• Paramedic assessment of older adults after falls, including community care referral pathway: cluster randomized trial

      Snooks, Helen A.; Anthony, Rebecca; Chatters, Robin; Dale, Jeremy; Fothergill, Rachael T.; Gaze, Sarah; Halter, Mary; Humphreys, Ioan; Koniotou, Marina; Logan, Phillipa; et al. (2017-10)
    • Paramedic attitudes and experiences of enrolling patients into the PARAMEDIC-2 adrenaline trial: a qualitative survey within the London Ambulance Service

      Lazarus, Johanna; Iyer, Rajeshwari; Fothergill, Rachael (2019-12-01)
      OBJECTIVES: The aim of this study was to gather the views and experiences of paramedics who participated in a large-scale randomised controlled drug trial and to identify barriers to recruitment. DESIGN: We surveyed paramedics using a questionnaire consisting of a mix of closed and open ended questions. SETTING: The study was conducted within the London Ambulance Service, London, UK. PARTICIPANTS: 150 paramedics who were trained to enrol patients into the PARAMEDIC-2 randomised controlled trial of adrenaline versus placebo in out-of-hospital cardiac arrest and who returned the questionnaire. RESULTS: 98% of study participants felt prehospital research was very important, and 97.3% reported an overall positive experience of being involved in a drug trial. Only 5.3% felt uncomfortable enrolling patients into the trial without prior consent from the patient or a relative. Over one- third (39.3%) identified one or more barriers to patient recruitment, the most common being the attitudes of other staff. CONCLUSION: We found a strong appetite for involvement in prehospital research among paramedics and an understanding of the importance of research that prevailed over the complexities of the trial. This is an important finding demonstrating that potentially ethically controversial research can be undertaken successfully by paramedics in the prehospital environment., https://www.ncbi.nlm.nih.gov/pubmed/31791962. 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-2018-025588
    • Paramedic delivery of bad news: a novel dilemma during the COVID-19 crisis

      Campbell, Iain (2020-10-30)
      As a result of the COVID-19 global pandemic, paramedics in the UK face unprecedented challenges in the care of acutely unwell patients and their family members. This article will describe and discuss a new ethical dilemma faced by clinicians in the out-of-hospital environment during this time, namely the delivery of bad news to family members who are required to remain at home and self-isolate while the critically unwell patient is transported to hospital. I will discuss some failings of current practice and reflect on some of the ethical and practical challenges confronting paramedics in these circumstances. I conclude by making three recommendations: first, that dedicated pastoral outreach teams ought to be set up during pandemics to assist family members of patients transported to hospital; second, I offer a framework for how bad news can be delivered during a lockdown in a less damaging way; and finally, that a new model of bad news delivery more suited for unplanned, time-pressured care should be developed. https://jme.bmj.com/content/early/2020/10/30/medethics-2020-106710 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/medethics-2020-106710
    • Paramedics' experiences of end-of-life care decision making with regard to nursing home residents: an exploration of influential issues and factors

      Murphy-Jones, Georgina; Timmons, Stephen (2016-10)
      Introduction For a patient nearing the end of his or her life, transfer from a nursing home to the ED can be inappropriate, with potentially negative consequences, but transfer in these circumstances is, regrettably, all too common. There is a lack of published literature exploring how paramedics make decisions in end-of-life care situations. This study aims to explore how paramedics make decisions when asked to transport nursing home residents nearing the end of their lives. Methods Phenomenological influenced design with a pragmatic approach. Semi-structured face-to-face interviews were conducted with six paramedics in an English NHS Ambulance Trust and subsequent data collected by text message. Audio-recorded interviews were transcribed verbatim and analysed using a thematic approach. Results Three themes emerged in relation to the decision to transport patients from nursing homes to EDs in end-of-life care situations. Paramedics identified difficulties in understanding nursing home residents’ wishes. When a patient no longer had the capacity for decision making, paramedics’ reasoning processes were aligned to best interest decision making, weighing the risks and benefits of hospitalisation. Paramedics found it challenging to balance patients’ best interests with pressure from others: nursing staff, patients’ relatives and colleagues. Conclusions A range of factors influence paramedics’ decisions to transport nursing home residents to EDs in end-of-life care situations. Decision making became a process of negotiation when the patient’s perceived best interests conflicted with that of others, resulting in contrasting approaches by paramedics. This paper considers how paramedics might be better trained and supported in dealing with these situations, with the aim of providing dignified and appropriate care to patients as they reach the end of their lives. https://emj.bmj.com/content/emermed/33/10/722.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/emermed-2015-205405
    • A pilot study of pre-hospital initiation of therapeutic hypothermia using intra-nasal cooling

