Managing complexity and ambiguity.

The theme of managing complexity and ambiguity encompassed challenges with differentiating ABD from other forms of behavioural agitation and weighing up what to do, including identifying the right pharmacological intervention for patients who required chemical sedation.

For example, ‘Eddie’ described trying to differentiate which patients presenting with agitation were potentially experiencing ABD, to determine how they should be managed clinically.

“So I try to engage with the male, […] and it became clear that although the male was having some paranoid thoughts, […] he would have little moments where he would engage with me, and look at me and actually would say something sensible.”

‘Eddie’

Here, ‘Eddie’ sheds light on an important differentiating sign of ABD, the ability to ‘engage’ with the patient and establish if they have a loss of insight. Other participants also referred to the ability to ‘engage’ with ABD patients as a differentiating sign, such as ‘Jordan’ who described assessing how a patient connected with his appearance during one interaction: “…he knows what he’s saying, he reckons I’ve got a big […] your brain is working…”. There is ambiguity in differentiating ABD from other forms of agitation which APs must navigate to make treatment decisions. Participants appeared to find the ability to engage with patients helpful in reducing this uncertainty.

As APs with chemical sedation within their scope of practice, many of the participants were particularly concerned with the decisions they made in relation to this intervention. ‘Pat’ described a case where they used chemical sedation to manage an ABD patient, and this acted as an enabler to good care.

“We had control, literally control of the scene and were able to […] assess him properly. Let’s do a top to toe, check for any injuries, have we missed anything, all the things you’d like to do with these patients, but you can’t ’cause you can’t get near them.”

‘Pat’

The use of chemical sedation here allows ‘Pat’ to ‘literally [take] control’ and creates an opportunity to examine the patient. Prior to the chemical sedation taking effect, the police were in effect controlling the scene, and the combination of agitation and restraint prevented clinical assessment, prolonging the lack of information in relation to the patient’s physiological condition, increasing the complexity of the scenario and heightening the clinical risk. The use of chemical sedation has allowed access to the patient, and thus access to information which in turns begins to reduce the complexity and ambiguity of the incident and assists in determining subsequent ongoing management.

In making restraint decisions, ‘Charlie’ spoke about their concerns in relation to how much information they had about patients’ underlying physiology and how this affected their choices, particularly in relation to chemical sedation.

“What you are doing is […] taking an action, be that physical restraint or chemical sedation to a patient who you’ve got no idea what their baseline physiology is, and you’ve therefore got no idea how they will respond to those agents.”

‘Charlie’

‘Charlie’ is particularly concerned about the unpredictability of the patient’s clinical course which results from a lack of information, and the increased risks which result. ‘Jordan’ was also concerned about this issue, adding that “…you just don’t know how people respond, sometimes you give somebody 5 mg of midazolam, and they’re GCS 3 [unresponsive to verbal and physical stimulus] and need airway management, but sometimes people take 15 mg of that stuff, and they’re still really agitated, really aggressive and fighting the police.” There is an inherent uncertainty here about the outcome of ‘taking an action’ which is an important context for decision-making. APs are making decisions which have serious consequences and are doing so in the knowledge that they have a limited influence of the outcomes.

The above accounts speak to ambiguity of diagnosis. We end with ‘Charlie’ who describes a case in which they were dealing with legal ambiguities and the need to make a defensible decision.

“There is a level of immediacy, there is no least restrictive option and […] the Mental Capacity Act gives us a basis of action […] and we are acting in his best interests.”

‘Charlie’

In this example, ‘Charlie’ has used a systematic and structured approach to work through relevant issues to their decision. This appears to have simplified the decision and reassured ‘Charlie’ that there is a legal basis for restraint, reducing ambiguity.

Feeling vulnerable to professional consequences.

The feeling vulnerable to professional consequences theme incorporates the concerns which participants spoke of in relation to the high-risk nature of these incidents, and what that might mean for professionals should the patient have a poor outcome, in particular concerns relating to medicolegal processes.

In the first example in this theme, ‘Eddie’ recalls a case from early in their advanced practice career where they used chemical sedation, and the patient stopped breathing for a time immediately after the drugs were administered.

“And to this day I can still remember exactly what happened in that case. Because for those few seconds where it looked like she’d stopped breathing, that was absolutely terrifying, because my immediate thought was—I’ve done this. By sedating the patient, and have I given the right drugs, have I made a drug error, have I given too much? And actually, I double checked, and triple checked my drug dosages prior to administering the drugs. And still I thought I may have made an error, but I hadn’t.”

