• Focused cardiac ultrasound in out-of-hospital cardiac arrest: a literature review

      Brown, Nick; Quinn, Tom (2021-01-02)
      Focused cardiac ultrasound (FoCUS) is emerging in emergency medical systems, particularly in the context of prognostication in out-of-hospital cardiac arrest. However, FoCUS has not been formally incorporated into UK guidelines because of a lack of evidence. Furthermore, concerns have been raised that FoCUS can distract people from providing other essential and evidenced elements of care. This broad literature search aims to shed light on the practice of FoCUS in cardiac arrest by reviewing articles related to in-hospital and out-of-hospital practice. The findings are conspicuous by the lack of high-quality studies, particularly regarding prognostication. Association between ultrasound findings and outcome are asserted, as is the feasibility of paramedic use of FoCUS, although the evidence is from small and non-randomised studies and subject to bias. Abstract published with permission.
    • Framework for assessment of the 12 lead ECG in transient loss of consciousness

      Edwards, Timothy (2012-11)
      Abstract published with permission. Following the introduction of pre-hospital thrombolysis, the acquisition and interpretation of the 12 lead ECG has become a routine part of UK paramedic practice. Although there is a growing body of evidence that confirms the diagnostic ability of paramedics in this area, little is known regarding the ability of paramedics to scrutinise the 12 lead ECG for other abnormalities. Recent publication of NICE guidance (NICE, 2010) relating to transient loss of consciousness (T-LOC) requires practitioners responsible for assessment of the 12 lead ECG post T-LOC to be competent in identifying a range of abnormalities. This paper describes a novel assessment framework in the form of a mnemonic designed to assist paramedic students in scrutinising the ECG for abnormalities post T-LOC. The need for further research to validate this assessment framework in educational and clinical settings is emphasised.
    • Frequent callers to the ambulance service: patient profiling and impact of case management on patient utilisation of the ambulance service

      Edwards, Melanie J.; Bassett, Gary; Sinden, Levi; Fothergill, Rachael T. (2015-05)
      Background A minority of patients make frequent and excessive calls to the ambulance service, placing a significant burden on limited resources at a time when demand on urgent and emergency care systems is steadily increasing. Little is known about the reasons underlying frequent caller behaviour or the best way to manage this group of patients. Objectives The present study aimed to (i) profile frequent callers to the ambulance service and (ii) evaluate the impact of a case management interventional approach on frequent caller behaviour. Methods A retrospective review of data from a 2-year period (from 1 April 2009 to 31 March 2011) was conducted. Patients were included in the analysis if they had been accepted for case management intervention by the Patient-Centred Action Team during this period and met the study inclusion criteria. Results The review identified 110 frequent callers who met the study inclusion criteria. The majority of frequent callers (86%) had multiple and complex reasons for calling, including frequent medical need, acute or chronic mental health condition, older age and unmet personal or social care needs. In the majority of cases (82%), multiple interventional strategies were required. A significant reduction in median call volume was observed from preintervention to postintervention (from five calls/month to zero calls/month). Conclusions Effective management of this complex patient group requires an individualised case management approach in order to identify and tackle the underlying causes of behaviour. https://emj.bmj.com/content/32/5/392.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/ http://dx.doi.org/10.1136/emermed-2013-203496
    • 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.
    • Genuine illness and injury during Europe’s largest emergency service major incident exercise

      Cannon, E.; Edwards, Timothy; Fothergill, Rachael T. (2017-05)
      Aim Previous studies of patient presentation rates at mass gatherings have been limited to social events. None have assessed presentation rates in the context of a large-scale emergency service exercise where individuals (actors playing hypothetical casualties) are exposed to an environment containing many potential hazards. Methods Exercise Unified Response was the largest multi-agency exercise ever held in Europe. It was a four-day major incident exercise in the UK, in which 2700 individuals acted as casualties. Clinical records completed by healthcare professionals providing on-site medical cover for the duration of the event were reviewed. Clinical records were included where the individual’s role in the exercise was listed as ‘actor’. Results Thirty actors required medical attention, giving a patient presentation rate (PPR) of 11.1 per one thousand actors. Of these, 10% were conveyed to hospital with musculoskeletal (n=2) or head injuries (n=1); an ambulance transfer rate (ATR) of 1.11 per 1000. Just under half of all patients (40%, n=12) had a contributory factor to seeking medical help, where they had: not eaten on the day (n=4); a pre-existing condition exacerbated by the exercise, such asthma (n=3); pre-existing symptoms of acute illness (n=3), or a pre-existing injury (n=2). Conclusion Patient presentation rate was in line with previous research1. However, we believe this is the first study to report similar data for a mass emergency service exercise. Our findings regarding the factors and pre-existing illnesses/conditions that contributed to individuals seeking medical help will be valuable in planning future large-scale exercises. https://bmjopen.bmj.com/content/7/Suppl_3/A3.2 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/ http://dx.doi.org/10.1136/bmjopen-2017-EMSabstracts.8
    • High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme

