Introducing medicalstudents to prehospitalcareMaryam Ahmad and Dane Goodsman, Barts and the London School of Medicine andDentistry, Queen Mary University of London, London, UKEmma Lightbody, Northampton General Hospital, Northampton, UK

SUMMARYBackground: Studies show thatprehospital care is an important,yet often neglected part of themedical undergraduate curricu-lum. Thus, the Prehospital CareProgramme (PCP) was introducedat Barts and the London School ofMedicine and Dentistry in 2008,aiming to expose medical under-graduates to this unique area ofmedicine.Context: The programme makesuse of the links between themedical school and the LondonAmbulance Service (LAS) and theLondon Air Ambulance (LAA), andplaces students from Bachelor ofMedicine and Bachelor of Surgery(MBBS) years 2–5 with mentors

from these services during a seriesof working shifts. During shifts,students are assigned a set oflearning objects and are in-structed to complete a speciallydesigned Student Report Form foreach case that they observe.Students are recruited onto theprogramme at the end of MBBSyear 1 through the submission ofa CV and a written application.Shortlisted candidates are inter-viewed and those that are suc-cessful are invited to join theprogramme at the beginning ofMBBS year 2.Innovation and implications:Interest in the programmehas increased exponentiallysince it was introduced in 2008.

It appeals to medical studentswho are enthusiastic aboutthe field of Emergency Medicineand Prehospital Care, and offersthem a unique opportunity toenhance their knowledge andexperience. It also encouragesstudents to develop genericskills, communication skills,interprofessionalism and recordkeeping.Conclusion: The PCP is a suc-cessful and immensely popularaddition to the MBBS curriculumat Barts and the London School ofMedicine and Dentistry. We hopeto observe and continue to sup-port similar replications at othermedical schools.

Prehospital careis an important,

yet oftenneglected partof the medicalundergraduate

curriculum

Communitylinkages

168 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 168–172

INTRODUCTION

The majority of British doctorsare not exposed to prehos-pital care during their train-

ing, and yet at some point in theircareer many doctors will have todeal with a medical emergencyoutside of the hospital environ-ment. Many doctors, both newlytrained and those who have beenqualified for many years lack theknowledge and experience of thespecific challenges faced in aprehospital environment. Theseinclude: safety; assessment; treat-ment; and patient transportationto an appropriate facility.1,2

One study reported that, whenasked, only 52 per cent of medicalstudents considered their trainingto be adequate enough to enablethem to provide an effectiveresuscitation service as juniordoctors.3 Another literature reviewstudy concluded that medical stu-dents would benefit from ‘a case-based’ approach in prehospitalcare learning, as it ‘stimulates andunderpins the acquisition ofknowledge, skills and attitudes’.4

At Barts and the LondonSchool of Medicine and Dentistry,a third-year medical studentrecognised this niche in theundergraduate medical curricu-lum, and proposed the idea ofdevising a Prehospital CareProgramme (PCP) open to allmedical undergraduate studentsthat would, in a structured man-ner, expose them to this uniquefield of medicine. Each student onthe programme is placed with aLondon Ambulance Service (LAS)or London Air Ambulance (LAA)mentor during their usual workingshifts, where they will see anumber of cases. For each patientattended the student completes aStudent Report Form (SRF) that isdiscussed with, and signed off by,their mentor. The LAS mentors areselected by our lead paramedic,and the LAA mentors are selectedby our lead clinician. Every stu-dent is assigned one mentorwhom they complete shifts with

for the year. All LAS mentors areable to undertake the same tea-cher coaching programme offeredto the doctors. The programmeinvokes ‘experiential learning’theory, which sees learning as aholistic, process-based endeav-our, in which students are activelyengaged – not just cognitivelyengaged – with the integratedfunctioning of the whole experi-ence, including thinking, feeling,perceiving and behaving.5

CONTEXT

DevelopmentThe programme was developedwith the assistance of seniorfigures from the medical school,LAA and LAS, who defined thelearning objects (we refer to learn-ing objects as opposed to learningobjectives, as we could not specifywhich of the items, or at what level,the students would be required toperform) and devised the course,using the relevant sources in theirrespective departments.

Initially a pilot programme wasdesigned and launched in 2008,and as a result of positive feed-back, the programme has had a fullintake of 10 students for the last2 years (2010 and 2011). Sincethe launch, the programme hasattracted increasing interest notonly from medical students butalso from paramedics, emergencymedical technicians and doctorswho are keen to become mentors.

Structure of the programmeStudents in their second year ofthe Bachelor of Medicine andBachelor of Surgery (MBBS) courseare placed with LAS ambulancecrews (usually one paramedic andone emergency medical techni-cian, EMT), in third year the stu-dents are placed with an LASparamedic in a fast-response unit(FRU), in fourth year they areplaced with LAA and in their finalyear they have the opportunity tocontinue working with any of theirmentors upon agreement withthem. Alongside the shift-basedwork, students are required tocomplete a variety of writtenassignments and attend AcademicForums, Clinical Governance Days(CGDs) and LAA team meetings – allof which support and reinforce theknowledge that they gain whilst onshift with their mentors.These attachments are outlinedin Table 1, which also includes theminimum number of shifts andmeetings to be attended each year.

