Preparing for pressure: Behind the scenes of our Foundations in Pre-Hospital Critical Care Course

Kevin Letchford, Clinical Education Manager & Critical Care Paramedic

When a new doctor or critical care paramedic joins Thames Valley Air Ambulance, they don’t arrive as beginners. Each one already has years of experience behind them.

But stepping into the world of pre-hospital critical care is different to the emergency room.

Our clinicians need to deliver complex medical interventions in the toughest conditions, for example a busy roadside; in people’s homes with anxious families looking on; or even in a ditch in the middle of the night.

That’s why we run our Foundations in Pre-Hospital Critical Care (FPHCC) course. I’d describe it as a springboard which helps experienced clinicians adapt their skills to the unique demands of working outside of hospital.

Part of our mission is to empower our critical care paramedics, doctors and the wider pre-hospital community with the knowledge, skills and confidence to deliver consistent and outstanding patient care through innovative education opportunities and lifelong learning.

The course takes place over four days and is designed to develop confidence and competence in managing critically ill or injured patients.

It includes a mixture of classroom-based lectures, practical skills, and simulations which replicate real emergencies. It’s carefully structured so that pressure and complexity increase from day one through to day four, following the principles of the pressure-performance curve.

What is the pressure-performance curve?

The pressure-performance curve is a bell-shaped trajectory that shows the relationship between pressure and performance.

When pressure becomes too much, people’s performance generally begins to suffer. But managed pressure is important for optimum performance – it’s why you often hear elite athletes talking about being ‘in the zone’.

In the world of Pre-Hospital Emergency Medicine (PHEM), that pressure could be the complexity of the injury or illness, the conditions you’re working in, having distressed family members nearby, or multiple distractions.

The course allows new clinicians – or ‘candidates’ – to understand how they respond to stress, helping them to develop strategies to deliver safe and effective care. By the end of the four days, candidates have experienced gradual and carefully managed journey to achieving optimal performance under pressure.

What else are we looking for from candidates?

Being able to carry out skills in hospital does not automatically translate to pre-hospital care. It’s a different skillset with unique challenges.

This course ensures everyone has a shared understanding of the challenges we face and can function as part of our tight-knit team. It’s as much about introducing our culture as it is about clinical ability.

When we evaluate candidates we’re not looking for perfection or the finished article. We fully expect them to get things wrong, because that’s how people grow and learn. The educational culture of FPHCC is designed to make it safe to do that, with teaching and collaborative learning at the heart of it.

Of course, clinical knowledge and skills are vital, but what we’re also looking for is candidates to demonstrate clear thinking, safe decision-making, and the ability to bring the team with them. The people who stand out are those who stay calm under pressure, communicate well, and adapt when things don’t go to plan.

So, how do we put people in situations where they’re learning, but also showing us how they cope under pressure?

The key is to build the pressure gradually.

Day one begins in the classroom, where we introduce the principles of Pre-Hospital Emergency Medicine. PHEM demands more than just clinical skills, it also requires the ability to lead, adapt, and make critical decisions in unpredictable, complex, and resource-limited environments. Candidates also explore how human factors, and coordination with other emergency services can shape the outcome.

On day two, it’s time to put the theory into practice. Candidates have an opportunity to perform surgical procedures we describe as high acuity, low occurrence or ‘HALO’. These include thoracostomy, thoracotomy, surgical airways and the emergency delivery of a baby – interventions which are rare but high-stakes, carried out under high stress situations, when every minute matters.

It’s then time to ramp up the pressure. Day three has the candidates traveling offsite to take part in multiple scenarios designed to replicate real emergencies.

There’s no telling what our crew could face on any given day, so our clinicians need to be ready for any eventuality. We use real data to design scenarios based on call outs they might expect to face within our region. For example, we have over 200 miles of motorway throughout Berkshire, Buckinghamshire and Oxfordshire so we’re regularly called to serious road traffic collisions.

One of the toughest tests this year was exactly that, a scenario where a car collided with a cyclist.

As the candidates arrive at the incident, ambulance paramedics are already on scene helping the patient. The patient is critically unwell and in need of urgent treatment, including pre-hospital blood transfusion.

From a clinical perspective, we’re looking for the candidates to demonstrate safe, structured decision-making, sound clinical judgement under pressure, and the ability to prioritise interventions effectively. We’re looking for high-quality patient care alongside clear communication with the whole team. It’s no easy task.

But as the scenario develops, there’s more than meets the eye.

The driver of the vehicle – clearly intoxicated – is acting frantic and disruptive, adding to the chaos. While our candidates focus their efforts on saving the patient’s life, a cry is heard from a nearby bystander: “there’s another cyclist!” The stark reality emerges that the driver struck not one cyclist but two, with the second casualty obscured by a hedgerow.

This sudden escalation raises the complexity of the scenario, increasing the pressure and forcing candidates to make rapid and difficult triage decisions.

Where possible, we use trained actors to play patients and bystanders. This helps to bring a level of authenticity to each scenario, replicating the emotions, tensions, and chaos of a real emergency.

This is perhaps most evident in one of the afternoon scenarios involving an intentional self-harm where the patient is found by her distressed partner.

Although it’s a simulation, it’s difficult for everyone involved. The realism of the scenario, combined with its emotional weight, can be challenging for candidates, crew, and observers alike.

The experience highlights not only the technical and clinical expertise required for the role, but also the emotional resilience required to manage situations that are both complex and distressing.

It’s precisely this realism, delivered in a safe learning environment, that makes these scenarios a powerful educational tool, preparing clinicians to face the realities of pre-hospital care with skill, composure, and compassion.

Last year, our crew were dispatched to 155 incidents involving intentional self-harm, so it’s sadly the sort of thing our crew could experience in a real emergency.

Each scenario is designed to stretch them. This is where the safety net comes in – the debriefs.

After each scenario a debrief takes place. They help turn those pressure moments into valuable lessons and that is where the real learning happens.

We have a structured model that we all follow, so the process is consistent, constructive and supportive. Each debrief focuses on three things: areas of strength, areas for improvement, and individual learning points that candidates can carry forward.

A big part of our educational culture is making it a genuinely safe space. We expect people to make mistakes; that’s part of the learning journey. It’s about growth, not criticism.

We also give candidates the space to reflect on how they felt in the moment whether they were calm, under pressure, or aware of their team’s needs. That emotional insight is just as valuable as clinical knowledge.

Delivering the course is a massive team effort.

What humbles me most is how people from across the charity and beyond want to be involved. It’s not every day that you see a senior medical director with a mop and bucket, helping to keep the environment safe; or, a volunteer acting as a concerned bystander. But that really captures the spirit of this course – no job is too small if it keeps things on track and creates the right learning space.

This team effort culminates on the final day, where candidates are joined by colleagues from the ambulance service and fire service to simulate a multi-agency response to a major road traffic collision.

The course is deliberately designed so that pressure builds step by step. We start with core principles and straight-forward scenarios, then add layers of complexity until candidates find themselves managing multiple patients in chaotic, unpredictable environments.

The goal isn’t to break anyone or push them to boiling point. It’s about showing them what they can achieve under pressure.

Our clinicians never know what the next call out might bring, but through our Foundations in Pre-Hospital Critical Care course they discover that with the right skills, teamwork and mindset they can rise to the challenge.

The course isn’t the end of their journey, it’s just the beginning. From here, candidates move into supervised shifts, ongoing mentorship, and further training. But FPHCC gives them their first taste of what it means to deliver critical care under pressure in unfamiliar environments, and the confidence to take that next step.