      Lyon, Richard; Henderson, Charles; Van Antwerp, Jerry; Weaver, Anne; Davies, Gareth; Lockey, David (2012-10-15)
    • The potential for bystander automated external defibrillator deployment in London, UK

      Smith, Christopher M.; Lall, Ranjit; Hartley-Sharpe, Christopher; Perkins, Gavin D. (2018-09)
    • A practical risk score for early prediction of neurological outcome after out-of-hospital cardiac arrest: MIRACLE2

      Pareek, Nilesh; Kordis, Peter; Beckley-Hoelscher, Nicholas; Pimenta, Dominic; Kocjancic, Spela Tadel; Jazbec, Anja; Nevett, Joanne; Fothergill, Rachael; Kalra, Sandeep; Lockie, Tim; et al. (2020-12)
    • Pre-hospital assessment of the role of adrenaline: measuring the effectiveness of drug administration in cardiac arrest (PARAMEDIC-2): trial protocol

      Perkins, Gavin D.; Quinn, Tom; Deakin, Charles D.; Nolan, Jerry P.; Lall, Ranjit; Slowther, Anne-Marie; Cooke, Matthew; Lamb, Sarah E.; Petrou, Stavros; Achana, Felix; et al. (2016-11)
    • The pre-hospital management of acute heart failure: a clinical audit of current practice

      Price, J.; Murphy-Jones, Barry; Edwards, Timothy (2018-04)
      Aim There has been a drive towards an increase in community-based management of heart failure. When patients experience acute heart failure (AHF), the complex nature of this condition poses diagnostic uncertainty for first responders. It is widely accepted that all patients should be transferred promptly to hospital, however with the introduction of pre-hospital diuresis, nitrate therapy and more recently non-invasive ventilation (NIV), the debate into the appropriateness and limitations of so-called ‘stay-and-play’ management strategies for patients in AHF has been re-ignited. We examine the current clinical assessment and management of AHF within the London Ambulance Service. Method Ambulance Patient Report Forms (PRFs) from cases that were coded with heart failure, shortness of breath, cardiac problem and in cases of GTN administration. These cases were further analysed by a clinical review panel to identify patients with suspected AHF. Results 182 patients were included in the analysis between April and November 2016. There was a 68% compliance with national guidelines for clinical assessment (history, examination and ECG). 51 (28%) patients presenting with AHF were appropriately identified and given a primary diagnosis of AHF by the attending clinician. 136 (76%) patients in the analysis received sublingual nitrate therapy. 90 (49%) patients received nitrates where there was no clinical indication. No patients in the analysis received NIV. Conclusion Some aspects of AHF assessment and management are not consistent with national guidelines. Our work has further demonstrated the diagnostic challenges facing pre-hospital clinicians and the potential overuse of nitrate therapy in this patient group. https://bmjopen.bmj.com/content/8/Suppl_1/A32.2 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-2018-EMS.85
    • Pre-hospital management of pain associated with an acute sickle cell crisis

