What is said about ‘#paramedicine’: an analysis of Twitter posts over the past decade

INTRODUCTION Over the past decade, paramedicine has been formalised in many countries, gaining recognition as a fully accredited health profession in various health systems in countries such as Australia and the United Kingdom.[1] The evolution of paramedicine has also seen gradual establishment and re-evaluation of clinical practice guidelines, regulatory frameworks and tertiary-level academic and research courses.[2] In Singapore, the Singapore Civil Defence Force provides nationwide emergency medical services (EMS), and it is a fire-based system activated by a centralised '995' emergency call and dispatch system. Paramedicine training has advanced, and a full-time diploma in paramedic science has been made available since 2021 to upgrade paramedics' understanding of treatment protocols and enable greater mastery in the management of complex medical emergencies.[3] Given the large burden of chronic diseases worldwide, a focus on diverting lower-acuity cases to community care pathways has also birthed an expanded scope of paramedic practice elsewhere. This is known as community paramedicine, which includes training in the assessment, treatment and referral of acute-on-chronic long-term conditions.[4,5] The generalist nature of paramedicine has never been more crucial, especially in the light of growing demands on EMS worldwide. This was particularly true during the coronavirus disease 2019 (COVID-19) pandemic, which saw huge increases in call volumes to EMS call systems worldwide.[6,7] Yet, the term 'paramedicine' per se lacks conceptual clarity and has varying interpretations,[8] and this may hinder the progression of the field as a whole. Cognisant of such advancements in the paramedicine profession and appreciating this against the backdrop of an ever-changing healthcare landscape, the multifaceted roles of 21st century paramedics should be further elucidated. This study, therefore, aimed to examine the contemporary topics in paramedicine from a global perspective vis-à-vis the public Twitter (rebranded as 'X') chatter around the term 'paramedicine'. With more than 250 million users globally, Twitter also encompasses a broad range of social demographics that may otherwise go unreported, making it the social media platform of choice.[9] METHODS The methodology for the present exploratory study was adapted from previous infodemiology studies that utilised Twitter to investigate social trends and expressed sentiments.[10,11] Using the search terms '#paramedic' OR '#paramedicine' OR '#paramed', we extracted original tweets posted in English from 1 August 2012 to 1 August 2022. We also used other search terms, including 'EMS' and 'EMT'; however, these abbreviations had broad usage over Twitter and appeared to pick up several non-paramedicine tweets and content. Retweets and duplicate tweets (i.e. tweets with identical sentences and words) were excluded from this study. BERTopic, a topic modelling technique that leverages state-of-the-art Bidirectional Encoder Representations from Transformers (BERT) embeddings and class-based term frequency-inverse document frequency (TF-IDF),[12] was then applied to generate dense clusters of interpretable topics and highlight key words in the topic descriptions. Unlike supervised machine learning, in unsupervised machine learning, the data do not have a known outcome, and as a language model, BERTopic has been pretrained on a large volume of free text and has demonstrated good stability across domains.[13] R (version 3.6.3) and Python (version 3.7.13) were used for all quantitative analyses. Subsequently, thematic analysis was performed inductively and iteratively by the study investigators; the study investigators familiarised themselves with the keywords and sample tweets, produced preliminary codes, formulated overarching themes, reviewed and refined themes, defined and specified themes and produced a write-up.[14] Intercoder reliability was not calculated as the study investigators reviewed the codes and themes independently, and coding disagreements were resolved by further discussion until consensus was reached. RESULTS A total of 225,074 initial tweets were identified for the period from 1 August 2012 to 1 August 2022. Of these tweets, 158,007 were eventually included in this study. A flowchart illustrating the tweet selection process with the help of unsupervised machine learning technology is shown in Figure 1. BERTopic generated six topics related to the public discussion surrounding paramedics and paramedicine. The total prevalence of these six topics was 85.5%, with the remaining 14.5% being tweets that were classified as outliers, that is, not assigned to any topics generated. This also helped to reduce noise, which can affect the topic representations.Figure 1: Flowchart illustrates the tweets' filtering and selection process.Reflexive thematic analysis by the study investigators further clustered the six topics into three major themes. Table 1 shows the details of the topics and sample tweets within each theme.Table 1: Three themes related to paramedicine, along with the respective topics and sample tweets (N=158,007).Collectively, topic 