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Abstract
Background Paramedics are often first providers of care to patients experiencing non-traumatic low back pain (LBP), though their perspectives and experiences with managing these cases remain unclear.
Objectives This study explored paramedic views of the management of non-traumatic LBP including their role and experience with LBP management, barriers to referral and awareness of ambulance service guidelines.
Design Qualitative study using semistructured interviews conducted between January and April 2023.
Setting New South Wales Ambulance service.
Participants A purposive sample of 30 paramedics of different specialities employed by New South Wales Ambulance were recruited.
Results Paramedic accounts demonstrated the complexity, challenge, frustration and reward associated with managing non-traumatic LBP. Paramedics perceived that their primary role focused on the assessment of LBP, and that calls to ambulance services were often driven by misconceptions surrounding the management of LBP, and a person’s pain severity. Access to health services, patient factors, defensive medicine, paramedic training and education and knowledge of guidelines influenced paramedic management of LBP.
Conclusion Paramedics often provide care to non-traumatic LBP cases yet depending on the type of paramedic speciality find these cases to be frustrating, challenging or rewarding to manage due to barriers to referral including access to health services, location, patient factors and uncertainty relating to litigation. Future research should explore patient perspectives towards ambulance service use for the management of their LBP.
- PUBLIC HEALTH
- Primary Health Care
- PAIN MANAGEMENT
- ACCIDENT & EMERGENCY MEDICINE
- Hospitals
Data availability statement
Data are available upon reasonable request.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study is reported in accordance with the Standards for Reporting Qualitative Research and included a multidisciplinary research team of individuals with backgrounds in qualitative research, psychology, paramedicine, chiropractic and physiotherapy.
The study recruited three types of paramedics—standard paramedics, intensive care paramedics and extended care paramedics—to explore different perspectives between paramedic specialities for the management of non-traumatic low back pain (LBP).
Three researchers performed data analysis to ensure consistency and consolidation of themes, to reduce misrepresentation and to minimise researcher bias by including researchers from different clinical backgrounds.
We noted thematic saturation during data collection via participant interviews, though recruitment was driven by the inclusion of a diverse sample of paramedic specialities.
The study findings may be impacted by selection of paramedics who were interested in managing non-traumatic LBP; additionally, participants were recruited from one state jurisdiction in Australia, which might impact the generalisability of the study findings.
Introduction
Internationally, non-traumatic low back pain (LBP) is an increasingly common presentation to ambulance services.1 2 Consequently, paramedics are often the first providers of care for people with LBP. Australian guidelines for paramedic management of LBP recommend the use of simple analgesia, hot/cold therapy and for people to remain active.3 4 Additionally, guidelines recommend that paramedics refer people with LBP to primary health services including medical centres, general practitioners and allied health services such as physiotherapy, chiropractic and pharmacy.3 4
Despite ambulance service guidelines, one-third of LBP presentations to Australian hospital emergency departments (ED) arrive by ambulance.5 If these patients are admitted to hospital, they are more likely to receive costly low-value care including lumbar imaging, opioids and surgery, compared with those managed by primary health services.5–11
Paramedics are often tasked with having to manage a broad spectrum of conditions ranging from lower acuity musculoskeletal conditions (eg, non-traumatic LBP) to higher acuity, emergency situations (eg, cardiac arrest) that require immediate decision-making pertaining to patient care. The need for quick action according to the severity of a person’s complaint and the urgency of care that is required may interfere with a paramedic’s ability to provide best care (eg, education, promoting physical activity and exercises). However, from a value-based healthcare perspective, comanagement of non-traumatic LBP (ie, non-serious LBP) by paramedics and primary healthcare clinicians (eg, general practitioners, physiotherapists, chiropractors and pharmacists) is crucial to reduce the burden on ambulance service resources and ED.12 13 At a patient level, factors such as patient compliance with paramedic recommended care pathways and patient expectations of care delivered remain a challenge for paramedics to be able to provide evidence-based care for LBP.14
Previous research has evaluated the use of pain medicines and non-pharmacological care strategies such as heat therapy and transcutaneous electrical nerve stimulation as effective alternatives to manage acute LBP by paramedics, though translation of non-hospital and at-home management strategies in the out-of-hospital setting is limited.15 Paramedics have reported inappropriate ambulance service use by patients with LBP suggesting that lack of knowledge of the health system and barriers to accessing healthcare services are key factors for using ambulance services.12 16 Furthermore, paramedics from within ambulance services have suggested that key performance indicators (such as time on scene and rates of conveyance), access to health service facilities and level of training influence paramedic decision-making towards patient care for LBP.17
This study aimed to provide an understanding of paramedic perceptions towards managing people with non-traumatic LBP including: their perceived capability to care for people with LBP, barriers to referring people with LBP to non-hospital care, awareness and influence of paramedic guidelines for LBP and possible solutions to avoid taking people with non-traumatic LBP to hospital. Gaining an understanding of perceptions of paramedics managing people with LBP is a vital step in improving the quality of care in the prehospital setting.