’Eddie’

‘Eddie’ is fearful of the patient coming to harm and their first thought was that they had “killed the patient”. There is an emphasis here on ‘Eddie’s’ actions potentially causing harm to the patient, and a fear so impactful they can recall the incident in detail many years later. ‘Eddie’ appears to focus initially on the potential for personal error, rather than other potential sources of the patient’s apnoea. They express fear and doubt, even though they know that they have followed the correct procedures.

’Eddie’ also reflected on how similar procedures are managed in different healthcare services and added that unlike other clinical settings APs work in relative isolation when chemical sedation is concerned. Whilst a team of ambulance professionals work together to care for the patient, the AP is typically the only clinician there with specialist knowledge and experience of the procedure, concentrating the responsibility on their shoulders—as ‘Eddie’ said, “this is on me.” This perhaps contributes to a sense of professional vulnerability due to a lack of immediate shared decision-making with other clinicians.

’Pat’ was also concerned about managing ABD cases in terms of providing chemical sedation, particularly around the risk of deterioration and how APs would experience associated investigations.

“ABD terrifies me. […]. We know at some point we are going to sedate somebody who will die. And that may be as a result of the sedation or […] they were going to die anyway. But we will never know that. And I fear being involved in that I really do. […] There’s internal investigations to go through. Then there’s an external process. There’s probably a referral to HCPC. […] Thinking that someone at some point is going to uncover something you should or shouldn’t have done. […] It sounds terrible, but this, this could be my last ever job. You know, this could be the job that breaks me.”

’Pat’

There are two key issues here, a fear of a patient dying and a fear around the investigatory processes which would follow that. Firstly, like ‘Eddie’, ‘Pat’ is ‘terrified’ and expresses ‘fear’ about a patient dying. In saying ‘we will never know’ we see that there is an intrinsic ambiguity in causes of deterioration, and this was an important burden for participants. Secondly, the idea of a death creates great apprehension for ‘Pat’, who refers to multiple investigations following such an eventuality. ‘Pat’ also expects a summary or arbitrary fitness to practice referral to the Health and Care Professions Council (HCPC), the regulatory body for paramedics in the United Kingdom and anticipates considerable personal critique and judgement.

Here we see mistrust of the investigatory process itself. ‘Pat’ speculates that video evidence might slightly contradict remembered evidence, suggesting that a trivial inaccuracy might bring their credibility into question in court: “‘… you didn’t do that at ‘52 [minutes past the hour], you did it at ‘53 [minutes past the hour], so how much of the rest of your statement is inaccurate?”. ‘Pat’ appears to be concerned about being vilified and unfairly criticised in an adversarial investigation process.

There is a fear that their career would not survive such a scenario. ‘Pat’ anticipates being “suspended” from duty suggesting that “It’s a very ambulance thing, isn’t it, a very paramedic thing that we associate discipline and error in the same bracket.” This impacts how ‘Pat’ feels about error making, with an emphasis on punishment rather than learning, creating additional fear and anxiety.

In the next example, ‘Charlie’ talks about what they anticipate happening from an investigatory point of view, should a patient with suspected ABD suffer a cardiac arrest in the context of an AP administering sedation.

“When you look at the blood gases of these patients and when you look at their physiology you just realise they are so, so sick some of them. But, we are going to go through that in detail, and we’ll wheel out ‘experts’ who’ve never seen these patients in the community before […] and we will be critiqued to that.”

’Charlie’

‘Charlie’ sheds additional insight into anxiety about the investigatory process. Specifically, what is articulated is mistrust in a process where people who lack APs experience of clinical practice in context, may be wheeled out as ‘experts’. There are two issues here. One is that the authority to critique is placed in the hands of these ‘experts’ and that their lack of relevant experience may be detrimental to the outcome. The second is an implicit failure to recognise and validate APs’ professional identities and their specialist knowledge and expertise.

Not all participants shared ‘Pat’ and ‘Charlie’s’ fear of the investigatory process. ‘Glenn’ below spoke positively about the support they would receive from their employer in such an event.

“I have real confidence that providing I do the right thing at the right time, that I will have a consultant doctor in the form of [a medical director] turn up after me in the court, and say ‘I think that’s about right and that’s what we wanted people to do and this is why’. I wouldn’t do this if I didn’t feel that there was support behind it.”

’Glenn’

‘Glenn’ brings insight about the importance of employer assistance and support. Acknowledging that a serious event may occur where bold after-event employer support would be needed. ‘Glenn’ is confident that their employer would back them up ‘in court’. This confidence is predicated on ‘Glenn’ doing ‘the right thing at the right time’, which is an important caveat given the ambiguity hampering diagnosis and treatment planning highlighted earlier. Our analysis cannot speak to why ‘Glenn’ experiences confidence where ‘Pat’ and ‘Charlie’ do not. It does, however, suggest the importance of employers creating a culture of high psychological safety in which the risks which APs and their patients face are understood, and support is made explicit.

