Category 1: protect me to protect you

All of our paramedic participants except one expressed concern for themselves and their families during the pandemic due to a perception of the risks their occupation posed:

Not so much catching it myself, but bringing it home to my family (P09)

They were concerned of risks to family members with underlying health issues, revealing internal conflict between their occupational role and the safety of their families. A wide range of underlying conditions were reported including pregnancy, asthma, immunosuppression (HIV negative) and leukaemia, and participants often mentioned concern for family members from these vulnerable groups and their elderly relatives.

my partner works as a frontline carer, he is immunosuppressed but is HIV negative… he has got significant risks, but obviously with me working in the frontline, and him in frontline as well, one of the early fears were do we basically separate or do I basically separate from him to reduce that risk. Whilst I would always do my job, I would never forgive myself if I thought for one moment that I had brought something from the community and brought it back home (P08)

Paramedics told how practising in this context was unlike anything they had experienced before, with an ever-present sense of fear and risk.

I felt anxious going to work, I felt scared going to work, it’s scary to think you can go to work and bring it home, that is not a nice feeling (P12)

All participants talked about front line HCW’s dying from COVID-19, and in April 2020, a paramedic within the study area died from COVID-19. From this point on all of the participants reflected on the death of their colleague, as shared by paramedic 14:

We have [name] working here… its knocked it a bit closer to home again,….it’s had a massive effect because he was such a big character (P14)

Powerful accounts were relayed of their sustained exposure and close proximity to patients with COVID-19 symptoms. Paramedic 15 who contracted COVID-19 along with her partner early in the pandemic, said prior to contracting COVID-19 she:

was petrified really, standing in a house where someone is coughing and spluttering for half an hour, and then conveying them to hospital, which took another hour…you are in the back of the vehicle 2 meters by 1 meter… with a patient who is coughing virus into the air potentially and I’m breathing that air in. so it was horrible really. (P15)

They reported attempts being made to mitigate the risks of working in this environment, which involved changes in practice and provision of personnel protective equipment (PPE). Such efforts however did little to alleviate this fear-filled context, which seemed to influence their morale. Paramedic 15 was:

really worried because I knew the masks didn’t fit me properly, so I was anxious and I felt a bit demotivated to be in work, that I didn’t want to be there because every day I was going in and it was a permanent risk really’ (P15)

Paramedics in our study reported this environment of fear influenced many areas of their lives, including changes to hygiene practices such as changing out of their uniform and showering in work, avoiding visiting friends and relatives, and talking more openly on making preparations for their own death. They also reported a dramatic reduction in workload and that people were avoiding care for fear of contracting COVID-19 which they felt was influenced by the media and conversely increased emergency calls to assess people who thought they had COVID-19.

There was a lot of fear among patients, which I can understand. You see a lot of death and fearmongering on the news, there was a lot of fear among patients. But then that also led to frustration amongst us on the road because we are going to patients who are phoning 999 because they have a bit of a cough. They basically phone us because they want us to check them over (P12)

Paramedics were sympathetic to these views, and admitted to their own internal conflicts when taking people into hospital, which they felt may not be in the best interest of their patients. A clear narrative for this dilemma was described by P15 who was unable to safely leave the patient at home, and was admitted to a COVID-19 ward

When I took the gentleman in who was off his legs to the COVIDCOVID-19 ward, I was talking to the nurse there and I said I felt like I was deciding almost his fate, which wasn’t very nice. (P15)

Paramedic participants raised occupational and pay related issues including the importance of protecting their income while acknowledging their fortunate position in comparison to others in society at this time.

I am alive and I have a job which is more than what most people have got at the moment. I have food and I’m not worried about bills (P10)

Additional overtime incentives were initiated by their employer, and whist views were mixed, paramedic 10 told of her fear in taking on overtime:

I have no intention of doing overtime……Less is more with me I think, it’s like Russian roulette isn’t it, you know the bullet is in the barrel and you will spin it because you have to go to work, but then I wouldn’t go and put two or three more bullets in the gun and spin it to take that chance (P10)

All participants except one had access to the recommended PPE, but they also reported frustrations on how PPE guidance had changed as the pandemic evolved and experienced variation in approaches to PPE across organisations other home nations.

there seems to be substantial differences between what Public Health England and Wales are throwing out in regards to what the World Health Organisation and the Resus Council are throwing out (P06)

