Publications from the West Midlands Ambulance Service. To find out more about WMAS visit their website at https://wmas.nhs.uk

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  • Evolution of triage systems

    Robertson-Steel, Iain (2006-01-26)
    The French word "trier", the origin of the word "triage", was originally applied to a process of sorting, probably around 1792, by Baron Dominique Jean Larrey, Surgeon in Chief to Napoleon's Imperial Guard. Larrey was credited with designing a flying ambulance: the Ambulance Volante. Baron Francois Percy also contributed to the organisation of a care system for the ongoing management of casualties. Out of the French Service de Santé, not only emerged the concept of triage, but the organisational structure necessary to handle the growing number of casualties in modern warfare. http://dx.doi.org/10.1136/emj.2005.030270 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/openhrt-2015-000281
  • Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial

    Nolan, Jerry P.; Deakin, Charles D.; Ji, Chen; Gates, Simon; Rosser, Andy; Lall, Ranjit; Perkins, Gavin D. (2020-01-30)
  • Haemorrhage from femoral vein cannula: an additional potential source of haemorrhage among intravenous drug users

    Cooke, R.; Fitzpatrick, J. (2009-08-21)
    Use of the femoral vein for self-administration of drugs is increasing among intravenous drug users. We report an unusual source of haemorrhage in an habitual intravenous drug user involved in trauma. https://emj.bmj.com/content/26/9/675. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2008.071175
  • Prehospital pleural decompression: a new way? : a new approach

    Mursell, Ian (2009-11)
    Needle thoracocentesis is the current UK ambulance services sole method of pleural decompression in suspected tension pneumothorax; however, the effectiveness of this procedure is questionable. This article will discuss the viability of an alternative method of pleural decompression—tube thoracostomy—providing comparisons to needle decompression and other current techniques used in prehospital care. The efficacy and safety of available techniques will be critically analysed and recommendations for the assessment and management of tension pneumothorax will be provided. Abstract published with permission.
  • Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial

    Rawlins, Lettie; Woollard, Malcolm; Williams, Julia; Hallam, Phil (2009-12-14)
    Objectives To determine whether listening to music during cardiopulmonary resuscitation (CPR) training increases the proportion of lay people delivering chest compressions of 100 per minute. Design Prospective randomised crossover trial. Setting Large UK university. Participants 130 volunteers (81 men) recruited on an opportunistic basis. Exclusion criteria included age under 18, trained health professionals, and cardiopulmonary resuscitation (CPR) training within the past three months. Interventions Volunteers performed three sequences of one minute of continuous chest compressions on a skill meter resuscitation manikin accompanied by no music, repeated choruses of Nellie the Elephant (Nellie), and That’s the Way (I like it) (TTW) according to a pre-randomised order. Main outcome measures Rate of chest compressions delivered (primary outcome), depth of compressions, proportion of incorrect compressions, and type of error. Results Median (interquartile range) compression rates were 110 (93-119) with no music, 105 (98-107) with Nellie, and 109 (103-110) with TTW. There were significant differences within groups between Nellie v no music and Nellie v TTW (P<0.001) but not no music v TTW (P=0.055). A compression rate of between 95 and 105 was achieved with no music, Nellie, and TTW for 15/130 (12%), 42/130 (32%), and 12/130 (9%) attempts, respectively. Differences in proportions were significant for Nellie v no music and Nellie v TTW (P<0.001) but not for no music v TTW (P=0.55). Relative risk for a compression rate between 95 and 105 was 2.8 (95% confidence interval 1.66 to 4.80) for Nellie v no music, 0.8 (0.40 to 1.62) for TTW v no music, and 3.5 (1.97 to 6.33) for Nellie v TTW. The number needed to treat for listening to Nellie v no music was 5 (4 to 10)—that is, the number of cardiac arrests required during which lay responders listen to Nellie to facilitate one patient receiving compressions at the correct rate (v no music) would be between four and 10. A greater proportion of compressions were too shallow when participants listened to Nellie v no music (56% v 47%, P=0.022). Conclusions Listening to Nellie the Elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute. Unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued. Further research is required to identify music that, when played during CPR training, increases the proportion of lay responders providing chest compressions at both the correct rate and depth. https://www.bmj.com/content/339/bmj.b4707. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/bmj.b4707
  • Clinical feedback to ambulance crews: supporting professional development

    Jenkinson, Emma; Hayman, T.; Bleetman, A. (2009-03-23)
    Ambulance crew involvement in patient care traditionally ends with handover of the patient at the emergency department (ED). We found that ambulance staff often asked informal questions about patients during subsequent visits. We therefore introduced a formal feedback service for ambulance crews in June 2005. This was initially run by a medical student, funded jointly by the trust and the West Midlands Ambulance Service. It is now run by an acute care practitioner. https://emj.bmj.com/content/26/4/309.1. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2007.053868
  • Prehospital care: the case of the misplaced tube