The programme is incorpo-rated into the MBBS course as aseries of linked Student-SelectedComponents (SSCs) throughyears 2–5. The student is assigneda specific time frame by themedical school within which tocomplete their SSC: this variesaccording to the year that theyare in. Our experience has shownthat most students completemore shifts than the minimumrequirement.

The programmeinvokes‘experientiallearning’ theory

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LearningAfter a case, the student mustcomplete an SRF for each patientseen. This covers a range ofinformation, as shown in Figure 1.

Following this, the studentsdiscuss the learning objects seenwith their mentors. Table 2 showsa list of common conditions thatstudents will encounter, dividedby speciality and subspecialty. Wehave listed these as learningobjects in the PCP student hand-book, and thus students mustkeep a record of each time theseare witnessed.

The learning objects cover awide range of medical emergen-cies, encompassing Medicine,Surgery, Psychiatry, Paediatrics,Obstetrics & Gynaecology, Ortho-paedics and Trauma. This diversityreflects what the students arelikely to experience whilst onshift during the course of the PCP.Students will re-visit the samelearning objects as they progressthrough the programme, allowingthem the chance to further con-

solidate their knowledge andunderstanding.

Additionally, once studentsenter year 4 of the MBBS andbegin to undertake shifts withthe LAA team, they will witness agreater proportion of traumacases than when working with theLAS, and thus there are further

LAA knowledge objectivesassigned. These are outlined inTable 3.

The PCP offers an opportunityfor students to learn about basicmonitoring and investigations,and to become confident with theinterpretation of the core inves-tigations listed below.

Table 1. PCP attachments by year

MBBSyear Attachment

Minimum numberof shifts

Minimum numberof LAA D&Dmeetings

Minimumnumberof LAACGDs

2 LAS crew(usually 1paramedicand 1 EMT)

6 1 0

3 LAS FRU 8 2 1

4 LAA fastresponse cars

8 3 2

5 LAA fastresponse cars

No minimum –projectto be agreed withmentors

Optional Optional

CGDs, Clinical Governance Days; FRU, fast-response unit; LAA, London AirAmbulance; LAS, LondonAmbulanceService; PCP,Prehospital CareProgramme.

Figure 1. Student report form

Students willre-visit the

same learningobjects as they

progressthrough theprogramme

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• Electrocardiogram (ECG)12-lead set-up andinterpretation.

• Blood glucose.

• Pulse oximetry.

• Respiratory rate.

• Blood pressure.

• Temperature.

• Pulse rate.

• Oxygen mask selection andset-up.

• Nebuliser set-up.

In addition to this, the pro-gramme gives students thechance to practise and enhancetheir communication and inter-professional skills.

RecruitmentAll students are introduced to theprogramme during their inductionweek in year 1 of the MBBS. They

are informed about the structure ofthe programme and are invited toattend monthly academic forumsthat will give them more insightinto what the programmeoffers.

Towards the end of MBBSyear 1 all students are invited toapply to the programme by sub-mitting a CV, written applicationand signed records of theirattendance at the academic for-ums. Shortlisted candidates areinterviewed. Candidates that aresuccessful at interview are invitedto join the programme at thebeginning of their second year.

Recruitment onto the pro-gramme is limited to a maximumof 10 per year group: this isbecause of the limited number ofLAA observer slots, a great num-ber of which are filled by theirown trainees and LAA electivestudents.

INNOVATION ANDIMPLICATIONS

Interest in the programme fromboth students and mentors hasincreased exponentially since itbegan in 2008. This is demon-strated both by the increasingnumber of applicants and also bythe number of students atacademic forum meetings, whichhas increased from 10 students in2008 ⁄ 2009 to 140 students in2010 ⁄ 2011. In addition, thesemeetings are regularly attendedby LAS paramedics and doctors.

The PCP appeals to medicalstudents who are enthusiasticabout the field of EmergencyMedicine and Prehospital Care,and offers them a unique oppor-tunity to enhance their knowl-edge and experience. Theprogramme provides learningopportunities related to a widearray of issues in the prehospitalcare setting. These include scenemanagement, patient evaluation,appropriate interventions andanticipation of the clinicalcourse. The PCP also introducesmedical students to record keep-ing in a supported and relevantmanner.

Currently we are unable to saywhether the programme has anynegative effects, as we have notencountered any at this stage. Weare engaged in analysing whatstudents actually experience, interms of learning objects, andwhether they feel increasedconfidence as a result of theprogramme.

