A pioneering pathway for pre-hospital emergency anaesthesia
Mark Hodkinson, Consultant Paramedic at Thames Valley Air Ambulance
When we’re by the side of the most severely ill and injured patients in our region, one of the critical skills we can bring to the scene is Pre-Hospital Emergency Anaesthesia (PHEA). It relieves pain, protects vital organs, and helps crews manage a patient’s airway. It’s an invaluable way of stabilising someone so that they are ready for transfer to hospital. PHEA is a complex procedure, but when delivered as soon as possible, the boost it gives to chances of survival and recovery are well-documented.
It’s not something we take lightly. Every PHEA delivered is supported by peer-reviewed clinical guidelines, robust governance, and access to real-time senior on-call clinical advisors. Every year, our clinicians go through a review of clinical competencies which tests their ability to deliver this highly skilled procedure in pressured environments. As a result, our crews routinely exceed the standards for safe PHEA set out by the Association of Anaesthetists.
We always ask ourselves: can we do more?
Traditionally, PHEA has been delivered by a doctor-paramedic team. However, since paramedic registration began in the UK in 2000, the profession has seen exponential growth, with roles expanding into specialist, advanced, and consultant practice across the healthcare sector, including in pre-hospital emergency medicine. Paramedics operating at specialist and advanced levels have demonstrated comparable intubation success rates to pre-hospital doctors.
This expansion was also recognised by the Faculty of Pre-hospital Care (FPHC) in 2016, when it opened the Fellowship in Immediate Medical Care (FIMC) examination to all doctors, nurses and paramedics involved in pre-hospital emergency care. This is the highest formal qualification for pre-hospital practitioners, and its curriculum includes safe delivery of PHEA.
Achieving the FIMC, alongside other qualifications, demonstrates that paramedics can obtain and utilise a high degree of specialist knowledge to safely deliver pre-hospital critical care, including PHEA.
At Thames Valley Air Ambulance, our mission is to do everything in our power to protect, save and revive lives. We want to provide the very best critical care at the scene and beyond. In 2022, I became Consultant Paramedic here, a role that puts us at the forefront of providing highly autonomous pre-hospital critical care.
This isn’t about lowering the bar, it’s about widening the path
As Consultant Paramedic, I am proud to say I am qualified to undertake independent PHEA, when working with another critical care paramedic. Not only is this a first for Thames Valley Air Ambulance, but I am one of only a handful of paramedics known to achieve this level of practice in the UK.
How did I get here? It’s been a long road. The first step was to pass the FIMC and complete the Royal College of Anaesthetists Initial Assessment of Competence (IAC), which is recognised as the first milestone in UK anaesthetic practice, through a placement within an NHS acute trust. This gave me access to supervised anaesthesia practice in a safe and supportive environment.
I then undertook a robust assessment of competence across nine key areas of safe delivery of PHEA. This includes airway management, difficult airways and failed intubation, maintenance of oxygenation and ventilation, maintenance of anaesthesia and pharmacology for PHEA.
There is a long-standing debate in this country over whether paramedics should deliver PHEA. For us, what it comes down to is this: we want to give people within our community the best possible chance of survival and recovery. Widening the path to delivering this critical skill is one way we see ourselves doing that.
We’ve developed a rigorous assessment process, benchmarked against national standards. Getting sign-off to perform PHEA didn’t mean I was unsupported. Every PHEA that I undertake as a Consultant Paramedic involves a discussion with our senior on-call advisors before delivery, and all interventions are monitored within our well-established clinical governance system.
It hasn’t been easy to get here. And that’s the point. The number of paramedics who navigate this route will be very low. The restrictions, advanced training and assessment I’ve undergone reflects just how high the stakes are for this procedure. What matters to us is that patients receive the highest level of care possible, no matter who is on shift that day.
Anything that comes outside of the recognised pathways is always going to raise eyebrows. But we welcome that conversation. We know this approach might seem controversial to some. But, for us, the patient is at the heart of everything we do.
Every hour spent studying, every assessment, every time I’ve had to evidence my skills, is justified by the end result. Every single person who makes it home to their family because of a PHEA delivered by a Consultant Paramedic and critical care paramedic team is proof that this decision has been worth it.
