RSS 1.0Publications - London Ambulance Service
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The future of paramedic intubation: who should be responsible?Prehospital airway management in trauma patients has been the subject of debate among many professionals for a number of years. At present, the gold standard for airway management and optimal ventilation is endotracheal intubation. Paramedics, as the frontline prehospital care providers, are currently able to practice endotracheal intubation in order to secure an airway, but only when the patient is comatose with no gag reflex. Training in endotracheal intubation has been under close scrutiny by regulatory bodies such as the Joint Royal Colleges Ambulance Service Liaison Committee, with emphasis on using other techniques to secure the airway, including supra-glottic airway devices. Rapid sequence induction and drug assisted airway management is only carried out by doctors working in the prehospital arena. However, a number of studies document that paramedics are more than capable of carrying out successful rapid sequence induction in trauma patients. This article considers the training received by paramedics in airway management, techniques that are employed and the influence of current literature on the debate over paramedic endotracheal intubation. Abstract published with permission.
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A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008Paramedic tracheal intubation has been practised in the UK for more than 20 years and is currently a core skill for paramedics. Growing evidence suggests that tracheal intubation is not the optimal method of airway management by paramedics and may be detrimental to patient outcomes. There is also evidence that the current initial training of 25 intubations performed in-hospital is inadequate, and that the lack of ongoing intubation practice may compound this further. Supraglottic airway devices (eg, laryngeal mask airway), which were not available when extended training and paramedic intubation was first introduced, are now in use in many ambulance services and are a suitable alternative prehospital airway device for paramedics. https://emj.bmj.com/content/27/3/226.long. 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.2009.082115
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Development and pilot of clinical performance indicators for English ambulance servicesIntroduction There is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing clinical demands on services. We report on progress on the national pilot of clinical performance indicators for English ambulance services. Method Clinical performance indicators were developed in five clinical areas: acute myocardial infarction, cardiac arrest, stroke (including transient ischaemic attack), asthma and hypoglycaemia. These were determined on the basis of common acute conditions presenting to ambulance services and in line with a previously published framework. Indicators were piloted by ambulance services in England and results were presented in tables and graphically using funnel (statistical process control) plots. Results Progress for developing, agreeing and piloting of indicators has been rapid, from initial agreement in May 2007 to completion of the pilot phase by the end of March 2008. The results of benchmarking of indicators are shown. The pilot has informed services in deciding the focus of their improvement programme in 2008–2009 and indicators have been adopted for national performance assessment of standards of prehospital care. Conclusion The pilot will provide the basis for further development of clinical indicators, benchmarking of performance and implementation of specific evidence-based interventions to improve care in areas identified for improvement. A national performance improvement registry will enable evaluation and sharing of effective improvement methods as well as increasing stakeholder and public access to information on the quality of care provided by ambulance services. https://emj.bmj.com/content/27/4/327. 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.2009.072397
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Supporting research and development in ambulance services: research for better health care in prehospital settingsBackground This paper discusses recent developments in research support for ambulance trusts in England and Wales and how this could be designed to lead to better implementation, collaboration in and initiation of high-quality research to support a truly evidence-based service. Method The National Ambulance Research Steering Group was set up in 2007 to establish the strategic direction for involvement of regional ambulance services in developing relevant and well-designed research for improving the quality of services to patients. Results Ambulance services have been working together and with academic partners to implement research and to participate, collaborate and lead the design of research that is relevant for patients and ambulance services. Conclusion New structures to support the strategic development of ambulance and prehospital research will help address gaps in the evidence for health interventions and service delivery in prehospital and ambulance care and ensure that ambulance services can increase their capacity and capability for high-quality research. https://emj.bmj.com/content/27/4/324. 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.2009.072363
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Acute cocaine toxicity: assessment and cardiac riskThe UK has the highest prevalence of drug use within Europe, with a 13% increase in cocaine and ecstasy related deaths reported between 2004 and 2005. This is significant to emergency medical personnel because cocaine toxicity can present clinically as acute coronary syndrome (ACS) minus typical associated risk factors. Cocaine use has an immediate effect on the body, having an onset of action seconds to minutes after administration. The resultant effect is manyfold, but can be divided into the two broad categories of central nervous system and cardiovascular effects. Cocaine misuse is a trigger of ACS, acute myocardial infarction and sudden death in a population of patients largely free of classic cardiovascular risk factors. Emergency medical staff are in a position to provide early and effective management through history-taking and assessment tools in conjunction with therapeutic intervention. The aim of this article is to highlight the presentation and consequence of acute cocaine toxicity in relation to its assessment, management and cardiac emergencies within the prehospital setting. Abstract published with permission.
