Interview with Tony Walker, ASM (Part 1)

Background:

Prof Tony Walker ASM has almost four decades of experience in the ambulance and emergency services sector, working across a range of senior clinical, operational and leadership roles, most recently as Chief Executive Officer of Ambulance Victoria where he led significant transformation to improve the health and wellbeing of their workforce and their response to the community.

Tony is a Registered Paramedic, a Fellow of the Australasian College of Paramedicine, and holds a Bachelor of Paramedic Studies, Graduate Diploma of Emergency Health (MICA) and Master of Education.

He is a Member of the Australian Institute of Company Directors, a Director of Fairhaven Consulting and non-executive director of several not-for-profit organisations.

Tony is published in an extensive range of literature relating to advancements in paramedic practice and pre-hospital systems of care.

Tony has been awarded the Ambulance Service Medal for his significant contribution to the development of ambulance services at a state and national level and the National Heart Foundation President’s Award and Australian Resuscitation Council Medal (ARC) for his significant contributions to improving cardiovascular health and resuscitation practice and outcomes.

He was a finalist for the Australian Mental Health Prize in 2019 in recognition of his work in improving paramedic mental health and wellbeing.

Newman--

Are you still a paramedic?

Walker--

I’m still a registered paramedic. I’ve maintained my registration even since retiring from my Chief Executive role and still do a lot of academics. So, I’m keeping that activity. Just not clinically focused now which is great.

Newman—

How did you choose to become a paramedic?

Walker—

Well, that was interesting. My mom was a nurse and so I sort of grew up in an environment of health. I decided early on I wanted to do something in health. I think probably driven by my mom’s experience and so initially thought of doing nursing but couldn’t get into the nursing schools at the time.

I worked as an operating theatre technician for about five years supporting anesthetists and operating theatres at one of the major hospitals in Melbourne (Info: Melbourne is the capital and most populous city in Victoria and the second-most populous city in Australia after Sydney. Greater Melbourne has a population of 5.2 million).

While doing that role I got to see the intensive care and ambulance paramedics who were delivering patients to the hospital and was very impressed with what I saw and thought that would be a pretty cool job. I went through the process of applying, applying, applying – and eventually got in. I think I was driven by that experience of wanting to help but also seeing some quite amazing people just calmly delivering amazing care to people, often bringing the most critical patients directly into the operating theatre and their approach still sticks with me 40 years later.

I still remember the way in which they approached their patients and their calmness and demeanor just got me thinking this would be a very good job. I never regretted it. I’ve loved every minute of my career since then.

Newman—

I did a ride-along in Melbourne and it has stuck with me ever since. That call more than 30 years ago -- and those paramedics really helped shape my career and my approach to care. Our system was so algorithm-based at the time. We weren’t looking at the human context. The patient presents with chest pain and we ran down a checklist-style approach. I used to call it trick-based EMS.

I rode with these Melbourne paramedics, and we went to a couple of calls and one was for an elderly woman with chest pain. Of course, I was thinking, “Cool. I’m going to get to see what their protocol is…” and they turned to me and said, “Hal, do you know how to make a cuppa tea?” and I remember thinking, “What the heck” and they said you go make some tea and bring it in for the patient. We’re going to gather up a proper history. They had seen her before and they were familiar with her history and yet they invested the time and the effort to listen and perform a contextual patient evaluation, which I’d never seen before. Their care was calm and amazing and that very human approach stuck with me. They accomplished everything they needed to do, and the patient benefited from their expertise – but it was all so human-focused.

How did emergency prehospital care in Australia evolve so differently?

Walker—

The genesis of the services as you said is different. I think the ambulance services in Australia and to a degree the UK, very much started from some St John Ambulance and so obviously the American community ones do have a strong EMS/fire background.

I think that that's been some part of it. It's been a medical model. There are a lot of health professionals involved with St John over the years that volunteered, and then moved to the sort of civil-based services that formed over time. I think in the Victorian context, one of the biggest things that shifted the dial in that service, was the introduction of the mobile intensive care ambulance, in 1971-72. That move from first aid to advanced care, almost overnight. We had intensive care ambulance officers out there, canulating, intubating, defibrillating -- working with doctors on ambulances who said, “Actually, we don't need to be here anymore. You've got this. We'll just provide that sort of broader supervision.”

