cardiac arrest. While paramedics had arrived before their death, no advanced paramedic (AP) – the only emergency ambulance staff trained to carry out advanced cardiac life support (ACLS) – were on the scene to treat the patient in time.
As well as ACLS, APs have the option to give patients any of 23 medications that paramedics are prohibited from administering. These include sedatives and high-strength pain relief.
APs – who undergo a two-year master’s (MSc) degree on top of the three-year undergraduate course completed by all paramedics – can also carry out a number of life-saving procedures that a paramedic has not been trained to do. These include cardioversion, intubation and intravenous cannulation.
According to HSE figures, in 2023 an ambulance reached 72 per cent of all life-threatening cardiac or respiratory incidents within 19 minutes of the initial 999 call. For other life-threatening callouts, ambulances reached this time target in 46 per cent of cases that year.
But, without an AP on the scene, the time a patient has to wait for a life-saving intervention may be much longer than the time it takes for an ambulance to arrive.
Sources in the National Ambulance Service (NAS) have told IMT of their fears that a shortage of APs actively working on the ground is delaying patient care and endangering lives.
They described another alleged incident where a patient whose heart had stopped went on to experience CPR-induced consciousness while paramedics were performing chest compressions on them.
In response to the pain that the life-saving CPR was causing, the patient began trying to push the paramedics away – something that, if successful, would have removed all hope of survival.
The solution to such a challenge would have been sedation. However, as paramedics are not trained to sedate patients, an AP would be required. A source told IMT that paramedics continued chest compressions – all while the patient fought against their life-saving actions – for 30 minutes before an AP arrived.
While these events were alleged to have taken place in relatively built-up areas, the problem of AP access is further exacerbated by the difficulties faced in reaching at-need patients in remote rural locations.
“I’ve found that, for about half a dozen cardiac arrests over the last few years, I’ve had either no ALS (advanced life support) coming to me whatsoever or have had a delay of 45 minutes to an hour in getting an AP response,” claimed one rural-based paramedic.
He told IMT of cases where patients in severe pain, sometimes living as far as 90 minutes away from their nearest trauma centre, have been left unable to access the high-strength pain relief that only APs can provide in an ambulance setting.
“It’s incredibly frustrating to just watch a patient in front of you suffer when you know that there are interventions that can be done to improve their condition, and you just have to sit there and hope that suddenly an advanced paramedic is going to become available.”
NAS responds to more than 400,000 calls annually, employs around 2,400 staff at 100 locations, and operates 675 emergency vehicles.
According to an internal audit taken earlier this year, there are 417 HSE staff currently working with the service who are registered as advanced paramedics. The majority were trained to this standard by NAS in programmes accredited by University College Cork.
However, since early 2023 NAS has stopped training new advanced paramedics, and the last internal AP recruitment took place in 2021.
The healthcare workers who spoke to IMT outlined how, since then, they have seen many colleagues with this qualification move into jobs that don’t involve emergency ambulance call-out duties, while others who have retired or resigned from the service have not been replaced.
Irish Medical Times asked NAS how many of its trained APs are actively responding to emergency calls as the core part of their job, but did not receive a figure from the agency.
Despite APs operating under clinical guidance from the Pre-Hospital Emergency Care Council (PHECC), the HSE told us that there is no specific advanced paramedic employment grade.
Instead, a new grade of ‘specialist paramedic’ has been created ‘to address how staff with MSc-level education are employed and deployed to meet patient needs’.
Among this group are critical care paramedics, the majority of whom work in inter-hospital ambulance transfers of patients, and community paramedics, whose aim is to treat, outside of the ED, lower-priority patients who do not need the higher levels of treatment that APs can provide.
“Health services in Ireland continue to see a considerable growth in older patients with more 999 patients needing interventions and clinical decisions which are not within the scope of practice of either paramedics or advanced paramedics,” a HSE spokesperson said.
“In this context, PHECC has developed a Framework for Community Paramedicine in Ireland while NAS has prioritised education capacity on both growing the paramedic workforce to improve access for patients, and the development of community paramedics who have the capacity to treat patients in the community setting and thus avoid an unnecessary ED attendance.”
In a January meeting of PHECC, members were informed of two complaints made around the non-availability of AP training, as well as a number of TDs who voiced concerns on the issue.
According to minutes from the preceding PHECC meeting last December, the council noted the ‘decline’ of APs on its register of pre-hospital healthcare workers and said that the matter will be ‘considered for inclusion’ on its risk register.
Another paramedic told IMT that he is now regularly submitting reports to the HSE National Incident Management System (NIMS) after experiencing adverse events where he believes patient care has been compromised by the lack of an AP.
“I’m throwing in a few NIMS (incident reports) every month – things like ‘the patient needs this type of care, needs a drug, or needs some kind of intervention that I can’t give’,” he said, before claiming that the reports ‘seem to be falling on deaf ears’.
“The HSE is so patient safety-driven – that’s why I can’t understand. If I didn’t give a patient a drug as a paramedic – an insufficient drug, or pain relief – they (management) would be coming down on me for that,” he added.