Methods
This qualitative study is reported in accordance with the Standards for Reporting Qualitative Research.18
Design
This qualitative study used semistructured individual virtual interviews via Zoom (Zoom Video Communications, USA) to explore paramedic perceptions and experiences towards managing people with non-traumatic LBP and used a phenomenological approach to describe lived experiences of paramedics. The study involved a multidisciplinary team including qualitative and LBP researchers (from public health, behavioural science and psychology), a New South Wales (NSW) paramedic clinician and a paramedicine academic who provided regular commentary to promote reflexivity.19
Setting
NSW Ambulance serves a population of approximately 8.1 million people and employs over 5000 paramedics who respond from over 230 stations including metropolitan, regional, rural and remote locations across NSW, Australia. NSW Ambulance receives over 1.1 million emergency calls via triple zero annually and responds to nearly 1.3 million cases (including emergency and non-emergency cases).
Participants and recruitment
Participants were registered paramedics employed by NSW Ambulance who were active in the workforce. NSW Ambulance credentials paramedics as non-specialist general paramedics or specialist paramedics. Specialist paramedics include extended care paramedics and intensive care paramedics. Extended care paramedics are specialists in the assessment and management of low(er) acuity complaints and have increased capability to treat patients at their home or within the community.20 Intensive care paramedics are specialists in the assessment and management of high(er) acuity (eg, life-threatening presentations) with increased capability to manage time-critical cases and provide advanced life support typically only provided in hospitals.3
A multifaceted strategy was used to ensure a diverse range of paramedic clinicians were recruited. This included advertising via state-wide employee email lists and through active snowballing with assistance from participants. An expression of interest form was distributed via email and included a QR code and uniform resource locator that directed participants to study information including consent to be contacted by the research team regarding participation, and a survey to collect participant characteristics. One researcher (SPV) reviewed the collected participant characteristics and invited a diverse sample of paramedics by clinician type, work location, age, experience, training in LBP management, number of cases of LBP managed each week and interest in managing LBP cases, to be interviewed. Recruitment ceased when 30 paramedics—10 general paramedics, 10 extended care paramedics and 10 intensive care paramedics—had been interviewed. This approach was used to explore the perceptions of each paramedic speciality towards managing non-traumatic LBP.
Data collection
An interview guide was developed by the research team and reviewed by two qualitative researchers (TC and KP), and NSW Ambulance paramedic (PS) (online supplemental material 1). Topics included paramedics’ experiences and feelings towards managing non-traumatic LBP, their perceived role and approach to management, barriers to patient referral, understanding and awareness of current paramedic guidelines, and potential solutions to improve management of non-traumatic LBP outside of hospital. Interviews were conducted between January and April 2023. Interviews lasted on average 45 min, were audio recorded and transcribed verbatim.