      Apps, Andrew; Malhotra, Aseem; Tarkin, Jason; Smith, Robert; Kabir, Tito; Lane, Rebecca; Mason, Mark; Ali, Omar; Rogers, Paula; Banya, Winston; et al. (2013-07)
      BACKGROUND: Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy. OBJECTIVE: To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme. METHODS: We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG-group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed. RESULTS: During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th-75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2-58.5) versus 18.1 μg/l (6.7-32.4) for group B (p=0.03); and 15.5 μg/l (3.8-22.0) for group C (p<0.001), suggesting greater infarct size in group A. CONCLUSIONS: A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty. https://pmj.bmj.com/content/postgradmedj/89/1053/376.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/postgradmedj-2012-130818
    • High-risk non-ST elevation acute coronary syndromes (NSTEACS) for paramedics

      Reed, Ashley (2012-08)
      Abstract published with permission. Pre-hospital clinicians frequently encounter patients suffering acute coronary syndromes (ACS) and they form an integral part in recognising and conveying the ST-elevation myocardial infraction (STEMI) patient to the most appropriate destination, namely the heart attack centre (HAC). The emphasis has been upon the recognition and subsequent management of the STEMI patient. The non-ST elevation acute coronary syndrome (NSTEACS) patient has a similar mortality and morbidity yet does not receive the same pathways as STEMI. This article aims to provide an understanding based on a case study around NSTEACS with supporting evidence relating to risk stratification, clinical trials and clinical guidelines of what needs to be developed to enhance the care we provide to the NSTEAC patient in the pre-hospital arena.
    • Human factors within paramedic practice: the forgotten paradigm

      Summers, Andy; Willis, Sam (2010-09-01)
      It would seem hard to imagine how you could draw a comparison between a commercial airline pilot struggling to land a stricken plane in a storm and a paramedic fighting to save the life of a patient in cardiac arrest. Although very different circumstances, they both have one thing in common: that is, they are both vulnerable to a condition known as ‘the human factor’. Examples of where Human Factors (HFs) exist within the prehospital profession can be various, common examples are environmental distractions e.g. noise from bystanders, mobile phones, machines, or more simply caused by lack of sleep and inadequate nourishment. This article discusses human factors within the prehospital environment and will highlight the benefits of being able to recognize and act upon them, with a specific focus upon the impact they can have on the ambulance practitioner operating in the field. It discusses human factors training and recognizes the role of crew resource management (CRM) and its importance within the prehospital profession. Abstract published with permission.
    • Identification of characteristics of neighbourhoods with high incidence of out-of-hospital cardiac arrest and low bystander cardiopulmonary resuscitation rates

      Brown, Terry P.; Hawkes, Claire A.; Booth, Scott J.; Fothergill, Rachael T.; Black, Sara; Bichmann, Anna; Pocock, Helen; Soar, Jasmeet; Mark, Julian; Benger, Jonathan R.; et al. (2017-09)
    • Identifying and overcoming barriers to automated external defibrillator use by GoodSAM volunteer first responders in out-of-hospital cardiac arrest using the Theoretical Domains Framework and Behaviour Change Wheel: a qualitative study

      Smith, Christopher M.; Griffiths, Frances; Fothergill, Rachael; Vlaev, Ivo; Perkins, Gavin (2020-03-10)
      Objectives: GoodSAM is a mobile phone app that integrates with UK ambulance services. During a 999 call, if a call handler diagnoses cardiac arrest, nearby volunteer first responders registered with the app are alerted. They can give cardiopulmonary resuscitation (CPR) and/or use a public access automated external defibrillator (AED). We aimed to identify means of increasing AED use by GoodSAM first responders. Methods: We conducted semistructured telephone interviews, using the Theoretical Domains Framework to identify and classify barriers to AED use. We analysed findings using the Capability, Opportunity, Motivation, Behaviour (COM-B) model and subsequently used the Behaviour Change Wheel to develop potential interventions to improve AED use. Setting London, UK. Participants: GoodSAM first responders alerted in the previous 7 days about a cardiac arrest. Results We conducted 30 telephone interviews in two batches in July and October 2018. A public access AED was taken to scene once, one had already been attached on scene another time and three participants took their own AEDs when responding. Most first responders felt capable and motivated to use public access AEDs but were concerned about delaying CPR if they retrieved one and frustrated when arriving after the ambulance service. They perceived lack of opportunities due to unavailable and inaccessible AEDs, particularly out of hours. We subsequently developed 13 potential interventions to increase AED use for future testing. Conclusions: GoodSAM first responders used AEDs occasionally, despite a capability and motivation to do so. Those operating volunteer first responder systems should consider our proposed interventions to improve AED use. Of particular clinical importance are: highlighting AED location and providing route/time estimates to the patient via the nearest AED. This would help single responders make appropriate decisions about AED retrieval. As AED collection may extend time to reach the patient, where there is sufficient density of potential responders, systems could send one responder to initiate CPR and another to collect an AED. https://bmjopen.bmj.com/content/10/3/e034908 https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
    • Impact of arrest characteristics on VF waveform analysis and corresponding patient outcomes

