• Clinical guidelines — one year on

      Irving, Steve; Millins, Mark (2014-01)
    • Developing leadership in the UK’s ambulance service: a review of the consultant paramedic role

      Hodge, Andrew (2014-03)
      Abstract published with permission. Background: This study seeks to understand part of the emerging clinical leadership framework implemented in the UK’s NHS ambulance services in recent years. The aim is to explore the relatively new role of consultant paramedics and understand their leadership activities in relationship to nationally determined requirements, and the challenges they face performing this crucial leadership role. Methods: Semi-structured interviews were conducted with all consultant paramedics in the UK in 2013. Thematic analysis and coding were used to analyse the data and identify emergent themes. Additionally, basic demographic data was collected for comparison against national requirements. Findings: The findings illustrated three key themes: credible clinical leadership, an emerging empowered profession, and role expectations. There is a clear indication that consultant paramedics are a key part of clinical leadership for the paramedic profession. However, they are challenged to remain clinically competent by undertaking regular clinical practice and providing visible leadership on the ground, while strategically taking the profession forward. Operational resistance and power issues were highlighted as some of the problems faced by these clinical leaders. Implications: The findings may prove useful for employers in reviewing their clinical leadership structures, and in workforce planning for future consultant paramedics. The paramedic profession and its professional body may equally find this study useful for informing future strategic planning.
    • Exploring the developmental need for a paramedic pathway to mental health

      Elliott, Ruth; Brown, Paul (2013-05)
      Abstract published with permission. The following article discusses an organisational development need of a national ‘Mental Health Pathway’ to enable paramedics to provide the appropriate care for people who present mental health issues. The Department of Health acknowledges the huge modernisation of the ambulance service in England and faster access to people with immediate life-threatening conditions; however, the service is also responding to an increasing number of patients who have an urgent primary care need, which includes mental distress, as opposed to clinical emergency. The Department of Health (2009) policy calls for a ‘new vision’, where the ambulance service could increase efficiency and effectiveness towards patients who are experiencing non life-threatening emergencies. The key aims are to form a programme of advancement to address both improving mental health and accessibility of services for people with poor mental health. The vision of the policy is that by 2020 mental and physical health will have equal priority. The development of a mental health pathway within the ambulance service may help to reduce admissions or re-attendance, while improving care for patients. An evidence-based approach is used to provide a balanced, logical and supported argument within a reflection of practice. This is evaluated against a hypothetical patient’s case study, which reflects common issues faced by paramedics and ambulance technicians. The analytical process considers patient, professional, organisational and multi-disciplinary team perspectives.
    • Human factors, cognitive bias and the paramedic

      Allen, James (2019-01-12)
      The consequences of human factors and cognitive bias can be catastrophic if unrecognised. Errors can lead to loss of life because of the flawed nature of human cognition and the way we interact with our environment. Seemingly small mistakes or miscommunications can lead to negative outcomes for patients and clinicians alike. It is easy to see therefore why the College of Paramedics now recommends the teaching of human factors at higher education institutions. Using a problem-based approach, this article aims to inform prehospital clinicians about how human factors and cognitive bias can affect them and their practice, and how these can be mitigated. Abstract published with permission.
    • Improving post-resuscitation care after out-of-hospital cardiac arrest

