Paramedic Dynamic Risk Assessment related to Suspected Respiratory Disease in the context of SARS-CoV-2: a Mixed-Methods Study

Following the outbreak of the COVID-19 pandemic, paramedics were required to adhere to strict PPE guidelines informed by limited evidence, largely derived from retrospective studies. This contributed to conflicting recommendations from healthcare bodies regarding resuscitation practices in cardiac arrest, with chest compressions and defibrillation generally considered low risk for aerosol generation, in contrast to airway interventions such as endotracheal intubation (Couper et al., 2020). Before entering clinical settings, paramedics must rapidly balance the risk of harm to themselves against potential harm to patients should care be delayed. This dynamic risk assessment is complex, subjective and time-critical, and decisions to don PPE, and accept the associated delays, should be informed by evidence. However, limited data exists regarding aerosol generation during chest compressions, or the protection PPE affords rescuers, and little is known about paramedics’ experiences of working in PPE or the factors influencing non-adherence. This mixed-methods study addressed these gaps by combining semi-structured interviews exploring paramedics PPE experiences (n=16) with real-world measurement of aerosol generation during chest compressions and defibrillation in out-of-hospital cardiac arrest (n=18). Non-adherence was posited as being linked to professional identity theory, including identity fusion and moral injury, shaped by societal expectations and crisis narratives such as ‘clap for heroes’. Aerosol data were inconclusive but suggested elevated airway aerosol levels during resuscitation, indicating a potential transmission risk to rescuers. This thesis makes an original contribution to knowledge by integrating real-world, prehospital aerosol measurement with qualitative analysis of paramedic decision-making under uncertainty. By empirically examining resuscitation-associated aerosol exposure in operational ambulance settings and theorising how professional identity and contextual pressures influence dynamic risk assessment and PPE adherence, the study advances understanding of how risk is negotiated in time critical prehospital care. It further introduces the concept of the ‘blue mist’ to describe time-critical cognitive narrowing in emergency settings, providing an evidence-informed foundation for future guidance, education and respiratory PPE design in ambulance services.