1 (the predominant topic) and topic 2 reflected recognition of the role of paramedics (Theme 1), topics 3 and 4 highlighted the challenges (mental health-related) faced by paramedics in their line of work (Theme 2) and topics 5 and 6 reflected the value of continuing education for paramedics (Theme 3). We also analysed the temporal trends for the tweets belonging to the identified themes [Figure 2]. It was evident that the COVID-19 pandemic likely brought greater attention to this group of health professionals, as well as their associated physical struggles and emotional toll, with majority of the tweets belonging to Theme 2 posted from 2019 onwards.Figure 2: Graph shows temporal variations in the normalised frequency of tweets belonging to the three identified themes.DISCUSSION Through an unsupervised machine learning analysis of Twitter posts, we examined contemporary topics in paramedicine and the way they were discussed by members of the profession and the public. The present study builds on the emergent stream of studies that used Twitter and novel machine learning approaches to identify dominant themes and to understand social trends.[10,11,15] With a growing demand for EMS, and more patients requiring complex medical care within the community, prehospital systems of care and primary care services are facing unprecedented challenges, including difficulties in the recruitment and retention of EMS workers.[16] In fact, in the 2020 EMS Trend Report, the retention of EMS personnel was found to be one of the most critical issues confronting EMS organisations today.[17] It is heartening that there is increasing recognition of the related physical and emotional challenges faced by paramedics (as highlighted by Theme 2) today, as compared to 5 or 10 years ago. There is evidence that the physical and emotional challenges faced by frontline paramedics were made worse by the COVID-19 pandemic, which saw huge increases in EMS call volumes.[5,6,18] Paramedics were also required to attend to cases in full personal protective equipment and work extended hours during the pandemic, which can result in increased heat exhaustion and psychological stress.[19] This was reflected in the conversations regarding job burnout and the mental health impact of the pandemic on paramedic first responders; the physical and emotional toll of COVID-19 on EMS workers cannot be understated. In our data, we also noted an increase in public chatter around these topics from 2019 onwards. This is probably not unique to the paramedic profession. A study found that among people who self-identified as doctors on Twitter, many responded to the ongoing pandemic by tweeting prosocial behaviour ('stay home' and 'social distancing' were common phrases) and advocating for their own profession ('help us' and 'healthcare workers' were common phrases).[20] As the care provided by EMS evolves, the role of the paramedic has also evolved. In addition to providing advanced life support, paramedics are increasingly trained to manage long-term conditions and acute presentations of mental ill health.[3] However, a recent systematic review found that while paramedics can safely apply their extended skills to assess and treat patients in primary care, there were existing conflicts and lack of standardisation in relation to their job titles, roles and responsibilities.[21] An important aspect for all healthcare workers would be continuing education to maintain and learn new skills. This was highlighted by Theme 3, as we saw conversations surrounding technical difficulties faced by paramedics, especially in terms of advanced airway management. Advanced airway management in the prehospital setting has always been a priority for paramedicine education and research.[22] However, there are still some controversies. For example, although, endotracheal intubation is performed to optimally oxygenate, ventilate and protect critically ill patients from aspiration, its use in the prehospital setting is variable and has associated safety and efficacy concerns.[23] For the purposes of training and education, podcasts appear to be a popular and accessible mode (Topic 6). This should be further considered for educational purposes. This study has some limitations. As the majority of Twitter users are from North America and Europe, the findings of this exploratory analysis may not be generalisable to certain countries and communities. In addition, paramedics also operate in a broad range of contexts and may have a variety of related job titles, including emergency medical technicians, ambulance operators, public safety officers, etc.[24,25] As such, certain tweets and sentiments may not have been picked up using our present search strategy, and this may have introduced some selection bias to our study. In conclusion, public conversations over Twitter highlighted the first-responder role of paramedics, the job-related challenges and the need for continuing professional education. These areas should be further examined, such as, through more structured focus group studies, and they may help inform the equipoise of paramedicine training and education priorities as the profession steadily evolves. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.