Concerns were reported over their training and the quality of PPE, and all except two felt it was not designed for ambulance service use. Paramedic 14 shared his thoughts on the quality of equipment and reported his concerns around using out of date PPE:

we are using masks now with stickers with 2012 on and I know that we are only using them because we can’t get any of the newer masks, and that is not what you want to hear…you want to know what you are wearing is safe to do your job. (P14)

Nine of the participants reported that their well-being and mental health had been negatively impacted on by the pandemic. They talked about their collective anxieties around COVID-19, and the effect the ever-presence of the virus in their practice. Paramedic 9 said:

as a station we were definitely a little on edge. Cleaning door handles in the station, going round starting my shift, cleaning any touchable things I could think of, kettles, taps anything like that and that is not me… it’s turned me into a bit OCD about it. It’s definitely affected my mental health (P09)

Paramedics talked about the difficulties they felt in providing care in emergencies due to COVID-19, and how this resulted in frustrations and tension in them.

one night, unfortunately, I had 3 cardiac arrests, which was tough and unfortunately the guy I was working with needed the versa flow hood, so I was on my own…that was really really hard going on your own… everything about it felt wrong and it was such hard work and it was frustrating. (P12)

Only one participant reported having accessed well-being or mental health support promoted or provided by their employer, and this was a routine call from the well-being team with support which they declined. Participants did however reflect on the increased focus and provision of support for mental health within ambulance services in recent years.

I think the mental health side of it is 100 times better than what it was, I don’t think we had anything before (P14)

Despite this, participants either did not feel they needed such support or accessed this from other sources such as their family, friends, colleagues, private counsellors, the service Chaplain or information publically available. Following the national lockdown our participants described the importance of exercise, being outdoors and in nature for their well-being during the pandemic, along with the need for time to recover between duties. They told how the pandemic had resulted in them doing more activities with their families and had rekindled interest in activities such as walking and cycling. Paramedic 10 shared how during lockdown, the 1 hour a day out walking was so important and:

But I have started back cycling, that was one of things I was allowed to do, so the bike has been covered with a blanket in the garage for months, and because you were allowed to cycle and pretty much nothing else, I started again. (P19)

Categories 2: rapid disruption and adaptation

All participants faced rapid disruption to their personal and working lives. This included issues such as adhering to the lockdown rules, social distancing, holiday cancellations and difficulties visiting family. This rapid disruption subsequently required rapid adaptation.

when you find yourself in a situation whereby the world is a completely different place so quickly you have to adapt, you have to (P7)

They told of the need adapt, learn and assimilate new information quickly. This included clinical information around the COVID-19 virus, clinical guidance and ways of working in PPE. Paramedic 12 shared how it could be overwhelming:

you have been thrown information constantly, there’s updates after updates after updates, things are changing near enough I wouldn’t say hourly but frequently changing. Yes you are probably being suitably informed but it is overwhelming (P12)

All of the paramedics reported the rapid change in encountering patients reluctant to accept care, and how they faced difficult clinical and ethical decisions in their practice which had become far more challenging due to the context of the pandemic.

I would say at least about 50% are refusing to go in…. so you are really having to convince and weigh up the balance of fighting against that, because if you do take them in and they do catch it and they do die, its weighing up the responsibility of that as well (P05)

And

I spent nearly an hour and a half trying to convince the family that the risk factors were significant enough that actually going to the A&E and so did the doctor … 2 and a half hours later we did manage to gain consent to wilfully go to hospital (P07)

Paramedics also said people were presenting much sicker due to delaying care for fear of contracting COVID-19 as expressed by P07:

People are really poorly out there because they are leaving it too late (P07)

All of the paramedics faced changes to clinical practice and guidance and while there were mixed views, for some, information felt rushed.

I feel they were pushed out too quickly without adequate training and understanding from frontline crews, and I fear this will lead to risky decisions being made that would not otherwise benefit the patients (P11)

There was also a suggestion that during the pandemic, a more pragmatic approach was being taken to clinical practice guidelines and the quality of care was being compromised. Some paramedics expressed concerns about their professional registration:

The HCPC [Health & Care Professions Council] came out early on and said they will make allowances, they will consider the coronavirus if our decision making is called into question (P18)

The pandemic was thought to have expedited many changes in clinical practice including in end of life care (EoLC). Powerful accounts were shared of managing patients at the end of life during the pandemic which avoided delays and hospital admission, which gave them satisfaction. Paramedic 18, however, told of his discomfort over EoLC treatment packs, telling how he and his colleagues were:

Uncomfortable about it because they have just been put on trucks with very little training on it (P18)