      Fisher, Ruth (2020-01)
      Abstract published with permission. Introduction: The average rate of survival following an out-of-hospital cardiac arrest (OHCA) in the UK was 7–8% at the start of 2019. An estimated 60 000 OHCAs are attended by UK ambulance services annually and, despite developments in prehospital and post-resuscitation care, there are significant variations in survival between regions and countries. Aims: This study aims to identify the potential for care pathways, evaluate UK practices and review the evidence for direct referral of OHCA patients to dedicated cardiac arrest centres. Methods: Evidence was gathered from 20 articles identified through a systematic search of articles related to OHCA and post-resuscitation care, as well as from NHS England in relation to performance and outcomes. Results: Between April 2018 and January 2019, 30.6% of patients experiencing an OHCA had a recorded ROSC (return of spontaneous circulation), and 10.2% survived. However, the 58.7% compliance with the post-ROSC care bundle by ambulance services suggests variations in the delivery of post-resuscitation care. At present, UK ambulance services stabilise and transfer OHCA patients with ROSC to the nearest emergency department, which may not provide specialist services. Holland and Norway report survival rates of 21% and 25% respectively, and operate a centralised approach to post-resuscitation care through designated cardiac arrest centres, which provide specialist care that helps to improve the likelihood of survival. While no randomised controlled trials have been carried out in relation to cardiac arrest centres, it is recognised that the quality of care in the post-resuscitation phase is important, as this is when the highest proportion of deaths occur. Conclusion: Further research into specific care pathways and centralised care should be carried out, and an OHCA postresuscitation care pathway should be developed to improve the delivery of care and survival.
    • Is it time to change? The use of intranasal fentanyl for severe pain in the pre-hospital setting

      Parkinson, Martin (2014-11)
      Abstract published with permission. The treatment of pain is a commonplace issue for today’s paramedics, where the need for new analgesics to overcome cannulation barriers is gathering momentum. Intranasal fentanyl has proven itself to be a very safe and effective form of analgesia that overcomes those barriers and can help paramedics provide a higher standard of care. Although research into its use in the prehospital environment is still limited, evidence of its effectiveness in the accident and emergency department has highlighted its potential for helping paramedics treat severe pain where venous access is compromised. Studies have shown that intranasal fentanyl compares with the analgesic standard set by intravenous morphine and is rapidly becoming the drug of choice in the paediatric accident and emergency department.
    • Is there scope for an observational pain scoring tool in paramedic practice?

      Harvey, Christopher (2014-02)
      Abstract published with permission. In the pre-hospital environment, attending an older person can pose many challenges, including a lack of a detailed history, polypharmacy and co-morbidities, as well as a lack of out-of-hours support to name but a few. These challenges are enhanced further when the patient is cognitively impaired by syndromes such as dementia. There appears to be very little research available into how the pain of older people with dementia is assessed and managed by paramedics. This article highlights a literature review that was carried out to explore the evidence base and possible implementation of the Abbey Pain Scale, with the view of conducting a study in the near future. Particular focus is made on the education and training required to implement the tool, other environments where it has been adopted, as well as benefits and limitations.
    • JPP letters - Recongnising ECG Landmarks

      Poskitt, Philip; Simpson-Scott, Karen; Mendes, Aysha (2018-10)
    • A mannequin study comparing suitability of the i-gel™ with a laryngeal mask airway device

      Mark, Julian; Walker, Alison; Davey, Christine (2011-08)
      Abstract published with permission. Objectives: To compare the suitability of the i-gel™ (Intersurgical Ltd, UK) supraglottic airway device with a single-use laryngeal mask airway (LMA) in the hazardous area response team (HART) environment and the urban search and rescue (USAR) environment. Method: five chemical, biological, radiological and nuclear trained urban search and rescue paramedics attempted five insertions of each supraglottic airway device into a Laerdal® ALS mannequin (Laerdal, Norway) in three separate environments: normal (supine, waist high), HART (wearing gas-tight suits and respirators) and USAR (in a simulated confined space). As a control group, five anaesthetists also attempted five insertions of each supraglottic airway device into a Laerdal® Airway Trainer (Laerdal, Norway) under normal conditions. Time from first touching the device to successful inflation of the mannequin's lungs’ using a self-inflating bag-valve device was recorded and operator opinion was captured using a four-point Likert scale. Results: insertion of the i-gel airway was significantly faster than insertion of the LMA in simulated USAR conditions (P<0.001), there was no significant difference in control conditions or when wearing gas-tight personal protective equipment. There was no difference in the number of attempts required to achieve correct placement of either supraglottic airway device in any situation. Conclusions: this study has demonstrated that, in simulated USAR conditions, the i-gel supraglottic airway device performs at least as well as the LMA and is significantly quicker to insert. The authors therefore recommend that the i-gel is introduced into the USAR HART environment with further clinical evaluation in this and other prehospital settings.
    • The National Ambulance LGBT Network Conference 2017