Supplemental material
Analysis
Data were inductively analysed thematically using framework analysis to understand clinicians’ experience and perspectives.21 22 Framework analysis uses a matrix approach whereby rows reference the cases (ie, participants) and columns depict themes, providing a structure to systematically analyse themes and cases.21 23 The first step following transcription involved one researcher (SPV) reviewing the transcripts and developing a list of emerging topics and/or themes. Identified topics and themes formed the basis of the coding framework. Two researchers (TC and KP) independently read a subset of transcripts and generated lists of codes and themes to ensure the framework was comprehensive. The three researchers then discussed, consolidated and revised the framework. One researcher (SPV) coded all interviews into the final Excel framework and codes were aligned with themes and subthemes. The coders then discussed their findings in depth with the framework revised accordingly to ensure that all prominent themes were identified and understood contextually. In order to ensure trustworthiness of our findings and to execute reflexivity throughout the research process, an interview guide was developed to capture relevant data from paramedics, interviews were audio recorded to establish accurate accounts of participant experiences and perceptions and a random subset (10%) of interviews were double coded by researchers (TC and KP) to ensure consistency, reduce misrepresentation and to minimise researcher bias due to having different clinical backgrounds.24 25
Patient and public involvement
NSW paramedics were invited by NSW Ambulance service to participate in this research following Human Research Ethic Committee approval. Paramedics were informed of the duration of time required to be interviewed. The research questions were developed with assistance from the Director of Research at NSW Ambulance and one paramedic clinician to improve the understanding of the management of non-traumatic LBP. The experiences and views from paramedics informed the results of this paper. The published study results will be disseminated to NSW Ambulance to distribute to the workforce. In addition, these results will be sent to included paramedics who were selected to receive study results.
Results
Participant characteristics
Thirty paramedics were interviewed consisting of 10 extended care paramedics, 10 general paramedics, 7 intensive care paramedics and 3 dual qualified paramedics (extended care paramedic and intensive care paramedic specialities). Over half of the participants were men (n=17) and paramedic ages ranged from 22 to 58 years and included paramedics stationed in metropolitan (n=22) and regional/rural/remote (n=8) settings in NSW. Participant characteristics are reported in table 1.
Characteristics of included participants
Overall, the paramedic’s accounts demonstrated the complexity, challenge and frustration associated with managing non-traumatic LBP cases. Paramedics perceived that their primary role was to determine the severity of LBP, to administer analgesia, to provide education, to facilitate patient mobility and to provide transport to hospital. A summary of paramedic interview quotes is provided in online supplemental material 2. We organised the findings into four overarching themes: (1) the management of non-traumatic LBP, (2) barriers to patient referral, (3) knowledge and awareness of guidelines and (4) solutions to improve management of non-traumatic LBP outside. Most paramedics had limited knowledge and awareness of current paramedic guidelines and identified gaps in guidance surrounding low-acuity musculoskeletal management.
Theme 1: the management of non-traumatic LBP
Paramedic views towards managing non-traumatic LBP
All paramedics across the different specialities recognised that non-traumatic LBP cases were common presentations to ambulance service and acknowledged that while ‘it’s a lot easier if you just take everyone to hospital, that’s not always what’s best for them, or the ED (paramedic 21—extended care paramedic)’. Extended care paramedics reported receiving additional training in LBP management that gave them more confidence in managing these presentations. Half of the general paramedics and most intensive care paramedics interviewed described receiving little additional training in LBP management, yet often find themselves managing these presentations with much less knowledge than extended care paramedics.
Almost all general paramedics and intensive care paramedics reported managing non-traumatic LBP as ‘frustrating’ or ‘challenging’. Most general paramedics and intensive care paramedics suggested that the amount of time required to manage these cases within their assigned case-cycle time was challenging. Intensive care paramedics acknowledged that while some LBP cases ‘may be someone’s emergency’ (paramedic 30—intensive care paramedic), they described feeling frustrated that they had to manage time-consuming, LBP cases, making them unavailable to respond to incoming high-acuity emergencies such as cardiac arrest, that they receive additional training to manage.
It’s a complicated call out for us because obviously people are in pain and want a solution to their pain. But it’s also a call out that can be managed outside of hospital (paramedic 17–general paramedic)
Extended care paramedics described managing non-traumatic LBP presentations as ‘challenging but rewarding jobs’ (paramedic 25—extended care paramedic). They reported non-traumatic LBP cases to be time-consuming and mentally exhausting jobs due to the amount of reassurance and education required to manage these cases within the community. They also recognised non-traumatic LBP presentations as ‘quite rewarding jobs when you can avoid an unnecessary hospital presentation with effective management’ (paramedic 5—extended care paramedic) and ‘when you have the patient up and walking and see that they’re much more comfortable’ (paramedic 25—extended care paramedic).