Paramedics in our study said how their interaction pre-pandemic with people with mental health issues was often tactile, involving holding hands and using nonverbal communication. Participants explained how the pandemic had significantly changed this.

the human side of our job feels like it has been taken away, and its really put into sharp contrast how much humanity we usually have in our job … personally I have found it really difficult leaving relatives behind and especially when you have got time critical, possibly not going to survive patients. We had a lady with a very dense CVA the other day…and had to leave her daughter standing crying on the side of the road. (P03)

And

Before you would go in and have chats or banter with them its lost all that, first thing you do is put a mask on them, it can’t be nice for the family coming in with all this stuff on, and I think its lost a lot of that relationship between the paramedic and the patient (P14)

All of the participants except one reported a rapid rise in the use of technology in their personal and working lives such as video conferencing and mobile phone apps.

I speak to my children on a daily basis by phone or group video, which is something else we have got into the habit of doing now. We will get into a group call which we have never done before (P13)

They also shared the positive impact of the pandemic on use of such technology across the wider healthcare system:

The NHS in regard to medical advances has been very fearful in moving forward, particularly with video conferencing and now seeing GPs using Zoom, which is amazing (P07)

Categories 3: trust in communication and information

All of our participants accessed information from a wide range of sources, and told how trust in information sources was essential. For some, there was general confusion on what sources could be trusted:

I don’t know who to trust with it (P12)

There were mixed views on information provided by the Government; for some there was distrust in their motives, and a feeling information was being politicised with the government being careful to protect themselves.

Because they [the Government] have done that to protect themselves and not us as healthcare workers… the thing is, you don’t really know from what you’re seeing how true everything is. (P12)

Eleven of the paramedics felt suitably informed by their employer, and provided rich accounts of the many platforms and mediums that were used in this process, such as the:

excellent policy of daily updates and ZOOM meeting to ensure all staff were aware of the latest updates (P01)

They did however report how the constant negative reporting of COVID-19 was having an impact on the kinds of presentations they were encountering in their clinical practice:

Those people were saying they were watching the news 24 hours a day, all the media reports, googling things they didn’t know about and getting themselves into a point they end up calling us through stress. So very bizarre times. (P16)

All participants told of the danger of information overload for them and the public. They also believed social media could be negative and positive. Positive accounts included its role in communicating with colleagues, friends and family and the Facebook group provided by their employer. Some however did not use social media and avoided it to protect their mental health. Media reports providing daily updates and reporting the challenges they faced were a constant reminder of their job and were not welcomed and created anxieties and difficulties with loved ones.

I try not to watch the news, and I mean I had it on constantly, and I realised it was having an effect on my daughters mental health (P10)

During the early stages of the pandemic, many front-line staff including paramedics took to social media posting pictures and videos of themselves which ranged from messages of protecting the NHS to highly choreographed dances in theatre scrubs, PPE, nursing and clinical uniforms. Paramedic 10 said:

I don’t think it is right that we are posing in masks, and I mean the medical professional as a whole, dancing up and down the corridors meters away, potentially from ITU where people are fighting for their lives… you wouldn’t get a crematorium bloke doing a song and dance in a crematorium would you (P10)

Categories 4: United in hardship

Despite the significant challenges and fear, Paramedics reported a sense of solidarity across their profession and organisation in being united working together to tackling the pandemic.

I think generally people come together in a crisis normally and I think it’s taken this to make WAST and other services a lot nicer place to work for. Because we are all up against it though aren’t we, we are in it together (P10)

They also told of the positive aspects of the COVID-19 pandemic on the communities within which they lived and worked and recognised that the visible public support such as gifts and clapping was nice, but some felt somewhat embarrassed

It’s really nice to get to know that you are supported, it is emotional, but I do get somewhat embarrassed by it, because we are out there doing a job and decisions we make are informed decisions. (P13)

During the pandemic there was a very visible campaign in the media of NHS Heroes. This narrative was promoted within society by charities, media and government. Despite this, all of the participants except one did not consider themselves to be ‘Heroes’ but rather, felt they were just doing their job.

What is the definition of a hero?… I go to work every day, and I know if I caught it I know my dad would call me a hero, I know my daughter would be beside herself but eventually she would probably think of me as a hero, but yeah I would be a liar if I didn’t say there were times I think of myself as a hero, but ultimately I am a human being who is scared (P10)

The heroic definition of paramedic 10 was equally reflected in the accounts of the other paramedic participants, who all felt a professional responsibility to society to provide care during a pandemic but would not choose to be exposed to such risk if they had a choice and shared a sense of melancholy that if they weren’t doing this, who would be?