      Gunn, Alistair; Renshaw, John (2018-03)
      Abstract published with permission. In 2015, the National Ambulance Lesbian Gay Bisexual and Transgender (LGBT) Network was founded to help improve the experiences of LGBT people who contact the ambulance service; expand the support offered to ambulance staff; and create a visible presence in the community. Since its formation, committee members, regional representatives and ambulance staff from across the country have worked tirelessly towards these core objectives, and to share best practice between regional ambulance LGBT networks. In August of 2017, the Network held its second annual conference to emphasise some of the health inequalities that LGBT people are known to experience when accessing health care. Over the course of the day, delegates were able to learn about interventions and support measures that are available through a series of workshops on issues such as dementia care and post-traumatic stress disorder. This conference report documents the success of the National Ambulance LGBT Network Conference 2017 and provides an overview of the engagement and support packages that are currently under development to support staff wellbeing and patient experience.
    • Non-invasive ventilation as a prehospital intervention for acute COPD exacerbation

      McCreesh, Samuel (2019-09-11)
      Abstract published with permission. Chronic obstructive pulmonary disease (COPD) is the second most common respiratory illness in the UK, affecting over 1 million people. Acute exacerbations of COPD are a common presentation to the ambulance service and account for thousands of hospital admissions annually. Acute respiratory failure accompanies approximately 20% of exacerbations. Current prehospital treatment focuses on oxygen and pharmacological therapy to treat the underlying causes. Non-invasive ventilation (NIV) is a method of ventilatory support that does not require endotracheal intubation, avoiding significant risks associated with intubation and sedation. While some UK ambulance services have introduced NIV, UK guidelines primarily focus on hospital use. International trials have shown prehospital NIV to be more effective than standard treatment in terms of reducing the need for intubation and invasive ventilation in hospital. However, further research is necessary before NIV is introduced widely in UK prehospital paramedic practice.
    • Pain: highlighting the law and ethics of pain relief in end-of-life patients

      Parkinson, Martin (2015-07)
      Abstract published with permission. As the world of palliative medicine is rapidly becoming a fixture in the pre-hospital field of practice, this article looks to explore the ethical and legal issues surrounding pain relief for end-of-life patients by paramedics. Particular attention is focused on the moral and ethical principles of care as proposed by Beauchamp and Childress (2008), as well as the legal aspects of care as set out by the European Court of Human Rights. Through the use of law cases, this article looks to demonstrate precedence for practice, as well as the implications that arise thereof. This article concludes that, although many aspects are still a grey area for paramedics, the depth of law cases, alongside the moral arguments, show that providing paramedics act with the best interests of the patient at heart and work within a multi-disciplinary team, the administration of analgesia to prevent suffering can be legally and ethically proven.
    • Pain: understanding the biopsychosocial model and the paramedic’s role within the multi-disciplinary team

      Parkinson, Martin (2015-05)
      Abstract published with permission. Pain, and its consequent management, is a major factor in today’s ambulance service, with up to 50% of patients reporting pain among their symptoms when contacting the emergency service. This article explores the role of the paramedic within the multi-disciplinary team and asks the question: ‘What is the appropriate treatment?’ A study of the biopsychosocial model shows that modern clinicians who focus solely on the biomedical model are under-treating the patient’s pain by ignoring the psychological and sociological aspects. All this belies a culture of pain management where recognition and treatments of painful conditions bias heavily on some diseases while ignoring or dismissing others. This can, in the eyes of patients, make the individuals complicit with the neglect of painful and life-altering conditions that may permanently change the patients focus and aspirations for the future, and disconnect the patient from the people that are there to help them.
    • Palliative emergencies in the pre-hospital setting

      Parkinson, Martin (2014-10)
      Abstract published with permission. Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols. Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient’s pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment. Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures. Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.
    • Paramedic management of out-of-hospital postpartum haemorrhage with TXA