      Chadkirk, Ralph (2017-07)
      Abstract published with permission. Sickle Cell Disease and its acute manifestation as a sickle cell crisis has a severely deleterious effect on predicted mortality and quality of life of its sufferers. Serious sequelae can occur, resulting in severe neurological and cardiovascular impairment. In the majority of cases these patients will present to pre-hospital clinicians with acute intractable pain unmanaged by the patient’s own analgesia. Unfortunately, some evidence reports that pain is commonly under-treated with assumptions made about drug-seeking behaviour. The evidence presented in this paper will indicate that Entonox should no longer be routinely used for the management of sickle cell pain. Instead, emphasis should turn to the use of potent intravenous opiates (where intravenous access can be reliably and aseptically gained). The use of diamorphine and ketamine for extreme pain should be investigated by pre-hospital services, as should the use of non-steroidal anti-inflammatory drugs.
    • Pre-hospital paediatric pain management in the London ambulance service

      Shaw, Joanna; Murphy-Jones, Barry; Fothergill, Rachael T. (2018-04)
      Aim In 2006 the London Ambulance Service (LAS) developed a laminated card to allow for better pain assessment for children. The card contained a faces-based scoring system used in hospitals.1 LAS paediatric pain assessment and management was reviewed in 2012 demonstrating improvement in assessment of pain as a result of the card. Administration of pain relief also improved, however further progress was needed in analgesia provision and immobilisation. Following the review, paediatric pain management and immobilisation was included in LAS clinical training sessions, and a paediatric immobilisation equipment review was conducted. This project aimed to determine whether these additional initiatives further improved paediatric pain management. Method A retrospective review was undertaken of 229 clinical records from October 2014 to January 2015 for patients aged 12 years and under whose primary complaint was a possible fracture or dislocation. Clinical records were compared with national clinical practice guidelines for paediatric pain management. Results Findings showed nearly all patients had a pain assessment recorded (n=223, 97%), an improvement sustained from 2012 (+34% since 2006). We found an increase in the percentage of children having their injury immobilised (+22% since 2012; sustained from 2006; n=90/216, 42%) and being given analgesia when required (+18% since 2012;+61% since 2006; n=170/209, 84%). Conclusion The systematic cyclical process of reviewing care, implementing change and re-measuring, whilst resource intensive, has demonstrated huge improvements in paediatric pain management over time. https://bmjopen.bmj.com/content/8/Suppl_1/A26.2 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-2018-EMS.69
    • Pre-hospital resuscitation: what shall we tell the family?

      Brown, Nick (2016-02)
      Abstract published with permission. Cardiac arrest is a rarely attended event as a proportion of overall paramedic workload. When paramedics do attend such an event the management focus is largely concerned with clinical intervention and there may not be the capacity or appreciation for offering ongoing support to family members present. Indeed, even training may not have covered this element of care. Regardless of the prognosis for the patient, evidence suggests that there is benefit in directly involving relatives during the resuscitation. Engaging them with carefully considered and informed dialogue certainly seems humane at least. In which case, a structured and holistic approach should be employed where clinical care and emotional support go hand in hand.
    • Predicting non-cardiac aetiology: A strategy to allocate rescue breathing during bystander CPR

      Dumas, F.; Farhenbruch, C.; Hambly, Cindy; Donohoe, Rachael T.; Carli, P.; Cariou, A.; Rea, Thomas D. (2012-01)
    • Predictors of survival and favorable functional outcomes after an out-of-hospital cardiac arrest in patients systematically brought to a dedicated heart attack center (from the Harefield Cardiac Arrest Study)

      Iqbal, M. Bilal; Al-Hussaini, Abtehale; Rosser, Gareth; Salehi, Saleem; Phylactou, Maria; Rajakulasingham, Ramyah; Patel, Jayna; Elliott, Katharine; Mohan, Poornima; Green, Rebecca; et al. (2015-03)
    • Prehospital adrenaline administration for out-of-hospital cardiac arrest: the picture in England and Wales

      Booth, Scott; Ji, Chen; Soar, Jasmeet; Siriwardena, A. Niroshan; Fothergill, Rachael T.; Spaight, Robert; Perkins, Gavin D. (2018-09)