The paramedic role
Most paramedics described their role was to determine the type and severity of LBP, to manage a patient’s pain by administering analgesia before deciding on an appropriate pathway for care, and to prioritise patient education. Extended care paramedics reinforced that ‘education’ to be key in the successful management of non-traumatic LBP. This involved educating patients; on the role of extended care paramedics and managing patients within the community, on signs and symptoms of serious pathology versus mechanical LBP, on management strategies including: medication use, exercises and stretches and alternate referral pathways for continuity of care.
Education. Trying to educate people about why it’s important and why it’s (LBP) not dangerous and why they need to follow the steps that you're telling them to really does take a lot. But I think that’s also the most valuable thing, teaching them how to cope so that they feel like they have the tools to continue on with their daily life (Paramedic 24—extended care paramedic)
Interestingly, some general paramedics and intensive care paramedics suggested that their role was to ‘provide analgesia and transport to ED’ while other general paramedics and intensive care paramedics reinforced the use of education, reassurance, importance of mobility and referral to general practitioners and medical centres as their key role in the management of non-traumatic LBP.
It’s at this level, the general duties that we're very limited in our assessment. I would argue that they're pretty poorly equipped to assess the back. And probably not overly motivated to do it, so dose the patient up with pain relief and transport them to ED (Paramedic 8—general paramedic)
The majority of paramedics across the different specialities reported building patient rapport, developing trust and having open discussions on LBP management strategies to be part of their role in the decision-making process regarding patient care.
There’s a huge amount of liaison with the patient and discussion about risk versus information versus reward for them and figuring out what’s best practice for them. I mean, the patient needs to feel that they have power in their prehospital journey (Paramedic 10—extended care paramedic)
Paramedic perception of why patients with non-traumatic LBP use ambulance services
Nearly all paramedics agreed that the most common reason for people with LBP to use ambulance services was due to lack of education and understanding of how to manage their LBP and to access health resources. For example, paramedics described their patients believing they needed to go to ED to have their back ‘fixed’, to receive medication and imaging, or to ‘bypass the ED waiting room’.
I do find it always comes back to that lack of education they call an ambulance…But that’s in their mind, that’s their perception. If they call an ambulance, they’re going to get a stretcher and they’re going to get X-rayed, and CT, you know, they just want an answer. They want a quick fix and an answer or a diagnosis (Paramedic 6—extended care paramedic)
Other common reasons for using ambulance services were due to pain severity and immobility experienced by the patient, the use of government-concession cards allowing free ambulance use, and due to psychological aspects associated with their LBP.
They are fearful and worried. They think that they've broken their back, and they think that they might actually be paralysed. A lot of them are really scared doing movement is going to cause damage (Paramedic 18—extended care paramedic)
Less commonly reported reasons to use ambulance service were due to a persons’ living arrangements (ie, living alone), having no access to transport, or due to family involvement in patient care. Paramedics also suggested that family members were responsible for calling ambulance services because they were distressed by seeing their loved ones in pain.
You know, elderly, living on their own, no family to assist, and no means of transport (Paramedic 2—general paramedic)
Strategies for managing LBP
All paramedics reported patients’ experience of pain, their medical history and their ability to move to influence management strategies.
Almost all paramedics acknowledged that some form of analgesia was provided to non-traumatic LBP presentations to reduce pain and to facilitate movement. Most paramedics recognised the use of opioids such as morphine as a ‘last resort’ for non-traumatic LBP. General paramedics and intensive care paramedics reported that administered opioid medication influenced referral pathways for patient care, often resulting in transport to ED.