The PCP team has been keento gain feedback from both stu-dents and mentors about theirlearning experiences and skillsgained. The feedback receivedhas been overwhelmingly posi-tive, and useful suggestions toimprove the course have beenreceived and implemented. Inrecent years the PCP has becomesignificantly oversubscribed,which has resulted in the

Table 2. Common conditions encountered inprehospital care

1 Cardiology

Cardiac arrestTachycardias and bradycardiasMyocardial infarctionDifferential diagnosis of chest painOther, e.g. congenital cardiacabnormality

2 Respiratory

AsthmaCOPDAnaphylaxisPneumothorax

3 Metabolism

Diabetic emergenciesKidney stonePoisoning – drugs and alcoholOther, e.g. vomiting

4 Neurology

Cerebrovascular event –haemmorhagic ⁄ ischaemic

Differential diagnosis of decreasedconsciousness

Differential diagnosis of seizureOther, e.g. reduced limb sensation

5 Obstetric

Imminent birthMassive obstetric haemorrhageMiscarriageOther, e.g. suspected ectopicpregnancy

6 Surgery

Differential diagnosis of acuteabdomen

Head injuryHaemorrhage control andmanagement

Other

7 Psychiatry

DepressionSchizophreniaSelf harm and suicideOther, e.g. drug-induced psychosis

8 Orthopaedic

Limb fractureBack painOther, e.g. suspected cervical spineinjury

COPD, chronic obstructive pulmonary disease.

The programmegives studentsthe chance topractise andenhance theircommunicationand interpro-fessional skills

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development of a new programmewhere students are assigned2-week placements with the LASmentors: this is called the LASSSC, and enjoys the same levelsof success as the PCP. The PCPdevelopment team have beenactively involved in supportingsimilar developments at othermedical schools in the UK. Theprehospital care structure differs

significantly across the UK, butthe approach to learning and thementorship demonstrated by thePCP are transferable. In additionto this, the PCP resulted in theinitiation of student representa-tion on the Executive Council ofthe British Association ofImmediate Care Schemes(BASICS), providing a centralresource that can be accessed

online through the BASICSwebsite, for interested studentsacross the country.

CONCLUSION

The Prehospital Care Programmewas initiated by a small team ofenthusiastic and committed indi-viduals, and has now become asuccessful and immensely popularaddition to the MBBS curriculumat Barts and the London School ofMedicine and Dentistry. We hopeto observe and continue to sup-port similar programmes at othermedical schools.

REFERENCES

1. Allison KP, Kilner T, Porter KM,

Thurgood A. Pre-hospital care—the

evolution of a course for undergrad-

uates. Resuscitation 2002;52:

187–191.

2. Porter KM. Training doctors in pre-

hospital care: the West Midlands (UK)

approach. Emerg Med J 2004;21:509–

510.

3. Graham CA, Guest KA, Scollon D.

Cardiopulmonary resuscitation. Paper

1: A survey of undergraduate training

in UK medical schools. J Acc Emerg

Med 1994;11:162–164 (doi: 10.1136/

emj.11.3.162).

4. Williams B. Case based learning a

review of the literature: is there

scope for this educational paradigm

in pre-hospital education? Emerg Med

J 2005;22:577–581.

5. Kolb A, Kolb D. Learning Styles and

Learning Spaces: Enhancing

Experiential Learning in Higher

Education. Academy of Management

Learning and Education. 2005;4:

193–212.

Corresponding author’s contact details: Maryam Ahmad, Barts and the London School of Medicine & Dentistry, Queen Mary, University ofLondon, Garrod Building, Turner Street, Whitechapel, London E1 2AD, UK. E-mail: Maryam_ahmad_89@hotmail.com

Funding: None

Conflict of interest: None

Ethical approval: The NHS Ethics committee for our trust deemed that the study ‘‘qualifies as Service Evaluation and so will not require

Ethical Review or registration with us’’. Signed permissions were gained from each student on the programme to allow use of data from

their report forms for our study. No individual student is identifiable.

doi: 10.1111/j.1743-498X.2012.00528.x

Table 3. The London Air Ambulance (LAA) learningobjects

LAA learning objects (for students in MBBS years 4 and 5)

Crush syndrome Head injury

Road traffic collisions Spinal injury

Maxillofacial injuries – bleedingcontrol and airway management

Chest injury – blunt and penetrating

Gunshot wounds Burns

Electrocution Major incidents

Drowning Extrication and workingwith other services

Hanging Management of fractures

Fractures and dislocations Rapid sequence induction forintubation

Amputation Thoracostamies and chest drains

Table 4. Applicants to the PCP by year

2008 2009 2010 2011

Number of applicants N ⁄ A 6 40 40

Number interviewed N ⁄ A 6 15 15

Number successfullyrecruited onto the programme

3 5 10 10

PCP, Prehospital Care Programme.

The approach tolearning and the

mentorshipdemonstrated

by the PCP aretransferable

172 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 168–172