We have lost colleagues, and if this virus wasn’t here they would be around now, and that isn’t what you expect when you become a paramedic I don’t think. I never expected a global pandemic which could kill us to happen (P15)

The outpouring of public support for paramedics within the NHS did however reveal tensions in their relationship with some members of society. Paramedics told how some in society were blasé, not observing social distancing rules, and the Victory in Europe (VE) day celebrations were cited as examples. It was suggested by paramedics that when COVID-19 was over, they would be forgotten about by the public and return to long hospital delays, inappropriate use of ambulances and violence and aggression directed towards them

once it’s over they will forget about us again and it will be back to abusing people again and sitting around in hospitals and where has this been until now when you needed us (P14)

BSP: Tragic Choices

The BSP in PECC-19 was recognised to involve Tragic Choices. We draw on the work of Calabresi and Bobbitt23 who explored how societies allocate tragically scarce resources and make such ‘Tragic Choices’. This perspective considers the various methods for allocating and dispensing goods and services with paramedics during a pandemic, which includes resources such as equipment, labour, knowledge and information, care and services. The BSP reflects life’s pricelessness and Calabresi and Bobbitt’s23 discussions on such pricing of the invaluable and the cost of costing, which we argue occurs when ordinary activities and resources become increasingly scarce and tragic in a pandemic.

Calabresi and Bobbitt23 highlight that price does not place a value on goods or activities, but rather, it permits comparisons, such as the cost of investing in healthcare, preparing for pandemics, PPE and pay, all of which can be compared in price with other activities such as building safer roads for instance. These prices do not however place a value on life, but when compared, they can illuminate the cost; for example, of how many lives may be saved by building safer roads rather than spending on building new hospitals for instance. The informative worth of price, costs and the value we assign to issues revealed in this study on paramedic care cannot therefore be ignored, or otherwise we risk losing more lives in this and future pandemics, and paradoxically undermine life’s pricelessness.

An EGT of the Tragic Choices in providing paramedic care during the 2020 COVID-19 pandemic

An EGT was constructed of the Tragic Choices faced by paramedics in providing care during the 2020 COVID-19 pandemic. Exploration of the Tragic Choices that such pandemics necessitate reveals the variety of processes by which these choices are made across the thematic categories presented above, and outlined in the EGT (figure 1) which includes the BSP of Tragic Choices at its centre, influenced by Tragic personal and professional choices, Tragic organisational choices and Tragic societal choices.

Tragic personal and professional choices

Challenging personal and professional choices were experienced by paramedics in our study around protecting themselves, their families and their duty to provide care during the pandemic. While the public considered them heroes, paramedics did not consider themselves within this characterisation. Many definitions of heroism to society exist, but key factors include: the voluntary nature, risk of harm, acting for benefit of others and without expectation of gain.24–26 Our paramedics were indeed acting in the benefit of others, but reported feeling scared and it was a job they were paid for. Tangherlini27 found similar self-deprecatory accounts from paramedics of such heroic status and so acceptance of such hero characterisation is complex.

Tragic professional choices were revealed in clinical practice; especially with PPE, including its dehumanising impact, frustrations over quality and variation in guidance across organisations. Such disparity in guidelines have also been reported in the literature.28 They faced rapid changes in their role in provision of EoLC, which some were not confident in, and while studies have previously reported this,29–33 empowering staff at the point of delivery of EoLC has been deemed crucial and can make a real life impact.30 The pandemic may have expedited developments in paramedic provision of EoLC and tragic decisions may have been made. However, powerful positive EoLC encounters were reported by paramedics which may reflect professional and organisational growth which can emerge from such crises.34 35

Tensions were revealed with clinical decisions, balancing risks and benefits of managing patients at home. These decisions may again involve Tragic Choices and moral compromises which HCW’s are often confronted with and can have far-reaching consequences when searching for the best treatment option36 37 Hoffmaster& Hooker (2013) 37 contend that often policy makers are removed from the devastating heartbreak, sorrow and guilt of personal Tragic Choices and consequently, the moral burden of legitimacy and responsibility falls not just on the Tragic Choice itself, but also on how the Tragic Choice is made. Paramedics in our study reflected on the cost of isolation measures and anxiety in patients; many of whom were elderly and experiencing increased loneliness. Such feelings of loneliness, and anxiety during the pandemic have been reported elsewhere,38 with the elderly and those with chronic conditions said to be paying the highest price due to increased age and disease related risks.39 40

Ethical and professional issues revealed around the paramedic-patient relationship, have been reported in other studies,41–44 and have potential to result in moral injury, which is the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code.45 Powerful accounts of Tragic Choices may also reinforce public drama, with reports in the media of paramedics constantly second-guessing themselves as to whether people needed to go to hospital, and choices that may ‘make a patient better or kill them’.46 Family members, friends and the wider public received daily reminders of their role, and risks they faced, and paramedics in our study told how they could not escape these reminders when off duty.