I think the classic approach that you would see would be potentially some layered pain relief, paracetamol, ibuprofen, and methoxyflurane seems to get used quite often (Paramedic 29—intensive care paramedic)
A clear distinction between the different specialities was the use of methoxyflurane to facilitate movement. General paramedics and intensive care paramedics often suggested using methoxyflurane as an effective strategy to get the patient moving quickly to assist with extrication. Additionally, they described key performance indicators such as time on scene, that is, the amount of time a paramedic is recommended to be on scene with a patient, as a factor that influenced their management strategies.
So generally, the ambulance services KPIs are that you should be transporting within 30 minutes of being on scene or moving to make a decision (Paramedic 17—general paramedic)
Alternatively, extended care paramedics were able to spend ‘as much time as required’ with patients allowing paracetamol and ibuprofen to take effect while providing patients with education, reassurance and exercises to manage their LBP. If paracetamol and ibuprofen were ineffective at managing a person’s pain, extended care paramedics were able to administer methoxyflurane or opioids such as oxycodone due to their access to a wider scope of medications.
Regarding non-pharmacological strategies, some paramedics described how their experience and confidence in managing non-traumatic LBP drove their management strategies, for example, ‘empowering the patient’ (Paramedic 24—extended care paramedic) and ‘equipping them with the tools’ (Paramedic 25—extended care paramedic) to be able to manage their own complaint.
Despite not having access to heat packs themselves, most paramedics encouraged patients to use heat (eg, heat packs, hot shower) if accessible, and many paramedics acknowledged that their inability to access heat was a barrier to being able to provide best-care practice. All extended care paramedics and some general paramedics and intensive care paramedics reported including light exercises and getting the patient walking in their management.
We don’t have access to heat packs, but this is something that’s come into my practice more recently, and that was based on seeing what they do in ED when I would turn up with patients with non-traumatic LBP, the first thing that the ED would do, they’d break out these little instant heat packs that they could stick on to someone’s lower back, but ambulance don’t provide anything like that (Paramedic 27—intensive care paramedic)
Theme 2: barriers to referring patients to non-hospital care
Accessibility to health services and location
Paramedics from all qualifications reported that accessibility to health services was driven by ‘time of day’ and ‘geographical location’. Paramedics responding to complaints outside of business hours (Monday–Friday; 09:00 to 17:00) reported having no access or ability to refer to community health services to assist in patient management due to most medical centres or allied health services being closed, and that ED—a 24-hour service—was their only available alternative. Additionally, paramedics working in rural/remote settings reported difficulties with getting patient appointments with local doctors due to lack of general practitioner access and availability.
The wait time and the time of day are the primary issues. Just because time of day, like I said, outside of business hours, it’s not really possible. And wait time, look that week to three-week mark, depending on which surgery you're talking about is a significant issue (Paramedic 12—general paramedic)
Paramedics insisted that they were restricted in their ability to supply sufficient medication to bridge the gap between paramedic visit and a patient’s appointment with a health professional. For example, an extended care paramedic who has a wider scope of accessible medications to manage non-traumatic LBP can leave a patient 30 mg (six; 5 mg tablets) of oxycodone, ‘that should tide them over for up to two days’. Outside of this window, the patient has no access to pharmacology to help manage their LBP.
Most paramedics recognised allied health professionals to be an appropriate referral option for patients with non-traumatic LBP; however, there was uncertainty as to whether they could directly refer to these health services. Many paramedics suggested that referral to allied health services was encouraged by ambulance service, though it was often a secondary referral that was initiated by the patients’ general practitioner.
Patient factors
Paramedics across all specialities identified patient expectations, patient compliance and the associated costs of allied health service use as a barrier to referring LBP cases. Paramedics frequently reported patient preconceived ideas including ‘the need to be taken to ED to be fixed’ (paramedic 17—general paramedic), that ‘they called an ambulance because they wanted to be taken to ED’ (paramedic 1—general paramedic) and that they ‘need imaging’ (paramedic 5—extended care paramedic) as a barrier to alternate referral pathways. Extended care paramedics suggested patient accountability for their LBP was a significant barrier to referral.