Those men, at the time, set the standard, I think for clinical care because they were so passionate about making sure it was done right. They had so much trust in them from the medical community and the broader community. That they set the standard of care that I think is continued at that very high benchmark all the way through.

And it's been adopted I think throughout Australia and by a number of people moving around the country and I think it's in other services have done the same thing. So, I think there's been this sense of that you describe that case before of the cup of tea. It reflects that sense of what we call here in Victoria ‘Best Care’, which is a principle of doing the best for that person at that time, which is not necessarily what the system wants, because the system, particularly now as you highlight, the system would be saying "Next case. You've got to keep moving. We've got another one waiting."

People are sensitive to that, but it doesn't distract them from doing the best for that patient. That’s the care you want your mom or your dad, or your brother, or your sister getting. So, I think that sort of infuses itself into the DNA.

The other big thing for Ambulance Victoria is that they've been nearly adopters of things such as early defibrillation, manual defibrillation in the late 1980s again on the back of the intensive care paramedics in the early 1970s.

And there's been this idea of really taking that principle of measure and improvement and how do you keep getting better and what can you do best? How do you know, measure what you do and make it better every time.

I think that constant sense of not resting on your laurels has been important in driving change. We could do better here. We could deliver better care here. We could give a better drug. We could give a better intervention. We could do some research to see things are better and that's been put in place by some very, very impressive medical directors, who have been part of a working partnership. Not the sort of hierarchical model, but very we've all got a role and we work together for the best outcomes for our patients.

Newman—

How does the research inform the practice of emergency prehospital care in Victoria?

Walker—

I think like any EMS service, Ambulance Victoria has government-imposed metrics around performance. And so response times are still measured and much as we'll all have used them, they are what they are. Your funders put those in place. It's very important for a subset of patients but there are so many other things we could be measuring. Professor Karen Smith who was doing research, when I was there, 20 something years ago, worked really hard with their medical director Professor Steve Bernard and others to actually develop a series of measures that looked at clinical outcomes.

So, we could say, we might not be meeting some response times, but the clinical care we're delivering is exceptional and so I think that's really critical because there's a real risk sometimes that you get so focused on response times that you lose the forest for the trees. You become so enamored in trying to address those. But actually it's a small subset of patients and reality is we’ve got a broader subset of patients and we take longer to get to them but they're better outcomes. It’s almost in contrast to the sort of historical view of what EMS does.

So, I think that was a big one. Asking yourself the questions: How do we measure the quality of care that we're delivering and measure also the feedback from our patients? They tell us what they think about the care.

It’s one thing for us to think we're doing great work. But, the arrogance comes through and we forget to ask what are patients want and to be honest, they'll tell us they probably want you to get there quickly, they want you to be nice to them, they want you to take away their pain – all reasonable things.

As the system of care has changed over time to become more nuanced. We're doing so much more non-emergency. They're looking at what are the different pathways and care because people want their problem solved. They think the solution is to call for the ambulance. So how do we help them understand. You don't have to decide what you need. We’ll help you work through a solution for your particular problem, which may in Emergency or it may also be a telehealth consultation with a doctor in an emergency department a couple of hundred kilometres away.

When we looked at the research, it was very much about research driving improvement. When we put research into the organization, particularly Professor Karen Smith, and nowadays, Ziad Nehme (Dr Ziad Nehme is a paramedic and a Heart Foundation Future Leader Fellow with expertise in prehospital emergency care and resuscitation research. Nehme is the Director of the Centre for Research and Evaluation, Ambulance Victoria), a paramedic researcher, it was very much about saying, “Where are we at? And what could we do to improve?”

And often when we looked at that, we'd say, “Well, actually the research is lacking” and so we would do the research trials, ourselves and test different things. We tested the use of therapeutic hypothermia. Particularly in cardiac arrest. We implemented rapid sequence intubation on the back of a significant nationally funded trial. We put in place some changes to oxygen administration that led to international changes.