The tragic professional and personal choices being made by paramedics in our study were also experienced by others during the COVID-19 pandemic,47 who similarly reported such challenging decisions, balancing physical and mental healthcare needs with those of patients, aligning their duty to patients with the needs of their family and friends, and providing care with constrained resources. They reported feelings of fear, anxiety, and reported Tragic Choices they made in seeking support, which rarely involved their employer, but rather family, friends and close colleagues. The positive impact of exercise and being in nature was reported, and many studies have identified the positive relationship between nature and good mental health and well-being.48–51

Moral injury can however have benefits, as those individuals and organisations who have endured such experiences during the crises have experienced post-traumatic growth.34 Indeed, Rothes et al (2020) reported such professional growth and increased awareness in paramedics following their experiences with patients who died by suicide, but this relied on supportive cultures, training and preparation to overcome the negative emotional impact.35 Once again, tragic and costly choices may be required to invest resources and mental energies in these issues.

Tragic organisational choices

Our study richly revealed the influence of many choices made by the paramedics employing organisation. The COVID-19 pandemic is undoubtedly the most significant crises to have been faced by healthcare organisations and ambulance services internationally in modern times, yet societal crises can be strategically challenging to organisations outside of the pandemic context, and the associated disruption of demand, capacity, increased uncertainty and financial instability forces a reassessment of business operations.52 53 Ambulance services are in the front line response to the pandemic, and while preparations are made for such pandemics, the employing ambulance service were forced to learn, react and adapt as the pandemic unfolded. While rapid changes may have resulted in confusion and anxiety in areas of clinical practice and PPE, many positive issues emerged where the pandemic context appears to have stimulated a significant amount of innovation and cooperation. For instance, the organisation initiated more provision of clinical support, better information, communication and digitalisation, factors which may have created an environment for improved professional growth. It should be recognised that such accelerated innovation and growth was forced rather than discretionary, which can occur to ensure the organisation’s survival and because it had to.54 Limited assumptions can therefore be made if such innovation could be sustained outside of a pandemic context.

Paramedics in our study reported the importance of trustworthy communication in their personal and professional lives during the pandemic, which has also been reported in previous pandemics12 55 56. They also reported challenges of information overload, how social media could be positive and negative and how some avoided it. Tragic Choices are therefore again made around communication, where the content and medium of such communication may be positive, but may also add to public drama, confusion and the tragic context.

The study revealed many positive cultural and organisational issues, such as increased unity which has been reported during other pandemics.43 57 One such visible example of this spirit of solidarity and unity was WAST’s ‘Reach for the Razor’ campaign,58 where staff were encouraged to shave facial hair (light-heartedly) to prevent the limitations of face mask fit when hair is present. Organisations and staff, may therefore have choice in being in united in pandemics, but such unity may involve longer partnerships.

Increased problems with mental health and well-being were reported by participants, which are also reflected in literature59–62Kisely et al. (2020) 62 found HCW’s during pandemics exposed to virus are 1.7 times more likely to develop psychological distress and Post Traumatic Stress Disorder (PTSD) compared with non-exposed workers. Few participants sought support in our study which is also reported in the literature.10 Despite this, there are a lack of evidence based interventions for staff working in such high-risk occupational roles,63 64 which has prompted urgent calls for research to be prioritised in this area.65 Paramedic participants also reported incentives for working overtime during the pandemic, but many recognised the need for time off to recover; indeed working such overtime is associated with anxiety, depression and burn-out.66–68 Paramedics and employing organisations therefore face Tragic Choices when balancing service delivery during a pandemic with potential for increasing mental health problems and access to evidence based interventions.

Paramedics in our study felt we were not prepared for the pandemic and appeared to accept the unique situation, yet preparations were made and experiences of previous pandemics reported in the literature. Billings et al69 conducted a meta-synthesis of HCWs experiences of working on the front-line and views about support during COVID-19 and comparable pandemics. The results of this study were remarkably resonant with the themes within the present study and others Emergency Medical Services studies.29 70 Issues faced in the COVID-19 pandemic were therefore not totally unprecedented and questions therefore emerge around such Tragic Choices and learning lessons from previous, current and future pandemics, and the role and synthesis of research literature.