Needing to negotiate with other professionals.

The needing to negotiate with other professionals theme comprised challenges experienced by APs when dealing with police and other ambulance clinicians at the scene of ABD incidents, and focussed on how participants experienced these interactions.

‘Charlie’, for example, attended a suspected ABD case in which the police are already at the scene and found their interactions to be straightforward in this case.

“I said I’m really worried this is ABD, and I’m really concerned about what might be […] the cause of this, and the police officer went, who was the kind of lead officer until the Sergeant arrived subsequently, said to me ‘no I think this is ABD, this is like exactly like the video.’”

’Charlie’

In this incident, ‘Charlie’ connects with the police officer on their clinical concerns, developing a sense of urgency. The police officer validates ‘Charlie’s’ clinical impression. Here, it appears that the sharing of information between professionals has facilitated cooperation, and enabled a helpful relationship based on a shared recognition of the situation, insofar as the patient is an ABD patient for the purposes of management.

In the next example, ‘Eddie’ recounts an incident they attended, in which a patient suspected of having ABD had been subdued by several police officers and was restrained physically, as well as mechanically with handcuffs and leg restraints. The participant suggested to the police that they reduce the level of physical restraint, after which the patient’s agitation reduced.

“That was met with a little bit of resistance from the police. They had had to fight with him quite a lot to get him under control, and there was me saying, ‘right, thanks for all your hard work officers, but now you can let go.’ And there was some concern that obviously he may then become very agitated, and they would have to start from square one in terms of restraint.”

’Eddie’

‘Eddie’ acknowledges the events which have occurred prior to their arrival and understands the consequences for the police if reduction in restraint is unsuccessful–they will have to ‘start from square one’. The police hold an important gate-keeping role here and recognising that their responsibilities and concerns differ from those of APs appears to have been an important factor in fostering cooperation in this situation. ‘Eddie’ goes on to emphasise the importance of providing meaningful explanations to the police: “This is why, and if it goes wrong, this is what we will do. So really explaining to police why I want them to do it, not just ‘do it’.”, echoing the approaches described by other participants.

In the following scenario, ‘Jordan’ has arrived at an incident where a man who has taken a large amount of cocaine and is agitated and is subject to significant physical restraint. During the struggle to bring the man under control, a police officer has been injured and the police are explicit in their expectation that ‘Jordan’ will provide chemical sedation, however’ Jordan’ does not agree that the patient requires this intervention.

“He said ‘we’re not going to stop physically restraining them until you sedate him’. I was thinking I was being coached into chemical sedation and he says, ‘we’ve had you guys out before, we’ve never had this problem before, just give him […] sedation. I said listen, this is me, I’m deciding whether I’m going to sedate this patient. You’re not telling me what to do and at the moment the only thing I think is causing this agitation is you physically restraining him.”

’Jordan’

As in the previous example, there is a dynamic which involves one professional group influencing the actions of another. In this case, it is the police attempting to influence the actions of APs, rather than the other way around as described earlier.

‘Jordan’ withholds chemical sedation because it is not clinically indicated. The police are seeking an alternative to physical restraint in a difficult case, perhaps highlighting the different lenses through which police officers and APs view these events, reinforcing the need for professionals to manage both agreement and disagreement on what course of action to take.

It seems that mutual sharing of information contributes to successful negotiations between professional groups. The establishment of professional connections between professional groups, which respond to different professional concerns and recognises the different ways police and APs view these events fosters cooperation.

Recognising and establishing primacy of care.

The recognising and establishing primacy of care theme encompasses the participants’ experiences of conceptualising the person with ABD as a patient and engaging with their professional duty of care for them. In this first example, ‘Eddie’ talks about the way police and APs as distinct professional groups view ABD patients.

“I think the police can sometimes see them as a bad person, whereas from a clinical perspective, I see these patients as very sick, and this is a medical emergency and actually this person doesn’t really understand what they’re doing…”

‘Eddie’

Here, ‘Eddie’ sheds light on the importance of how the person is categorised, specifically as a ‘patient’ with ABD rather than as a person who is characterised as ‘bad’. ‘Eddie’ emphasises the importance of keeping a focus on patients being ‘critically unwell’ to avoid getting “caught up in this escalation where the patient is getting more and more violent, ’cause then you, you can get angry at the patient…”. ‘Eddie’ is specifically concerned here about how conceptualising ABD patients as ‘bad’ rather than sick might affect how professionals engage with them. They highlight the potential for a vicious cycle of agitation, resistance, and restraint, and are worried that the patient’s agitation will trigger stress and anger within themselves which might influence how they respond to the patient. The professional identity of police and APs again appears to have an important impact on how they interpret ABD patient presentations, and how they respond to them, and it appears that both professional groups have a need to maintain self-control when dealing with difficult cases involving ABD.