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Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcomeObjective: To compare out-of-hospital cardiac arrest (OOHCA) characteristics in white and South Asian populations within Greater London. Methods: Data for OOHCAs were extracted from 1 April 2003 to 31 March 2007. Primary study variables included age, gender, ethnicity, response times from 999 call to ambulance arrival, initial cardiac rhythm, whether bystander cardiopulmonary resuscitation was provided before arrival of the London Ambulance Service (LAS) NHS Trust crew, whether the arrest was witnessed (bystander or LAS crew) and hospital outcome, including survival to hospital admission and discharge. Results: Of 13 013 OOHCAs of presumed cardiac cause, 3161 (24.3%) had ethnicity codes assigned. These comprised 63.1% (n = 1995) white and 5.8% (n = 183) South Asian people, with the remainder from other backgrounds. White patients were on average 5 years older than South Asians (69.5 vs 64.6, p<0.005). Response time (7.48 min vs 7.46 min), bystander cardiopulmonary resuscitation (34.4% vs 29.7%), initial cardiac rhythm (29.5% vs 30.4%) and survival to admission (22.2% vs 22.5%) and discharge (8.7% vs 8.9%) were comparable between the two ethnic groups. South Asians were slightly more likely to have a witnessed an OOHCA than their white counterparts (OR = 1.1, 95% CI 1.0 to 1.2). Discussion: The quality of care provided was comparable between white and South Asian populations. The data support the emerging view that South Asians’ high mortality from coronary heart disease reflects higher incidence rather than higher case fatality. South Asians had an OOHCA at a significantly younger age. The study demonstrates the importance of ethnic coding within the emergency services. https://heart.bmj.com/content/96/1/27. 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/hrt.2009.170183
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True posterior myocardial infarction: the importance of leads V7–V9An ambulance crew attended a patient complaining of chest pain with a clinical picture strongly suggestive of acute myocardial infarction (AMI). A 12-lead electrocardiogram (ECG) was obtained, which demonstrated ST segment depression of 1 mm in V2–V4 with upright T waves and hyperacute R waves in V1 and V2 (fig 1). A posterior myocardial infarction (MI) was considered and a series of posterior views was obtained to confirm the diagnosis. Leads V7 and V8 revealed ST segment elevation of 1 mm prompting removal to the cardiac catheter laboratory for expert assessment. Angiography later revealed a proximally occluded left circumflex as the infarct-related artery; which was successfully stented along with an incidentally critical mid-left anterior descending artery. https://emj.bmj.com/content/26/6/456. 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.2008.069195
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Comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substancesBackground: Advanced life support of patients contaminated with chemical, biological, radiological or nuclear (CBRN) substances requires adequate respiratory protection for medical first responders. Conventional and powered air-purifying respirators may exert a different impact during resuscitation and therefore require evaluation. This will help to improve major incident planning and measures for protecting medical staff. Methods: A randomised crossover study was undertaken to investigate the influence of conventional negative pressure and powered air-purifying respirators on the simulated resuscitation of casualties contaminated with hazardous substances. Fourteen UK paramedics carried out a standardised resuscitation algorithm inside an ambulance vehicle, either unprotected or wearing a conventional or a powered respirator. Treatment times, wearer mobility, ease of communication and ease of breathing were determined and compared. Results: In the questionnaire, volunteers stated that communication and mobility were similar in both respirator groups while breathing resistance was significantly lower in the powered respirator group. There was no difference in mean (SD) treatment times between the groups wearing respiratory protection and the controls (245 (19) s for controls, 247 (17) s for conventional respirators and 250 (12) s for powered respirators). Conclusions: Powered air-purifying respirators improve the ease of breathing and do not appear to reduce mobility or delay treatment during a simulated resuscitation scenario inside an ambulance vehicle with a single CBRN casualty. https://emj.bmj.com/content/26/7/501. 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.2008.061531
