• Prehospital Care, Advanced Practitioner
• Paramedics, Extended Roles
• Trauma

Extended skills for critical care paramedics (CCPs) in UK based systems have been extensively evaluated in recent times.1 ,2 Autonomous administration of ketamine for analgesia and conscious sedation has been identified as a core skill for CCPs but concerns have been raised about the level of exposure required to maintain competence.3 To date there have been no reports in the literature detailing the experience of ketamine administration by CCPs in the UK.

Midlands Air Ambulance operates a fleet of three helicopters within the newly established West Midlands Major Trauma Network. Two platforms are CCP-led with the remaining aircraft employing physician-CCP teams as part of the regional Medical Emergency Response Incident Team. A land based platform also operates outside of daylight hours staffed by a physician-CCP team. CCPs within the MAA/Medical Emergency Response Incident Team structure rotate across the different platforms on a regular basis.

A Patient Group Directive (PGD) was launched in September 2012 to support the autonomous administration of ketamine for analgesia and conscious sedation by CCPs within the West Midlands Major Trauma Network. All administrations of ketamine within the service are subject to detailed peer review as part of a well-established clinical governance structure.

During the 1st year following the launch of the PGD ketamine was administered by 10 different CCP-led teams a total of 29 times. While there were no violations of the PGD and no recorded adverse events following drug administration, less than 4% of all scene attendances by CCP-led teams during this period required ketamine. A further 100 cases of ketamine administration by physician-CCP teams occurred during the same period.

Our experience in a prehospital system with high levels of tasking to cases of traumatic injury is that CCPs can autonomously administer ketamine safely, in accordance with a PGD, but that it is rarely required. The structure of our service is reasonably unique in UK practice allowing CCPs to work across a variety of different platforms independently and as part of physician-CCP teams. Without the added experience afforded by operations on physician-CCP platforms in our system, the level of exposure that CCPs receive may be insufficient to maintain standards of competence in the administration of ketamine. Further collaborative research between UK based services in which CCPs administer ketamine autonomously is required to accurately assess levels of exposure and identify suitable frameworks to support skill retention.