• Prehospital risk stratification using a modified thrombolysis in myocardial infarction (PRISM TIMI) score: a retrospective medical record review

      Reed, Ashley (2016-09)
      Background Paramedics convey patients with non-ST elevation acute coronary syndrome (NSTEACS) to emergency departments (EDs). The patient should be risk stratified using a risk stratification model (RSM) in the ED to determine the risk of death or adverse cardiovascular events. This determines if the patient should be transferred to a specialist heart attack centre (HAC) for an invasive procedure. If paramedics were to risk stratify the patients in the prehospital environment using a Modified Thrombolysis in Myocardial Infarction (MTIMI) RSM this could result in primary triage to an appropriate hospital. This could reduce secondary transfers, decrease demand on EDs, provide better patient care, reduce length of hospital stay and could provide cost savings to the National Health Service. Aim To determine if paramedics’ use of a MTIMI RSM is more accurate than current practice at identifying and risk stratifying patients suffering from suspected high risk NSTEACS. Methods A retrospective medical record review. Results 108 patient notes were used in this study, 84 from the ED and 24 from the HAC. Current practice produced a c-statistic (c) of 0.73 (95% Confidence Interval (CI) 0.62 to 0.85) and the MTIMI RSM (c=0.72, 0.61 to 0.83). The best RSM overall was the abbreviated MTIMI RSM with only three variables identified through logistic regression [diabetes mellitus, over 65 years and the electrocardiogram (ECG)] (c=0.79, 0.68 to 0.89). Conclusions The main reason that current practice was similar to the MTIMI RSM was that they both used the ECG variable, which alone was approximately twelve times more prognostic than any other variable. The need to identify a RSM with a good prognostic power that can be used in the prehospital environment still exists. Therefore, other RSMs should be explored in a prospective study https://emj.bmj.com/content/emermed/33/9/e2.2.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/emermed-2016-206139.9
    • Prehospital use of ketamine and midazolam in an urban advanced paramedic practitioner service: a retrospective review

      Edwards, Timothy; Shaw, Joanna; Gray, Danielle; Thomson, Neil; Faulkner, Mark (2016-09)
      Background The use of ketamine and midazolam in physician-led prehospital care teams within the UK is well established. Although both agents are in use by paramedics within emergency medical systems in North America and Australasia, there is a paucity of data relating to administration by UK paramedics. Methods A panel of clinicians utilised a standardised data extraction form to review patient report forms for all cases where an Advanced Paramedic Practitioner (APP) administered ketamine or midazolam from 1st May to 30th September 2015. Reviewers assessed indications for and appropriateness of administration, and identification and management of adverse events. Results A total of 21 patients received ketamine for analgesia (n=20, 95%) or to facilitate rapid extrication (n=1, 5%). Pain scores were recorded in 18 patients (90%), the majority of whom experienced a reduction in pain post administration (n=17, 94%). No adverse events occurred following ketamine use. Midazolam was administered to a total of 80 cases. The most common indications for administration were maintenance of an advanced airway in patients with return of spontaneous circulation post cardiac arrest (n=37, 46%), management of acute behavioural disturbance (n=28, 35%) and prolonged seizures (n=15, 18%). Transient airway compromise occurred in 10% (n=8) of cases, all of which were managed appropriately. No other adverse events occurred. The administration of ketamine and midazolam was judged to be appropriate in all cases. Conclusions The use of ketamine and midazolam in the context of an urban APP service with high levels of additional education, procedural experience and selective targeting to emergency calls appears safe and effective. Further prospective studies are warranted to confirm these findings. https://emj.bmj.com/content/emermed/33/9/e8.1.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-2016-206139.26
    • Principlism: when values conflict

      Lindridge, Jaqualine (2017-04)
      Abstract published with permission. To ensure morally justified decisions, clinicians are encouraged to apply ethical theories and frameworks. Beauchamp and Childress’ ‘Four Principles’ approach to medical ethics, or ‘Principlism’ for short, is highly regarded as a simple methodology for considering ethical dilemmas, and is common to many undergraduate clinical programmes. On occasion, ethical dilemmas are complex and one or more of the four principles come into conflict with each other. Critics of the approach have suggested that there is a lack of guidance on how to resolve this conflict. This paper will argue that principlism facilitates an organised and thorough method of reflecting upon an ethical problem and is well suited to the pre-hospital setting. The problem of how to resolve conflicts between the principles will be explored, demonstrating the merit of the approach through its application to a real-life moral problem from the pre-hospital setting.
    • Psychological impact upon London Ambulance Service of the 2005 bombings

      Misra, Monika; Greenberg, Neil; Hutchinson, Chris; Brain, Andrea; Glozier, Nick (2009-09)
    • Psychosocial care for persons affected by emergencies and major incidents: a Delphi study to determine the needs of professional first responders for education, training and support