“The calls where you’re waiting on an AP and you’re looking at someone dying, and you know you can give an intervention… it’s quite hard.”
Several ambulance stations operate work rosters by partnering up paramedics with APs on shifts. However, due to AP shortages, paramedics are often left without a corresponding AP and are instead partnered with other paramedics.
IMT has been told of a significant number of stations across the country where the percentage of rostered emergency ambulance staff who are APs is as low as 10-15 per cent. A number of stations appear to have no APs rostered on any shifts.
As a result, APs have often felt the need to respond to emergency incidents when not on duty, particularly if they have access to a rapid response vehicle.
However, a recent instruction by NAS management for staff not to bring work vehicles home out-of-hours – in response to a benefit-in-kind dispute with the Revenue Commissioners – threatens the continuation of this practice.
In some cases where a family member is with the patient, paramedics working alone have had to explain to them why the medical interventions they can take to help their loved one are so limited.
“Mostly the general public doesn’t understand what a paramedic and what an advanced paramedic can do, so they’re none the wiser,” one ambulance worker said. “But anyone who is clued into pre-hospital care knows that there would be other options available to help improve their care.
“Especially with pain relief. If you’ve got a patient in front of you that’s screaming, even with entonox or penthrox, but they’re still in large amounts of pain, they themselves know that surely there’s more that can be done here.
“I’m having those difficult conversations where I’m telling the patient that I’m going to make a call on the radio and see if I can get anyone with a higher clinical level than myself to come out and give them something additional.
“Then I’m having to report back to the patient afterwards and tell them that, unfortunately, there is no one available, so they’re going to be in pain until we get to the hospital.”
In recent weeks the future framework for NAS, including the training opportunities open to paramedics, has been the source of industrial relations discussions.
NAS Director Robert Morton
In response to a parliamentary question from Sinn Féin TD Máire Devine in February, NAS Director Robert Morton highlighted the advanced paramedic allowance of just over €11,000 per annum which staff with the qualification receive.
“The cost of advanced paramedic education is significant with staff historically receiving an allowance equivalent in excess of 20 per cent additional pay, resulting in considerable competition for course places,” he said.
“The HSE has informed the representative trade unions that there is a need to strengthen the deployment of existing staff with specialist skills to match patient requirements before any consideration can be given to increasing the number of staff with such training.
“The work to do this is encompassed within a broader pay dispute, which is the subject of a WRC (Workplace Relations Commission) facilitated conciliation process, currently underway.”
At time of going to press, a deadline of March 26 had been set for unions and NAS to agree on a framework – including a revised pay package – under which paramedics will operate in the future. If an agreement is not reached by that date, SIPTU has said that it will ballot its members for industrial action.
In its statement to IMT, the HSE said the outcome of the WRC talks “is expected to enable a re-calibration of educational priorities, including the commencement of an MSc in Specialist Practice (Community) programme in September 2025 and an MSc in Specialist Practice (Advanced) programme in September 2026.”
However, SIPTU representatives are of the view that AP training should have continued while talks were underway and are concerned that the pause in providing courses has created a deficit within the pre-hospital care system. They hope that the two-year masters course can be restarted sooner to address this issue.
Sinn Féin TD Claire Kerrane
Meanwhile, Sinn Féin TD Claire Kerrane has received assurances that healthcare workers trained as APs outside of Ireland will soon be facilitated to work for NAS and have their previous qualifications recognised through specially-run short courses.
“I had been made aware of four or five lads in Connacht that were fully trained APs, but they were trained outside of Ireland, so they couldn’t work here” she said. “The privileging courses (to allow them work as APs here) had been paused.
“I did get a commitment from the HSE and the National Ambulance Service that they would do a privileging course in the first quarter of this year.”
Ms Kerrane has been raising concerns in the Dáil around a lack of APs in Roscommon for almost two years but has been left frustrated by the level of engagement with her concerns by Mr Morton.
“He doesn’t respond to any letters, or anything, at all. I’ve been writing to him for two years now and it’s just frankly a nightmare.”
Ms Kerrane believes that an appearance by the NAS director at a meeting of the next Oireachtas health committee may provide some much longed-for answers.
“That’s maybe a way we can draw him out a bit, because he is doing things very differently, and a lot of paramedics don’t seem very comfortable or happy.”
In his February response to Máire Devine, Mr Morton referred to a recent analysis of AP deployment, which he said, “identified that while the number of patient contacts has increased, the level of patient benefit is not commensurate with the level of investment.”
When asked if any patient deaths in the last decade could be attributed to a lack of trained APs, he said NAS is ‘unable to speculate on the cause of death of patients who are not in cardiac arrest (clinical death) at the time of a 999 call but subsequently present to the arriving crew in cardiac arrest’.
He added: “The only true correlation between whether an intervention MAY (his emphasis) have prevented death, i.e. a preventable death, is where the coroner makes such a determination. NAS has never received such a determination.” 