When you’re putting it back on the patient, you’re arming the patient with information and a pathway that they can go to, it’s up to them to do it. So, if they're not prepared to do it; if they come up against an obstacle, often they give up (Paramedic 22—extended care paramedic)
Additionally, extended care paramedics reported that use of alternate referral pathways such as referral to a primary care clinician (eg, general practitioners) was determined by the patient’s acceptance, trust and compliance with extended care paramedic advice.
I think the management of LBP seems to be focusing around reassuring them, motivating them, kind of hitting the right medication or medication regime, and then making a plan. A lot of that depends on getting them moving and a lot of that depends on how well you can reassure them. Make them feel safe. Cause they're quite scared and they're in pain (Paramedic 18—extended care paramedic)
Extended care paramedics also described recommending allied health services to patients but suggested that many patients ‘don’t have the money to spend on these services’ or ‘they don’t want to spend money on these services’ (paramedic 22—extended care paramedic).
Defensive medicine
Paramedics described the perceived risk of litigation and uncertainty surrounding litigation to be a barrier to referral. General paramedics and intensive care paramedics reported feeling capable of initiating referrals to other health services, though they raised uncertainty surrounding litigation as to who would be liable if an incident was to occur during transport to non-hospital health services. General paramedics and intensive care paramedics acknowledged that if they were unsure on the appropriate referral decisions or if they needed to make a quick decision regarding patient care, that the ‘safest option was to transport the patient to ED’. (Paramedic 30—intensive care paramedic).
I think the baseline for when two paramedics and a crew don’t agree with each other (regarding patient care), the baseline’s always going to be whatever choice is ultimately the safest option. And the safest option is generally going to be hospital in that instance because you know, the patient’s going to be attended to with the highest level of clinical care and they're going to be supervised from as soon as you finish with them (Paramedic 30– intensive care paramedic)
Alternatively, extended care paramedics mentioned that they needed to be able to validate their reasoning towards patient care and their referral decisions, and in some instances, this became a barrier to referral itself.
As an extended care paramedic, because our risk mitigation algorithm is so powerful, you really have to look at everything else. In order to not take them to the ED, they've called triple zero (Australia’s main emergency service number), they're obviously in enough pain that they want an ambulance response. If you are not going to take them to ED, you need to be able to validate why, and not just for the reason they called, but for every other reason they have (Paramedic 10– extended care paramedic)
Theme 3: knowledge and awareness of guidelines
Twenty-seven paramedics (out of 30) were aware that ambulance service guidelines for LBP existed in the extended care paramedic pathway, though most general paramedics and intensive care paramedics acknowledged that they did not know the specific recommendations within the protocol as it is outside of their scope of qualification. Most extended care paramedics suggested that the protocol had positively influenced the management of non-traumatic LBP presentations as it provided clinicians with confidence in determining the type and seriousness of LBP to initiate appropriate referrals within the community.
I think, in the context of extended care, they’ve really heightened the assessment process in that we quickly can determine whether these patients probably should go to hospital versus those that we could definitely manage at home (Paramedic 5—extended care paramedic)
Some extended care paramedics believed that the ‘back pain’ protocol could be improved as it only provides a ‘basic structure’ to management. Almost all general paramedics and intensive care paramedics mentioned that due to the inability to use the extended care paramedic ‘back pain’ protocol they revert to the ‘pain management’ protocol to manage non-traumatic LBP presentations. While they report that the protocol gives them confidence in administering pain medications, there is no specific guidance for managing LBP presentations.
I would say initially, very poorly, as a general duties paramedic—There’s not much in guidelines for lower back pain. It’s not until you get into the extended care paramedic role that you get guidance on treatment and referral (Paramedic 8—general paramedic)
Most general paramedics and intensive care paramedics reported that if it was possible, they would often try to phone an extended care paramedic to ask for guidance and advice regarding the management of non-traumatic LBP presentations. Few paramedics were aware of current non-ambulance guidance for managing acute LBP such as the NSW Agency for Clinical Innovation model of care for acute LBP.26
Theme 4: solutions to improve the management of non-traumatic LBP
Paramedics identified many opportunities to improve the management of non-traumatic LBP, a big part of which they viewed was to reduce ED transport. Paramedics suggested that better access to community health services and better interdisciplinary care between general practitioners, medical centres, paramedics and allied health professionals would improve the management of non-traumatic LBP presentations. Additionally, they recognised the development of more 24-hour care centres or virtual health options to assist in managing non-traumatic LBP cases outside of business hours and on weekends.