      Drury, John; Kemp, Verity; Newman, Jonathan; Novelli, David; Doyle, Christopher; Walter, Darren; Williams, Richard (2013-10)
      BACKGROUND: The role of ambulance clinicians in providing psychosocial care in major incidents and emergencies is recognised in recent Department of Health guidance. The study described in this paper identified NHS professional first responders' needs for education about survivors' psychosocial responses, training in psychosocial skills, and continuing support. METHOD: Ambulance staff participated in an online Delphi questionnaire, comprising 74 items (Round 1) on 7-point Likert scales. Second-round and third-round participants each received feedback based on the previous round, and responded to modified versions of the original items and to new items for clarification. RESULTS: One hundred and two participants took part in Round 1; 47 statements (64%) achieved consensus. In Round 2, 72 people from Round 1 participated; 15 out of 39 statements (38%) achieved consensus. In Round 3, 49 people from Round 2 participated; 15 out of 27 statements (59%) achieved consensus. Overall, there was consensus in the following areas: 'psychosocial needs of patients' (consensus in 34/37 items); 'possible sources of stress in your work' (8/9); 'impacts of distress in your work' (7/10); 'meeting your own emotional needs' (4/5); 'support within your organisation' (2/5); 'needs for training in psychosocial skills for patients' (15/15); 'my needs for psychosocial training and support' (5/6). CONCLUSIONS: Ambulance clinicians recognise their own education needs and the importance of their being offered psychosocial training and support. The authors recommend that, in order to meet patients' psychosocial needs effectively, ambulance clinicians are provided with education and training in a number of skills and their own psychosocial support should be enhanced. https://emj.bmj.com/content/emermed/30/10/831.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-2012-201632
    • Public health campaign to increase awareness of the risks of high blood pressure

      Donohoe, Rachael T.; Chamberlain, Douglas; Edwards, Melanie; Khengar, Rajeshree H.; Smith, Sarah-Jane; Mohammed, Daryl (2012-08)
      Abstract published with permission. The traditional role of the ambulance service as an emergency medical provider has evolved in recent times, with an emerging role being the promotion of public health. The current study explores this concept by evaluating one event in the ‘know your blood pressure’ (KYBP) campaign, conducted across Greater London by the London Ambulance Service NHS Trust (LAS) in April 2010. The event allowed members of the public to have blood pressure (BP) measurements and to receive advice on the health risks of high BP including stroke. Attendees with BP ≥ 140/90 were referred to their general practitioners (GPs).A subsequent telephone survey was conducted to assess campaign effectiveness. The event was attended by 2 274 people, 23% of whom had a high BP measurement. Overall 625 individuals participated in the telephone survey, over half of whom were referred for further medical attention. More than half of these individuals (56%) contacted their GP's surgery as advised. A number of individuals were either prescribed antihypertensive medication for the first time or were subsequently put on a higher dose or an alternative antihypertensive agent. An increase in knowledge of the risks of high BP was also reported. The positive findings demonstrate that ambulance services can have a role in promoting public health.
    • Public perceptions and experiences of heart attack, cardiac arrest and cardiopulmonary resuscitation in London

      Donohoe, Rachael T.; Haefeli, Karen; Moore, Fionna (2006-12)
      Coronary heart disease (CHD) is a leading cause of mortality and a common cause of out-of-hospital cardiac arrest in the UK. The London Ambulance Service NHS Trust attends about 9800 cardiac arrests each year. Of the cardiac arrests considered viable for resuscitation during 2004–5, 79% were of presumed cardiac aetiology. The overall rate of survival for this group of patients was 4%. Although bystander cardiopulmonary resuscitation (CPR) can significantly improve chances of surviving out-of-hospital cardiac arrest, it was initiated in only 30% of cases. 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
    • Radial versus femoral access is associated with reduced complications and mortality in patients with non-ST-segment-elevation myocardial infarction: an observational cohort study of 10,095 patients

      Iqbal, M. Bilal; Arujuna, Aruna; Ilsey, Charles D.; Archbold, Andrew R.; Crake, Tom; Firoozi, Sam; Kalra, Sundeep S.; Knight, Charles; Lim, Pitt; Malik, Iqbal S.; et al. (2014-08)
    • A randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial

      Patterson, Tiffany; Perkins, Gavin D.; Joseph, Jubin; Wilson, Karen; Van Dyck, Laura; Robertson, Steven; Nguyen, Hanna; McConkey, Hannah; Whitbread, Mark; Fothergill, Rachael; et al. (2017-06)
    • A randomised trial of expedited transfer to a cardiac arrest centre for non-ste out-of-hospital cardiac arrest: arrest

