• Emergency care of older people who fall: a missed opportunity

      Snooks, Helen A.; Halter, Mary; Close, Jacqueline; Cheung, Wai Yee; Moore, Fionna; Roberts, Stephen E. (2006-12-01)
      A high number of emergency (999) calls are made for older people who fall, with many patients not subsequently conveyed to hospital. Ambulance crews do not generally have protocols or training to leave people at home, and systems for referral are rare. The quality and safety of current practice is explored in this study, in which for the first time, the short-term outcomes of older people left at home by emergency ambulance crews after a fall are described. Results will inform the development of care for this population. https://qualitysafety.bmj.com/content/15/6/390 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. http://creativecommons.org/licenses/by-nc/4.0/ DOI 10.1136/qshc.2006.018697
    • Reflecting on events

      Lawrence, Pat (2008-02)
    • Ecstasy toxicity and the cooling factor

      Archer, Tom (2008-07-25)
      A rapid response unit (RRU) and ambulance were dispatched to a young adult reported to be fitting at the site of a “rave”. On arrival, the patient was being treated by a medical team who were providing cover at the event and the RRU paramedic. The patient was reported to have taken eight ecstasy tablets and had been fitting for approximately 10 min, but this had been terminated with 10 mg diazepam (Diazemuls) given intravenously. He had also been given 800 μg naloxone and 50 ml 0.9% normal saline had also been administered. https://emj.bmj.com/content/25/8/534 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. http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emj.2007.054783
    • True posterior myocardial infarction: the importance of leads V7–V9

      Lindridge, Jaqualine (2009-05-22)
      An 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
    • Comparison of powered and conventional air-purifying respirators during simulated resuscitation of casualties contaminated with hazardous substances

      Schumacher, Jan; Gray, Stuart A.; Weidelt, L.; Brinker, Andrea; Prior, K.; Stratling, W. M. (2009-06-22)
      Background: 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
    • What are the highest priorities for research in emergency prehospital care?

      Snooks, Helen; Evans, Angela; Wells, Bridget; Peconi, Julie; Thomas, Marie; Woollard, Malcolm; Guly, Henry; Jenkinson, Emma; Turner, Janette; Hartley-Sharpe, Christopher (2009-07-22)
      The recent UK Department of Health publication “Taking Healthcare to the Patient: Transforming NHS Ambulance Services”1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research. https://emj.bmj.com/content/26/8/549. 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.2008.065862
    • Psychological impact upon London Ambulance Service of the 2005 bombings

      Misra, Monika; Greenberg, Neil; Hutchinson, Chris; Brain, Andrea; Glozier, Nick (2009-09)
    • Out-of-hospital cardiac arrest in South Asian and white populations in London: database evaluation of characteristics and outcome

      Shah, Anoop S. V.; Bhopal, Raj S.; Gadd, Stephen; Donohoe, Rachel (2009-09-10)
      Objective: 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
    • Acute cocaine toxicity: assessment and cardiac risk

      Gardner, Karen (2009-11-27)
      The 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.
    • Out-of-hospital cardiac arrest in patients aged 35 years and under: a 4-year study of frequency and survival in London

      Donohoe, Rachael T.; Innes, Jennifer; Gadd, Stephen; Whitbread, Mark; Moore, Fionna (2010-01)
    • A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008

      Deakin, Charles D.; Clarke, Tom; Nolan, Jerry P.; Zideman, David; Gwinnutt, Carl; Moore, Fionna; Keeble, Carl; Blancke, Wim (2010-03)
      Paramedic 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
    • The implications of the NICE guidelines on neurosurgical management for all severe head injuries: systematic review

      Barratt, Helen; Wilson, Mark; Moore, Fionna; Raine, Rosalind (2010-03-19)
      Head injury is an important cause of death among young adults in the UK, and a significant burden on NHS resources. However, management is inconsistent, governed largely by local resources. The latest version of the NICE head injury guidelines suggests that more patients with traumatic brain injury should be transferred to receive specialist care. However, this raises issues about the capacity of regional neurosurgical units, particularly to accommodate patients who do not require surgical intervention. Objectives To critically evaluate the basis of the NICE recommendations about transfer for neurosurgical care, and examine the configuration of specialist services to assess the implications of increasing the existing number of transfers. Methods A systematic literature review was conducted of articles discussing the provision of emergency neurosurgical care for adult head injuries in the UK. Results Fifty-eight papers met the criteria for inclusion in the literature review, including seven papers cited in the NICE guidance. Fifty-one papers related to neurosurgical care, including papers on bed occupancy, transfer times and transfer policies. Conclusions The evidence NICE cited is of variable quality. Much of the research was conducted outside the UK, which raises questions about its relevance to the NHS. Care of traumatic brain injuries in the UK is already hampered by the inadequate capacity of regional neurosurgical units to meet demand, and transferring more patients would be likely to exacerbate this. Increasing the number of transfers could also worsen inequalities of access for other groups, such as elective patients, particularly in areas where facilities are most stretched. https://emj.bmj.com/content/27/3/173. 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.2009.075382
    • Supporting research and development in ambulance services: research for better health care in prehospital settings

      Siriwardena, Aloysius; Donohoe, Rachel; Stephenson, John; Phillips, Paul (2010-04-12)
      Background 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
    • Development and pilot of clinical performance indicators for English ambulance services

      Siriwardena, Aloysius; Shaw, Deborah; Donohoe, Rachel; Black, Sarah; Stephenson, John; National Ambulance Clinical Audit Steering Group (2010-04-12)
      Introduction 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
    • CPR with Chest Compression Alone or with Rescue Breathing

      Rea, Thomas D.; Fahrenbruch, Carol; Culley, Linda; Donohoe, Rachael T.; Hambly, Cindy; Innes, Jennifer; Bloomingdale, Megan; Subido, Cleo; Romines, Steven; Eisenberg, Mickey S. (2010-07-29)
    • The future of paramedic intubation: who should be responsible?

      Hodkinson, Mark (2010-08)
      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.
    • Treating the unexpected: the opiate overdose patient

      Willis, Sam (2010-12)
      Ambulance practitioners are regularly faced with those who present with a form of drug overdose. The subject of substance misuse can be controversial, delicate and are not always straightforward to manage. Not only can substance misuse be a sensitive topic to approach, but patients can be adept at hiding the signs and symptoms from friends, family and ambulance practitioners (Caroline 2008). In addition, it may be difficult to establish what exactly has been taken, when, and how much. Gaining consent to treat the patient can also be fraught with difficulties. This reflective account uses a case from practice which highlights several of the difficulties that ambulance practitioners face when dealing with this type of patient. Abstract published with permission.