Book Review—Paramédico: Around the World by Ambulance

I thought I was the cool one, having led EMS at senior levels on two continents—that was until I read Paramédico by Australian paramedic Benjamin Gilmour. His story—now also a made-for-TV movie—covers EMS across four continents, from first through third world and in every extreme of climate.

The book celebrates the differences and unique challenges of medics around the globe. It also draws the comparisons that, be it prehospital emergency medicine, ambulance services, EMS, mobile healthcare or whatever it is we call ourselves, wherever we are, we’re are all united in the adversity we share and the realization that our global profession is not simply a job, but a way of life. Paramédico charts Gilmour’s 15 year adventure—and sometimes odyssey—and he charts a proverbial busman’s holiday.

The story begins almost literally in the middle of nowhere—not a sub-Saharan desert or an Asian mountain valley, but in the Australian outback. In the vast expanse of the remote Australian bush, the “ambo” is the thin end of the medical wedge. Gilmour begins his story in the sparsely, mainly unpopulated bush as the sole medic, living in a deserted nurse’s home with only his trusty ambulance for company. That ambulance is ultimately driven to the hospital by whomever is available once he arrives on scene.

Gilmour’s next stop on his own EMS world tour is with Netcare 911 in Johannesburg, South Africa. Teamed up with medic Neil Rucker, Gilmour dons a much-needed bulletproof vest as he responds to calls in a place with a reputation as one of the most dangerous cities on earth. With an average murder rate of one every 30 minutes, Gilmour states “the round the clock blunt and penetrating trauma ensures Joburg is to medics what Milan is to fashion designers.”

After battling penetrating traumas on the front lines of the Southern Hemisphere, Gilmour travels north to London, where a lack of reciprocity with the UK National Health Service dashes his hopes of serving with the London Ambulance Service (LAS). To make ends meet he finds a job with a private ambulance service, serving London’s exclusive—and high dollar (or pound)—Harley Street medical community. His experience is anything but fulfilling. He finds the staff who operate the service are “LAS rejects” and paramedic “wannabes,” who like the sound of their own sirens for no apparent emergency reason. Gilmour is partnered with an uncultured, profane EMT who is far from the epitome of the hardworking, dedicated national health provider. His only course of action is resignation and further adventure.

Next up, Gilmour fast-forwards eight time zones to the Philippines for a short six-week stay. Alarm bells rang—due to the lack of alarm bells. It turns out there is no 9-9-9/9-1-1 national number, and the primary dispatch channel is, in fact, the local radio station reporting incidents and accidents. Because great numbers of patients are driven into EDs by private vehicles, there is little for the ambulance crews to do. But when they do actually get out in their donated U.S.-specification Type III ambulances, they’re delivering a standard of care far advanced from the ED, as the gifted equipment includes items like ventilators, which aren’t present in the EDs.

Macedonia, to those unfamiliar with world geography, is an old country that was reborn when the former Yugoslavia split apart. The birthplace of Alexander the Great, Macedonia is a land steeped in history and was firmly planted behind the Iron Curtain following World War II. In this European nation, now free of its former communist shackles, Gilmour finds a basic system that inadvertently achieves the vision of mobile healthcare the U.S. is still striving for in 2013. Gilmour joins an ambulance crew consisting of medic, nurse and doctor. The calls they respond to are dispatched to them only after the caller has survived an exchange with a brusque nurse call taker. Once on scene, the doctor/nurse combination not only achieve a rudimentary “see, treat and release” system, but prescribe and medicate in what appears to Gilmour to be record time. His adventure is not without its alcohol-fueled moments; as the feast of St. Nicholas looms, each family he visits has a high expectation that visitors will consume their home-distilled, high-octane hooch.

One of the shortest sections of the book contains a brief overview of the one thing I, as the reader, want to know more about. What started out as a backpacking vacation (those who know Aussies know they love to “go walkabout,” waltzing Matilda-style) ends with medical participation in one of the world’s most recent and memorable natural disasters. Gilmour arrives in Indonesia for his beach holiday just in time to survive the Indonesian tsunami and then become part of the impromptu medical response. From the point of witnessing the sea disappear before his very eyes only to return in a tidal torrent, Gilmour has to first run for his own life and then, once secure on the high ground, rally other medics to assist. His paramedic skills are put to use as the triage officer at an island medical center for patients arriving by the truckload from a shoreline that instantly became the sea bed.

In Pakistan, Gilmour spends time in the dangerous north, places like Peshawar, where the threat of suicide bombers is ever present. Despite the huge volume of patients generated by such events, he bears witness to a pure efficiency of the hospital system. Gilmour visits an ED not long after a bombing to find the department empty; upon asking where all the patients were, the reply isn’t that they arealready in surgery or off to the wards, it is, “The emergency department is for emergencies”—a salutary lesson for us all. Gilmour makes the sharp observation that in the Western world, nations are crippled by fear of medical litigation. In Pakistan there is no concept of negligence or associated lawsuits—it is simply “Allah’s way.”

On arrival in Iceland, Gilmour sets out to avoid the naked truth at all costs—a daily station tradition is to discuss goings on, naked, in the 10-man sauna! Gilmour does well to draw on the differences of acceptance of public nudity between nations, as the macho Aussie does not consider getting hot and steamy with all of his male work colleagues as a bucket list item. The Iceland portion of Gilmour’s story also gave me a laugh-out-loud moment as one tale recounts an issue I’ve certainly witnessed delivering EMS on two continents. Critical thinking is a key paramedical skill used on each and every job to save life and limb, but try discussing with your crewmate where to go eat, and all abilities to make command decisions vaporize into the ether. Many times in Richmond I’ve determined to open fast food eateries named “You Decide” or “I Don’t Care” just to solve the inevitable lunchtime venue debate of “Where should we go today?” ... “I don’t know, you decide.”

Hawaii sees Gilmour ride the ka’a malama ola—Hawaiian for ambulance. His experiences exposes him to the homeless problems faced on the islands. In addition to local folk facing hard times with no home but the street, there are also considerable “imports”—as it turns out, big mainland cities with large homeless issues solve their problems by offering one-way tickets to Honolulu. Gilmour also witnesses public and heart health Hawaiian style. Well known EMS Chief Patti Dukes penned and performs a CPR hula song to stress the importance about learning this vital lifesaving skill. As my own organization found when creating a rap song to teach the people of our city to cross the street safely, music is an excellent way to reach the masses. His chapter in the islands ends as it begins, on the ka’a malama ola, only this time he discovers that a vehicle that has had a run of bad luck and may have delivered poor patient outcomes is literally exorcised by a priest to expel the bad karma! (A future NPFA standard, perhaps?)

Paramédico literally paints an EMS atlas from the first to third world. Gilmour highlights good medicine and best practices in bad places and conversely bad medicine in good places. He captures the essence of global EMS and perhaps subliminally explains why an instant respect and camaraderie always strikes up within minutes of a visiting medic arriving at a station. We all do the same job, are under the same pressures, and we all, around the surface of our EMS world, simply care.

Rob Lawrence is chief operating officer of the Richmond Ambulance Authority. Before coming to the USA in 2008 to work with RAA, he held the same position with the English county of Suffolk as part of the East of England Ambulance Service. He is a graduate of the Royal Military Academy Sandhurst and served in the Royal Army Medical Corps. After a 22-year military career in many prehospital and evacuation leadership roles, Rob joined the National Health Service, initially as the Commissioner of Ambulance Services in the East of England. He later served with the East Anglian Ambulance Service as director of operations. He is also a member of the EMS World editorial advisory board.