Better access to more community health centres could drastically reduce the amount of low acuity presentations appearing at ED (Paramedic 7—extended care paramedic)
Paramedics across each of the specialities recognised that having an increased scope of medications to effectively manage musculoskeletal complaints would improve the management of non-traumatic LBP. For example, numerous participants described that having the ability to administer stronger non-steroidal anti-inflammatory drugs would bridge the gap between the use of paracetamol and ibuprofen to methoxyflurane and opioids.
I think Ketolorac would be really good. Like a stronger anti-inflammatory. But we don't have access to that prehospitally, so I just have to use what I have (Paramedic 21—extended care paramedic)
Paramedics identified health promotion on LBP management strategies as a key opportunity to improve patient education and understanding on LBP, and to reduce misconceptions and preconceived ideas that non-traumatic LBP is an acute emergency that requires transportation to ED and imaging.
I think that is probably education through a general practitioner is probably a really important starting point, and I just don't think that enough patients have access to that (Paramedic 26—intensive care paramedic)
General paramedics and intensive care paramedics acknowledged that while LBP is a common presentation to ambulance services there is a need for further education and training for the management of low-acuity musculoskeletal conditions.
Things like if we had the availability of heat packs, and better training and education as paramedics in terms of stretches or movements that will assist somebody to be able to mobilize better. Because at the moment I don’t feel that I’ve got a good grasp on the best way to be providing non-pharmacological management of these patients (Paramedic 27—intensive care paramedic)
Discussion
Paramedics often manage non-traumatic LBP cases, yet their experiences, role and management strategies are influenced by key factors including their knowledge of LBP management, access to resources such as medications and heat packs, access to health services including primary care clinicians and allied health services, patient factors, defensive medicine and their awareness of ambulance service guidelines. Paramedics also raised potential solutions to improve management of non-traumatic LBP and strategies to reduce ED transport including the development of 24-hour care centres and better access to health services, access to wider scope of medications, increased health promotion and additional training for paramedics to manage musculoskeletal condition.
Many paramedics found managing people with non-traumatic LBP to be frustrating due to lack of health literacy and limited understanding of how to access the most appropriate healthcare, and the role of paramedics. Paramedics work in high-stress environments and frequently manage higher acuity, life-threatening conditions. Hence, a source of frustration for paramedics was having to manage people who conveniently use ambulance services because of their socioeconomic status. For example, patients with government-issued concession cards use ambulance services via triple zero (000) for non-acute emergencies. While paramedics acknowledged that most people use their concession card appropriately for management of their LBP, there are others who deliberately misuse it due to convenience (eg, to request pain medication). Similarly, our findings align with previous research that reported 75% of presenting musculoskeletal complaints were perceived to be non-emergencies by paramedics in America, and paramedics in Canada viewed patient lack of knowledge of ambulance service to be a reason for ambulance use.16 In Australia, one study explored patient perspectives for ambulance use and found that while patients agree that ambulance use for non-emergence situations to be misuse of the service, they also believe that everyone is entitled to use ambulance service regardless of condition severity.27 Ambulance services within the USA, Canada and Australia face similar challenges relating to patient education and knowledge of ambulance services that lead to paramedic frustration. Educating populations on appropriate ambulance service use for musculoskeletal complaints may alleviate paramedic frustration and improve ambulance resource use.