Newman--

You're right. It made us all change our protocols.

Walker—

Mick Stevenson led that effort included a research trial that changed world thinking in some of these areas. (Mick Stephenson is an intensive care paramedic (MICA) and member of the executive team at Ambulance Victoria. He has been a paramedic since 1996 and a MICA paramedic since 1999. He has contributed to a number of prominent clinical trials as a co-author and steering committee member. These include research in the areas of cardiac arrest management, post resuscitation care, the potential harms of hyperoxemia in myocardial infarction and post cardiac arrest resuscitation, trauma systems and severe traumatic brain injury).

So, it was sense of constantly asking ourselves what can we do to improve? How do we make things better for our patients? And if we're not sure, not just resting on the laurels but going actually, let's do the research and find out for ourselves – and with our partners.

Newman—

I'm curious. So over here only about 20% of Priority 0 and 1 patients are actually transported under emergency conditions. What we haven't worked out is what you were just talking about. How did Ambulance Victoria become a navigator to the healthcare system rather than following the age-old model of “We'll send an ambulance. And then we'll transport you.” How do you get to this point? Where you're essentially navigating the system for people?

I think it was driven by the changes that we put in Victoria about nine to ten years ago. Where we put in place a fundamental change to a clinical response model and it was driven by the fact that we were not getting to the sick patients as quickly as we needed to -- people were waiting longer and it was just a sense of more and more, and it’s going to get the same solution. Einstein's famous line.

We basically paused and said, “We know from our database. That was the most important thing we had in clinical data, based on our electronic patient care record, allowed us to go back and look at patient types. Over the last few years, thousands of cases and say, actually, on the basis of that emergency 911 type call, they did not need the lights and sirens to hospital and we followed them up. They weren't seriously unwell and so on that basis, they could have had a lower acuity response. Or they could have gone to an alternative provider and so on the basis of that, we basically took the MPDS dispatch screen – you can imagine how that might make people anxious - but we had a volume and a clinical governance framework around it. So, we said, we'll take the dispatch grid, and we'll reallocate the priority codes. So, we still triage the sick patients, and they get an emergency ambulance straight away. But if you're not an emergency, you're going to be referred to one of the biggest secondary triage centers - clinical hubs in the world, which basically has over 200 paramedics and nurses working in it.

They get dispatched the call. And then they’ll spend 10 15, 20 minutes, similar to your experience 30 years ago, working through the individual to work out what do they actually need. If they pick up that it was a missed emergency call it gets sent back for emergency response. Otherwise, they'll now use video conferencing; they'll use other tools -- the patient might have such as blood pressure monitors and sensors to understand what the problem is and then connect them to the right service. The principle behind this is the right care at the right time and the right place and avoiding unnecessarily sending an emergency ambulance out so those emergency ambulances are available for those people that need them.

I think when you do that, what you end up with is an opportunity to say, “Now we've got an alternative disposition. For example, the work that Ambulance Victoria has been doing the last few years.

Nearly 75% of mental health calls that get dispatched to secondary triage don't get an ambulance responded.

They've now got residential aged care halfway. So instead of an emergency call to say, “I haven't got the ability to care for this patient. You need to come and take them,” they get plugged into secondary triage, they'll have a doctor, and a nurse involved in the care of their patient and they’ll work out what the best outcome is for that patient. Which is probably not going to the emergency department. So, it's really looking at these pathways, advice over the phone, different clinical pathways, doctors doing consultations. Community paramedics are now starting in Victoria who will go out to some of these cases. All about avoiding that emergency response and avoiding an unnecessary ambulance transport to the Emergency Department.

I have to say, though, it's about 20% of cases. I don't think Ambulance Victoria's necessary, the best in the world of this. I think you look at Wales, Scotland, Tasmania in Australia, is now moving this way. Wales and Scotland have got 50% because they're now not only doing the point of call, but they're doing it when paramedics get there as well. So, I think that it's not just when you pick it up at the call, but when the paramedics get there they'll then connect them in through the system. So again, avoid taking them from the home and that they're saying 50%, non-transport, which is I think the next generation is going to be in Australia as well.