In the following example, ‘Aubrey’ describes an incident where police are also in attendance and have commenced restraining a person.

“I’m not a huge fan of spit hoods, I’d rather use an oxygen mask. You know and reminding the police that they’re sick and not bad, and that they are patient not a criminal and you know, just creating that culture on scene.”

’Aubrey’

‘Aubrey’ volunteers a dislike of spit hoods (also known as spit guards), which are available to some UK police officers to protect them from detainees spitting on or at them. ‘Aubrey’ associates spit hoods with law enforcement. In this scenario, the symbolism of the oxygen mask suggests a clinical encounter, whereas the symbolism of a spit hood characterises a policing encounter.

‘Aubrey’ acknowledges that the police have developed their knowledge and approach to ABD patients and suggests that ‘reminding’ police that agitation in the context of ABD is clinically rather than behaviourally driven is helpful. This again characterises the incident as clinical rather than a law enforcement issue and suggests that ‘Aubrey’ perceives that the behaviours of the police may veer towards traditional policing behaviours at times in these scenarios. This appears to necessitate action to bring others back to the shared understanding which will facilitate cooperation between police and APs at the scene. ‘Aubrey’ speaks of creating a clinical culture at the scene, which they indicate might be different than a policing culture, but which facilitates the cooperation of the police and APs around a shared understanding of the person as patient first, and detainee second.

In the next example, ‘Glenn’ describes attending ABD incidents with the police and how they interact at the scene.

“It’s a clinical problem, not a law enforcement problem so typically what happens is, the police in the more extreme cases will send a supervisor. So you find yourself that supervisor, you make sure that their body camera is turned on. You find a couple of ambulance staff. And you get a little huddle together and one of the very early things you say is this is now my problem, and I just need your help to sort the problem out […] I find that once you once you use some very clear explicit language around that to say this is my problem, we can [manage] them under the capacity act, I’m responsible.”

’Glenn’

Here, ‘Glenn’ is positioning themselves as a leader and decision-maker. They establish ownership of the situation and ownership of the consequences. ‘Glenn’ is relieving the police of some responsibility, perhaps serving to alleviate some of their professional concerns regarding potential consequences should the patient have a poor outcome. ‘Glenn’ is presenting themselves as an enabler, in a context where police are concerned about death after police contact and the consequences that brings both in human terms for the patient, their families and the professionals involved, and in relation to the burdens of prolonged investigation. The adoption of a leadership position, taking responsibility for the scenario and clearly articulating what the ‘ask’ is of the police appears helpful in developing cooperation.

Like ‘Charlie’s’ example above, ‘Glenn’ also grounds their decision-making in relevant legislation. This may serve to connect the clinical perspective of the APs with the legal lens of the police and addresses how the responders might justify restricting the patient’s liberty in legal terms. ‘Glenn’ is connecting with the police on common ground, the use of the Mental Capacity Act (2005).

‘Harper’ touched on the issue of more junior paramedics and their interactions with the police.

“If you’ve got an inexperienced member of staff, they’re more likely to be led by the police. […] They may not even know that we should have primacy of care and we can actually say to the police, look you’re restraining him wrong, you need to do it this way or however you want to phrase it. I suppose it goes wider to that societal thing where you always obey police. They were swayed by the police informing them that he was a violent patient, so to be careful, but actually at the time there was quite a lot of police officers restraining him. […] They then just took that for granted even though they didn’t do their own assessment.”

‘Harper’

In discussing their observations of less experienced paramedics, ‘Harper’ makes several attributions in suggesting that they may be easily influenced by police officers. ‘Harper’ attributes a lack of appreciation of who should have primacy of care to inexperience and suggests that wider social norms about obeying the police may ‘sway’ inexperienced clinicians against questioning them. At the point of cardiac arrest, the patient in this case became unambiguously a patient experiencing a clinical emergency which should be clinically led, with policing issues secondary. For ‘Harper’ however, the case was unambiguously a clinical emergency prior to this stage.

‘Harper’ sheds light on the importance of professional curiosity. In this specific case, ‘Harper’ postulates that the paramedics were influenced by the warnings of the police and as a result have not explored the severity of the patient’s illness for themselves, and in doing so overlooked the need to intervene and establish clinical leadership of the incident. Noting this is an attribution, an alternative view might be that the paramedics were respecting the expertise of police in recognising and managing violence.