Tragic societal choices

Paramedics and other HCW’s were celebrated by visible campaigns of public support for the NHS through the media, politicians and Thursday night clapping and gifts. This context has echoes of Calabresi and Bobbitt’s23 notion that what counts as a Tragic Choice is in many ways a matter of public drama. Such public drama may have been influenced by campaigns such as the 'Stay Home, Protect the NHS, Save Lives' Protect the NHS’ slogan, reinforced through daily briefings, reports of increasing hospital bed capacity, deaths by COVID-19 and front-line workers being unable to access PPE. Calabresi and Bobbitt23 argue that when public drama in this way is central to designating tragic goods, society treats them as tragic when in fact, they need not have been tragically scarce, and devise an alternative allocation scheme to distribute them. Many of the choices and goods during usual times involve policy decision based on a range of factors such as clinical and cost effectiveness. Given warnings over the inevitability of a pandemic, questions therefore emerge from a public policy perspective around the role and influence of such public drama in decision making. As heart-warming as they are, such outpouring of public appreciation may misdirect attention from fundamental issues around our planning and resourcing of the current and future responses to pandemics, and indeed may be making these goods and services actually become more tragic in nature. We argue there may however be more choice inherent in the allocation and distribution of these issues, tragic as they may be, which led to the turning of ordinarily scarce resources into a tragically scarce ones, which again relates to value and the cost of costing.

Participants had been able to access the recommended PPE, but they also reported concerns over its quality, which has also been raised by other HCW’s71 72. Societies and governments globally have faced problems with PPE supply chains, as prior to the pandemic, China produced half the world’s face masks, and as COVID-19 spread across China their exports stopped.73 This is a vulnerability to society which reflects how this ordinary resource quickly became tragically scarce and subject to much public drama. Pandemic preparations no doubt saved lives, but some suggest this response was neither been well prepared nor adequate,74 75 and point to unheeded warnings over lack of preparation, including limited numbers of intensive care beds and PPE which were revealed at a time of austerity when bed numbers were being cut, which again highlights the Tragic Choices being made and potential subsequent costs.75

The high profile campaigns above along with directing of people to 111 as the first point of call, may have proved effective given increases in 111 calls and reductions in ambulance use of up to 16%76 77 at a time when ambulance services had been experiencing record levels of demand and yearly increases of around 5%,.78 79 Despite this, paramedics talked of patients avoiding care for fear of contracting COVID-19, which again has echoes of Tragic Choices, as Hope and Dixon80 suggest that the 'Stay Home, Protect the NHS, Save Lives' slogan was indeed too successful, and may have dissuaded people from going to hospital to treat other urgent conditions. Evidence is also emerging on such avoidance of emergency care and reciprocal increases in Out of Hospital Cardiac Arrests unrelated to COVID-19, along with stroke patients arriving too late to receive vital clot busting drugs.81

Paramedics predicted they would be forgotten about by the public after the pandemic and return to long hospital delays, inappropriate ambulance use and violence and aggression. Such a situation unfolded during the VE day celebrations, with reports of NHS staff having been stabbed in the back, with street parties and increases in intoxicated and violence patients assaulting staff.82 83 These issues clearly threaten the notion of being ‘United in Hardship’ and questions emerge around the relationship between HCWs duty of care owed to protect society during a pandemic and societies reciprocal obligations to protect them. Self-sacrifice and martyrism of health workers played out as tragic public drama forces us therefore to confront such issues of trust and how society and governments reward and pay for its healthcare system and its workers84 85 ?

The Organisation for Economic Co-operation and Development (OECD)86 found that 43.4% of NHS workers work up to 5 hours unpaid overtime per week, while 3.5% reported working more than 11 hours of unpaid per week. Huge variations were also found in investment in healthcare, with the UK investing £3257 per capita (9.8% of Gross Domestic Product (GDP), which is 18th of all OECD countries, despite being the fifth largest economy globally. This again highlights how governments and society cannot ignore the informative value of price, costs and the value we assign to paramedic care in pandemics. Every aspect from pandemic preparation and procurement of PPE to paramedic well-being may be informed by the price we are prepared to pay, how we value health services and the subsequent costs involved. Societies and governments will therefore continue to make Tragic Choices in this and future pandemics in order to protect unpriceable lives.