    Mursell, Ian (2010-03)
    This article critically reviews a fictional case study regarding a misplaced tracheal tube that was initially unrecognized despite a rigorous assessment to verify placement. It critically reviews the evidence surrounding verification techniques, tracheal tube securing and the principles of legal and ethical responsibility in patient handovers and transfer of care. Abstract published with permission.
  • PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

    Alghamdi, Abdulrhman; Cook, Eloïse; Carlton, Edward; Siriwardena, Aloysius; Hann, Mark; Thompson, Alexander; Foulkes, Angela; Phillips, John; Cooper, Jamie; Steve, Bell; et al. (2019-10-07)
    Introduction Within the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test. We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to ‘rule out’ ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the ‘very low risk’ group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting. Methods and analysis We will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment. Ethics and dissemination The study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.Abstract, URL This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI: 10.1136/bmjopen-2019-032834
  • European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation

    Perkins, Gavin D.; Handley, Anthony J.; Koster, Rudolph W.; Castren, Maaret; Smyth, Michael A.; Olasveengen, Theresa; Monsieurs, Koenraad G.; Raffay, Violetta; Grasner, Jan-Thorsten; Wenzel, Volker; et al. (2015-10)
  • What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom

    Snooks, Helen; Khanom, Ashrafunnesa; Cole, Robert; Edwards, Adrian; Edwards, Bethan Mair; Evans, Bridie A.; Foster, Theresa; Fothergill, Rachael; Gripper, Carol P.; Hampton, Chelsey; et al. (2019-12-28)
  • Physical health in mental health: considerations for paramedics

    Cromar-Hayes, Maxine; Seaton, Walter (2020-01)
    Abstract published with permission. Life expectancy for people with a mental illness diagnosis is 15–20 years less than those without, mainly because of poor physical health. Mental ill health affects a significant proportion of paramedics' patients, and practitioners could assess and promote their physical health even though contact time is limited. Factors affecting physical health include substandard and disjointed care, stigma and diagnostic overshadowing—where physical symptoms are dismissed as a feature of mental illness. Diagnostic overshadowing is not discussed in key paramedic literature, although patients with mental health problems are at risk of not having their physical needs being taken seriously. The paramedic's role in health promotion is receiving more attention. Making Every Contact Count (MECC)—a behaviour change model using brief interaction—could be adopted by paramedics to promote physical health, especially when linked to campaigns and local services. Health promotion is in its early days in paramedicine, and paramedics could learn from the experiences of other professions. (Abstract published with permission).
  • PaRAMeDIC: a randomized controlled trial of a mechanical compression device

    Smyth, Mike (2012-01)
    Abstract published with permission. Survival from out-of-hospital cardiac arrest (OHCA) is influenced by the quality of cardiopulmonary resuscitation (CPR). However, research shows that in the out-of-hospital environment, and particularly during ambulance transport, CPR quality is frequently sub-optimal. Mechanical compression devices can deliver high quality CPR, yet there is an absence of high quality evidence to demonstrate improved clinical or cost effectiveness outcomes. The PaRAMeDIC trial will compare manual CPR with mechanical CPR in adult patients with non-traumatic OHCA. Objectives: the primary objective is to evaluate the effectiveness of mechanical chest compressions using the LUCAS (Lund University Cardiopulmonary Assistance System)-2 on mortality at 30 days post-OHCA. Secondary objectives include survived event (return of spontaneous circulation at hospital admission), quality of life and cognitive function at 3 and 12 months, survival at 12 months and cost effectiveness. Method: the trial is a pragmatic, cluster randomized controlled trial. Ambulance vehicles are randomized to control or LUCAS arms. Patient allocation is determined by the first ambulance vehicle which arrives first on scene (manual CPR vehicle or LUCAS CPR vehicle). The trial will assess the clinical and cost effectiveness of the LUCAS-2 device. Trial Registration: The trial is registered on the International Standard Randomised Controlled Trial Number Registry (ISRCTN08233942).
  • Lecture notes: emergency medicine

    Armitage, Ewan (2011-12)
  • Lights, camera, disciplinary action?