      Nammi, Krishnakant; Jorgenson, Dawn B.; Liu, Ping-Yu; Innes, Jennifer; Matallana, Luis; Donohoe, Rachael T.; Whitbread, Mark; Prezant, David J.; Silverman, Robert A.; Freese, John P. (2010-12-01)
    • Impact of Early (≤24 H) Versus Delayed (>24 H) Intervention in Patients With non-ST Segment Elevation Myocardial Infarction: An Observational Study of 20,882 Patients From the London Heart Attack Group

      Panoulas, Vasileios; Rathod, Krishnaraj S.; Jain, Ajay K.; Firoozi, Sam; Nevett, Joanne; Kalra, Sundeep Singh; Malik, Iqbal S.; Mathur, Anthony; Redwood, Simon; MacCarthy, Philip A.; et al. (2020-06-03)
    • Impact of inter-hospital transfer for primary percutaneous coronary intervention on survival (10 108 STEMI patients from the London Heart Attack Group)

      Jones, Daniel A.; Bromage, D.I.; Rathod, Krishnaraj S.; Lim, Pitt; Virdi, G.; Jain, A.J.; Singh Kalra, S.; Crake, Tom; Meier, Pascal; Astroulakis, Zoe; et al. (2013-05)
      Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated whether direct transfer to a cardiac centre performing primary percutaneous coronary intervention (PPCI) leads to improved survival compared with transfer via a non-PPCI performing hospital in STEMI patients in a regional network. Methods This was an observational cohort study of 10 108 patients with STEMI treated with PPCI between 2004 and 2011 at eight tertiary cardiac centres across London, UK. Patient ’s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range 1.2 – 4.6 years). Results 6492 patients (64.2%) were transferred directly to a PCI performing centre (direct) and 3616, (35.8%) were transferred via a non-PCI performing centre (indirect). There were higher rates of previous MI and previous CABG in the indirect group, with higher rates of poor LV function in the direct group (table 1). Median time to reperfusion (symptom to balloon) in transferred patients was 58 min longer compared to patients admitted directly (p<0.001). However, symptom to first hospital door times were similar. Transferred patients had significantly lower rates of infarct-related artery (IRA) TIMI 0 flow (54.5% vs 62.9%, p<0.0001) and higher rates of IRA TIMI 3 flow (17% vs 10.7%, p>0.0001) at presentation compared to those transferred directly. Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without transfer (12.3% direct vs 14.3% indirect, p=0.060). Age-adjusted Cox analysis revealed inter-hospital transfer for PPCI was associated with all cause mortality (HR 0.89 (95% CI 0.79 to 0.99)), however this was not maintained after multivariate adjustment (HR 0.84 (95% CI 0.62 to 1.14)). Conclusions In this large registry survival appear comparable in patients with STEMI admitted directly versus transferred for primary PCI. This is despite longer symptom to balloon times. This unexpected finding may reflect the earlier initiation of medical therapy (eg, anti-platelets and GpIIb/IIIa receptor inhibitors) and earlier pharmacological reperfusion, reflected by lower IRA TIMI 0 rates at angiography in the patients transferred from a non-PCI hospital. https://heart.bmj.com/content/heartjnl/99/suppl_2/A22.2.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/heartjnl-2013-304019.30
    • The impact of shift work on emergency medical dispatching

      Roshanzamir, S.; Heward, Andy; Glucksman, Ed. (2006-04)
      Healthcare professionals are required to work to consistently high standards 24 hours a day, 365 days a year necessitating shift work to be employed. Shift work is often perceived to result in disruption to the worker, manifesting itself in terms of sleep, health, and social disruption, as well as job performance, standards, and safety, with substantial differences in fatigue identified between day and night shift workers. https://emj.bmj.com/content/23/4/321 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/ http://dx.doi.org/10.1136/emj.2005.032938
    • Impact of the terrorist atrocities of 7 July 2005 on the London Ambulance Services incident volume

      Yates, C.; Heward, Andy; Glucksman, E. (2006-12)
      During the past 20 years, there have been numerous terrorist atrocities and other major incidents within the boundaries covered by the London Ambulance Service (LAS) NHS Trust. Historic LAS records and anecdotal feelings suggest that the demands placed on the LAS during these incidents were significantly reduced, with fewer 999 calls received, but no work had previously been undertaken to evidence this suggestion. https://emj.bmj.com/content/23/12/e68 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/ http://dx.doi.org/10.1136/emj.2006.041574
    • Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: a comparative effectiveness before and after model

      Hunter, Rachael M.; Davie, Charles; Rudd, Anthony; Thompson, Alan; Walker, Hilary; Thomson, Neil; Mountford, James; Schwamm, Lee; Deanfield, John; Thompson, Kerry; et al. (2013-08)