Paramedics suggested that a solution to avoid patient transfer to ED would be more access to effective pain medication and non-pharmacological alternatives such as heat. Current models of care for acute LBP recommend the use of heat, paracetamol and advise the use of non-steroidal anti-inflammatory drugs, if paracetamol is ineffective.26 Previous research has evaluated the use of pain medicines and non-pharmacological care strategies such as heat therapy and transcutaneous electrical nerve stimulation as effective alternatives to manage acute LBP by paramedics,28 29 although the recently published guidelines from the WHO recommend against transcutaneous electrical nerve stimulation for adults with chronic LBP.30 Paramedics insisted that they do not carry heat packs in their vehicles to use for LBP cases and report this as a limitation to delivering best care, despite heat packs being a cost-effective alternative to pain medications. Ambulance services should consider integrating heat packs into their vehicles for paramedics to use as a first-line option to manage non-traumatic LBP. Additionally, further investigation into the effectiveness of non-steroidal-anti-inflammatory drugs to appropriately manage musculoskeletal conditions in the prehospital setting is required.
Most paramedics acknowledged that referral to allied health services is crucial for continuity of care but suggested that general practitioners should initiate referral due to uncertainty in ambulance service policy regarding whether direct referral was possible. Similarly, a study conducted in Canada found that paramedic understanding of community referral programmes influenced their decision to refer patients.29 Paramedics also highlighted that direct referral to allied health services would reduce strain on general practitioners and medical centres, and potentially reduce the number of non-traumatic LBP cases presenting to ED. Research in primary care has reinforced these opinions showing that patients valued early referral to allied health services by general practitioners for the management of LBP.30 Implementing strategies in the prehospital setting whereby paramedics can directly refer people with non-traumatic LBP to allied health services could improve the use of ambulance resources, provide patients with continual care and reduce ED presentation. However, it may result in patient out-of-pocket costs that patients are unwilling or unable to afford, and publicly funded services that provide timely access to allied health are limited, especially in regional areas.
The findings of this study may be limited due to the selection of paramedics who were interested in managing non-traumatic LBP. However, given the diversity of paramedic characteristics and the variation in perspectives reported, selection bias is unlikely. Additionally, the generalisability of the study findings must be considered as the included paramedics in this study are from one state jurisdiction in Australia. Given the consistency of themes with previous studies, we suspect that this study will be generalisable to other Australian-state jurisdictions. Furthermore, while some identified themes (eg, patient factors) may be generalisable internationally, other themes and subthemes (eg, access to health services and guidelines) are less likely to be applicable to other international jurisdictions due to heterogeneity that exists across prehospital services, particularly relating to non-urgent presentations. While we noted thematic saturation throughout our data collection via participant interviews, we insisted on including 10 participants across each paramedic speciality (ie, extended care paramedic, intensive care paramedic and general paramedic) to explore the different perspectives for the management of non-traumatic LBP. Finally, the perspectives of paramedics in this study are based on their experiences of managing non-traumatic LBP at the time that the interview was conducted and although all paramedics reported managing at least one LBP case per week, views between paramedics may differ according to their most recent LBP case.
Conclusion
Paramedics often provide care to non-traumatic LBP cases yet find them frustrating and challenging to manage. Key factors that influenced paramedic care were their training and education for LBP management, access to health services, patient factors, defensive medicine and knowledge of guidelines. Future research should explore patient perspectives towards ambulance service use for the management of their LBP.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study received approval by The University of Sydney Human Research Ethics Committee (2022/677). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We thank NSW Ambulance for collaboration, assistance in recruiting participants and their non-financial support in conducting this project. We also thank NSW Ambulance paramedics who offered their time to participate in this study.
References
Supplementary materials
Supplementary Data
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Footnotes
Twitter @PicklesKristen, @TessaCopp, @gustavocmachado
Contributors SPV, GCM, CGM, MSS, JCB and PS were responsible for developing the study concept and design. All authors were involved in developing and reviewing the study proposal. SPV and GCM were responsible for acquiring and storing study data. SPV, KP and TC conducted study analysis and interpretation of data. SPV drafted the manuscript. SPV is the acting guarantor of the contents of this paper. All authors revised the final manuscript.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. SPV is supported by a Chiropractic Australia PhD Scholarship.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. SPV is supported by a Chiropractic Australia PhD Scholarship.
Competing interests JCB is Director of Research at NSW Ambulance and PS is an employed paramedic at NSW Ambulance. JCB and PS assisted with the ethical application, recruiting paramedics and reviewing the final manuscript. All remaining authors declare that they have no competing interests.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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