      Wren, James (2017-09)
      Abstract published with permission. Background: As a result of some of the factors discussed within this systematic review, UK Paramedics are more likely to manage postpartum haemorrhage (PPH) within the out-of-hospital setting. This systematic review attempts to address the question: 'Is it suitable for TXA to be implemented within the UK paramedic management of out-of-hospital PPH?' Methods: Randomised control trials (RCTs) focusing on the effect of TXA upon blood loss during PPH were included within this review. A search strategy was created and applied to databases. Critical analysis of the included studies was carried out, and data were presented within tabular format and discussed through the use of narrative synthesis. Results: Eight RCTs were included within this systematic review. All studies found a significant reduction in the volume of blood loss during PPH when TXA was administered. Discussion: Although TXA was found to significantly reduce the volume of blood loss during PPH, existing evidence is insufficient to support its use within the UK paramedic out-of-hospital management of PPH. Without the presence of studies which are solely focused on the target population, it is difficult to generalise the findings directly to the UK out-of-hospital paramedic management of PPH. This systematic review does however support and supplement the findings of past and current research based upon the relationship between TXA and PPH.
    • Paramedic Pathfinder: is it really better than current practice?

      Goulding, James (2014-08)
      Abstract published with permission. Following the recent publication of an article on the Paramedic Pathfinder in the Emergency Medicine Journal, James Goulding argues that rather than highlighting a step forward for the paramedic profession, it serves as an indication that there needs to be more rigorous research before a change in current methods can be recommended.
    • Prehospital emergency anaesthesia: time taken to care for and respond to a critically injured patient

      Blinkhorn, Anthony (2019-07-10)
      The 2007 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Trauma: Who Cares? report recommended that people trained to administer anaesthesia and intubate severely injured patients should be available in prehospital environments. Published articles, reference documents and guidance reports were reviewed to compare the management plans and standard operating procedures produced by an ambulance trust in England that provides prehospital emergency anaesthesia (PHEA). Documents reviewed all provide a common un-referenced patient injury list showing indications to perform PHEA but do not state a time frame within which it should be performed. No minimum time before PHEA is started and how long is acceptable to wait for a specialist resource to arrive before an ambulance can transport to a hospital were found. Further work is required to establish and formalise this time frame. Abstract published with permission.
    • Prehospital management of a patient with severe sepsis

      Boardman, Sue; Richmond, Chris; Robson, Wayne; Daniels, Ron (2013-09-29)
      Paramedics have made a significant contribution to reductions in mortality for the time-critical conditions of acute myocardial infarction (AMI) and major trauma (Myocardial Ischaemia National Audit Project (MINAP), 2008), and they will be instrumental in helping to reduce stroke mortality in the near future (Department of Health 2006). These improvements have, and will be achieved by pre-hospital diagnosis and prompt aggressive treatment. There is however another time critical condition that is currently not being targeted, in which pre-hospital staff could significantly improve the patient’s chances of survival. This condition is severe sepsis. This article presents a case study of a patient with severe sepsis who is transported from a nursing home to the emergency department (ED), and explores how paramedics can diagnose severe sepsis by use of a screening tool, and discusses the practicalities of delivering evidence-based care en route to hospital (high concentration oxygen, intravenous fluid challenges, intravenous antibiotics, measuring blood lactate). The benefits of alerting the receiving hospital of a patient with severe sepsis are also discussed. Abstract published with permission.
    • PTSD, available support and development of services in the UK Ambulance Service

      Dodd, Greg (2017-06)
      Abstract published with permission. The role of front line ambulance staff in the UK has developed so rapidly that it is almost unrecognisable from days gone by, when scoop and run tactics were commonplace. With additional responsibilities, pressurised decision making and a range of sometimes complex interventions, unique pressures have also developed. The purpose of this article is to review pertinent information relating to how these additional pressures can metamorphose into specific conditions such as post traumatic stress disorder (PTSD). The prevalence of this and other debilitating conditions such as depression and anxiety specific to the ambulance service is reflected upon, whilst existing support from the ambulance service is examined. By broadening both knowledge and confidence relating to this increasingly significant problem, formulation of our own local improvements can take place in the near future.