      Patterson, Tiffany; Perkins, Gavin D.; Joseph, Jubin; Wilson, Karen; Van Dyck, Laura; Robertson, Steven; Nguyen, Hanna; McConkey, Hannah; Whitbread, Mark; Fothergill, Rachael; et al. (2018-01)
      Background Wide variation exists in inter-hospital survival from OHCA. Regionalisation of care into cardiac arrest centres (CAC) may improve this. We report a pilot randomised trial of expedited transfer to a CAC following OHCA without ST-elevation. The objective was to assess the feasibility of performing a large-scale RCT. Methods Adult witnessed VF OHCA of presumed cardiac cause were randomised 1:1 to either: (1) intervention: expedited transfer to a CAC for goal-directed therapy including access to immediate reperfusion, or (2) control: current standard of care involving delivery to the geographically closest hospital. The feasibility of randomisation, protocol adherence and data collection of the primary (30 day all-cause mortality) and secondary (cerebral performance category (CPC)) and in-hospital major cardiovascular and cerebrovascular events (MACCE) clinical outcome measures were assessed. Results Between Nov 2014 and April 2016, 118 cases were screened, of which 63 patients (53%) met eligibility criteria and 40 of the 63 patients (63%) were randomised. There were no protocol deviations in the treatment arm. Data collection of primary and secondary outcomes was achieved in 83%. There was no difference in baseline characteristics between the groups: 30 day mortality (Int 9/18, 50% vs Control 6/15, 40%; p=0.73), CPC 1/2 (Int: 9/18, 50% vs Control 7/14, 50%; p>0.99) or MACCE (Int: 9/18, 50% vs Control 6/15, 40%; p=0.73). Conclusions These findings support the feasibility of conducting a large-scale RCT to address a remaining uncertainty in post-arrest care. https://heart.bmj.com/content/104/Suppl_1/A7.2 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/heartjnl-2018-BCIS.13
    • A randomized trial of epinephrine in out-of-hospital cardiac arrest

      Perkins, Gavin D.; Ji, Chen; Deakin, Charles D.; Quinn, Tom; Nolan, Jerry P.; Scomparin, Charlotte; Regan, Scott; Long, John; Slowther, Anne-Marie; Pocock, Helen; et al. (2018-08)
    • Rationale and design of: A Randomized tRial of Expedited transfer to a cardiac arrest center for non-ST elevation out-of-hospital cardiac arrest: The ARREST randomized controlled trial

      Patterson, Tiffany; Perkins, Alexander; Perkins, Gavin D.; Clayton, Tim; Evans, Richard; Nguyen, Hanna; Wilson, Karen; Whitbread, Mark; Hughes, Johanna; Fothergill, Rachael; et al. (2018-10)
    • Redesigning the UK Emergency Ambulance

      Matthews, Ed; Fusari, Gianpaolo; Muhammad, Yusuf; Harrow, Dale; Stevens, Peter; Winsor, Richard; Benger, Jonathan; Dean, Dixie; Darzi, Lord Ara; King, Dominic (2013-09)
    • Reducing time to angiography and hospital stay for patients with high-risk non-ST-elevation acute coronary syndrome: retrospective analysis of a paramedic-activated direct access pathway

      Koganti, Sudheer; Patel, N.; Seraphim, A.; Kotecha, T.; Whitbread, Mark; Rakhit, Roby D. (2016-06)
      Objective: To assess whether a novel ‘direct access pathway’ (DAP) for the management of high-risk nonST-elevation acute coronary syndromes (NSTEACS) is safe, results in ‘shorter time to intervention and shorter admission times’. This pathway was developed locally to enable London Ambulance Service to rapidly transfer suspected high-risk NSTEACS from the community to our regional heart attack centre for consideration of early angiography. Methods: This is a retrospective case–control analysis of 289 patients comparing patients with high-risk NSTEACS admitted via DAP with age-matched controls from the standard pan-London high-risk ACS pathway (PLP) and the conventional pathway (CP). The primary end point of the study was time from admission to coronary angiography/intervention. Secondary end point was total length of hospital stay. Results: Over a period of 43 months, 101 patients were admitted by DAP, 109 matched patients by PLP and 79 matched patients through CP. Median times from admission to coronary angiography for DAP, PLP and CP were 2.8 (1.5–9), 16.6 (6–50) and 60 (33–116) hours, respectively ( p<0.001). Median length of hospital stay for DAP and PLP was similar at 3.0 (2.0–5.0) days in comparison to 5 (3–7) days for CP ( p<0.001). Conclusions: DAP resulted in a significant reduction in time to angiography for patients with high-risk NSTEACS when compared to existing pathways. https://bmjopen.bmj.com/content/bmjopen/6/6/e010428.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/bmjopen-2015-010428
    • Reflecting on events

      Lawrence, Pat (2008-02)