    Mursell, Ian (2012-02)
    Abstract published with permission. There seldom appears to be a day go by without the opportunity to watch ourselves or colleagues in the latest episode of ‘Emergency Hero Rescues’ or similar ‘real life’ television programmes. However, the growth of such shows and inherent public interest in the emergency services brings to light the question of whether such media coverage is of benefit or risk to our profession. For many of us, watching such programmes is a guilty pleasure, we don't want to watch, but are strangely drawn to them. How many times have you found yourself ‘tutting’ at the TV or shaking your head pointing out the error of our peer's actions? Regardless of our reactions to such programmes, public interest is difficult to deny and as such, television coverage of prehospital care is a subject for careful consideration.
  • Use of intranasal drug administration in the pre-hospital setting

    Creed, Chloe (2012-12)
    Abstract published with permission. This article explores the benefits of intranasal as a recommended route for drug delivery in the pre-hospital setting for healthcare professionals. It is currently used in Australia,USA and some UK Ambulance services and remains a preferred route in certain patient groups. Intranasal can lead to a reduction in needle stick injuries for the healthcare professional and allowing immediate drug therapy in a emergency setting for bystanders. Randomised control trial’s and evidencebased practice to discuss the absorption rate and different drugs that could be used through this route. After reading this article paramedics should be more aware of this safe route and its benefits in the emergency setting.
  • ‘They are not silly people – they know the difference’: clinician focus group views on a pilot randomised controlled trial of prehospital continuous positive airway pressure (CPAP)

    Miller, Joshua; Keating, Samuel; Scott, Alex; Fuller, Gordon W.; Goodacre, Steve (2019-09-24)
    Background Continuous positive airway pressure (CPAP) is not in widespread use in UK ambulance services, but could benefit patients with acute respiratory failure (ARF). As a new treatment in this context, clinician acceptability is an important factor in the feasibility of conducting definitive research in the prehospital arena. Methods As part of a pilot randomised controlled trial (the ACUTE study), nine trial-trained paramedics took part in three semi-structured focus groups. 204 trained staff had been given the opportunity to take part. The sample included six staff who had recruited to the trial, one who had not, and two who had withdrawn from it. Audio-recordings were transcribed and analysed thematically. Results Participants described facilitators to trial participation including: clear eligibility criteria and patient documentation, access to demonstration equipment, training away from the work environment, and repeated patient recruitment. Barriers to taking part included: the lack of protected time for training, inadequate workplace facilities for the electronic learning package used, adverse responses by receiving hospital staff, and infrequent patient exposure. Both paramedics who withdrew cited the inconvenience of carrying packs each shift. Some participants described anxiety and distress when opening packs to find a standard-care mask, and reported patients having similar reactions. Conclusions Future researchers could promote improved workplace computing facilities and increased provision of face-to-face training days, which were praised by participants in these focus groups, but limited to a single event distant from some staff. Greater stakeholder engagement by researchers could reduce the difficulties at hospital handover reported by some ambulance staff. Where blinding is not possible, the perceptions of clinicians and patients should be considered carefully, as this study shows both may have adverse emotional responses to being treated with standard care, particularly when prospective consent discussions describe the trial intervention as potentially beneficial., https://emj.bmj.com/content/36/10/e12.2 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2019-999abs.28
  • Keeping the beat: does music improve the performance of chest compression by lay persons?

    Rawlins, Lettie; Woollard, Malcolm; Hallam, Phil; Williams, Julia (2011-03)
    Background Early bystander cardiopulmonary resuscitation (CPR) increases survival from out-of-hospital cardiac arrest. Simplifying training can improve skill retention and confidence. A recent pilot study suggested music may help health professionals perform CPR. The song ‘Nellie the Elephant’ (tempo 100 bpm) is sometimes used to encourage compression rates in accordance with Resuscitation Council guidelines. This study investigates whether music helps lay persons perform compressions at 100 per minute. Methods This randomised cross-over trial opportunistically recruited lay volunteers who performed three sequences, pre-randomised for order, of one minute of continuous chest compressions on a recording manikin accompanied by no music (NM) and repeated choruses of ‘Nellie the Elephant’ (Nellie), and ‘That's The Way (I Like It)' (TTW). Results Of 130 participants, 62% were male, median age was 21 (IQR 20 to 25), 72% had no previous CPR training. Mode and IQR for compression rate were NM 111 (93 to 119); Nellie 106 (98 to 107), (TTW) 109 (103 to 110). Within-groups differences were significant for Nellie vs NM and Nellie vs TTW (p<0.001) but not NM vs TTW (p=0.055). A compression rate of 95 to 105 was achieved with NM, Nellie, and TTW for 15/130 (12%), 42/130 (32%) and 12/130 (9%) attempts respectively. Differences in proportions were significant for Nellie vs. NM and Nellie vs TTW (p<0.0001) but not for NM vs TTW (p=0.55). Relative ‘risk’ for compression rate between 95 and 105 was 2.8 for Nellie vs NM (95%CI 1.66 to 4.80), 0.8 for TTW vs NM (95% CI 0.40 to 1.62), and 3.5 for Nellie vs. TTW (95% CI 1.97 to 6.33). Conclusion and recommendations ‘Listening to Nellie’ (vs TTW or no music) significantly increased the proportion of lay persons achieving compression rates close to the 100 bpm guideline. Playing it during training and ‘real’ CPR may help rescuers deliver correct compression rates. https://emj.bmj.com/content/emermed/28/3/e1.18.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emj.2010.108605.6

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