• People in rubber suits and how to treat them: decompression injuries in divers

      McClelland, Graham (2013-09-29)
      The majority of our planet is covered in water and millions of people around the world enjoy exploring what lies beneath the surface of our seas and lakes. Diving is a popular activity, with a long history, that allows people to visit—for pleasure or for business—a different world. Diving is a sport with inherent risks. The hazards and potential for injuries, ranging from the minor to the life-threatening, are an unavoidable part of the activity. The factors involved in diving injuries and the signs and symptoms divers may present with, are many and varied. Decompression injuries are one of the potential injuries that will respond to appropriate treatment and may have the longest lasting effects. Confident treatment of decompression injuries is made easier by understanding the physics involved in breathing gases underwater. The definitive treatment involves recompression that should be provided at a specialist hyperbaric facility. Abstract published with permission.
    • The research paramedic: a new role

      McClelland, Graham (2013-10)
    • An observational study of patient characteristics associated with the mode of admission to acute stroke services in North East, England

      Price, Christopher; Rae, Victoria; Duckett, Jay; Wood, Ruth; Gray, Joanne; McMeekin, Peter; Rodgers, Helen; Portas, Karen; Ford, Gary A. (2013-10)
    • Research developments within the Allied Health Professions Research Network (AHPRN)

      Williams, Julia; Robinson, Maria; McClelland, Graham (2014-01)
    • Paramedic perceptions and attitudes to working with patients with alcohol related injury or illness

      Glencorse, Mark; Wilson, Graeme; Newbury Birch, Dorothy (2014-06)
      Abstract published with permission. Aims: To ascertain views, perceptions and attitudes of paramedics when working with patients presenting with alcohol-related injury or illness, and to explore perceived barriers and facilitators for the introduction of alcohol interventions to the NHS ambulance services. Methods: A total of 142 (24%) from 589 paramedics from the North East Ambulance Service NHS Foundation Trust returned completed surveys between January 2013 to April 2013, which included measures of current perceptions and attitudes of working with patients with alcohol-related injury or illness, and the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Results: Paramedics reported little to no formal training on working with patients with alcohol-related injury or illness (77%). Paramedics scored low across all domains of the SAAPPQ for working with both problem and dependent drinkers. Not having suitable counseling materials (77%), not enough training (72%) and no facilities or time to deal with prevention (69%) were key barriers. Conclusions: At this present time, levels of commitment, motivation, satisfaction, legitimacy and adequacy are low in front-line paramedics when working with patients with alcohol-related injury and illness. However, they are open to finding ways to provide interventions if they are adequately trained and have appropriate referral pathways open to them.
    • Introduction of the I-gel supraglottic airway device for prehospital airway management in a UK ambulance service

      Duckett, Jay; Fell, P.; Han, Kyee; Kimber, C.; Taylor, C. (2014-06)
      Aim To clinically review the use of basic and advanced airway management techniques within the North East Ambulance Service National Health Service Foundation Trust (NEAS) for cardiac arrests following the introduction of the i-gel. Method Two retrospective clinical audits were carried out over a monthly period (May 2011 and January 2012) using electronic and paper NEAS patient records. Results This audit confirmed that a range of basic and/or advanced airway management techniques are being successfully used to manage the airways of cardiac arrest patients. I-gel is emerging as a popular choice for maintaining and securing the airway during prehospital cardiopulmonary resuscitation. Success rates for i-gel insertion are higher (94%, 92%) than endotracheal (ET) tube insertion (90%, 86%). Documentation of the airway management method was poor in 11% of the records. The Quality Improvement Officers addressed this by providing individual feedback. Conclusions I-gel shows a higher success rate in cardiac arrest patients compared to the ET tube. Staff who chose to use methods other than i-gel indicated this was a confidence issue when using new equipment. The re-audit indicated an upward trend in the popularity of i-gel; insertion is faster with a higher success rate, which allows the crew to progress with the other resuscitation measures more promptly. Airway soiling and aspiration beforehand have been reasons staff resort to ET intubation. It is anticipated by the authors that i-gel will emerge as the first choice of airway management device in prehospital cardiac arrests. https://emj.bmj.com/content/emermed/31/6/505.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-2012-202126
    • Report from the first pre-hospital sepsis conference

      McClelland, Graham; Younger, Paul (2014-07)
    • Pre-hospital lactate monitoring for adults with sepsis

      Charlton, Karl (2014-09)
      Abstract published with permission. Background: Sepsis is a life-threatening condition that claims 37 000 lives in the UK. The sepsis six care bundle was developed by the surviving sepsis campaign in 2002 to address this high mortality rate. Part of this care bundle involves measuring blood lactate which is prognostic of mortality. Lactate can be measured by paramedics in the pre-hospital setting using hand held monitors similar to blood glucose machines, with accuracy that is comparable to laboratory measured lactate. Method: A focused electronic literature search was carried out on a number of different databases as well as a hand search of specific relevant journals. Data was also obtained from reference harvesting, although the limitations of this was appreciated. Experts in the field were also contacted with relevant data obtained. An ongoing pre-hospital trial monitoring lactate was also identified and these researchers were contacted with relevant data obtained. Conclusions: Pre-hospital lactate monitoring would promote better recognition of sepsis in adults and improve the quality of care. It could be used to initiate a specific treatment regime such as intravenous antibiotics. This would reduce the numbers of patients admitted to intensive care, helping to reduce mortality and costs for the NHS.
    • A comparison of actual versus predicted emergency ambulance journey times using generic Geographic Information System software

      McMeekin, Peter; Gray, Joanne; Ford, Gary A; Duckett, Jay; Price, Christopher (2014-09)
      Study objective The planning of regional emergency medical services is aided by accurate prediction of urgent ambulance journey times, but it is unclear whether it is appropriate to use Geographical Information System (GIS) products designed for general traffic. We examined the accuracy of a commercially available generic GIS package when predicting emergency ambulance journey times under different population and temporal conditions. Methods We undertook a retrospective cohort study of emergency ambulance admissions to three emergency departments (ED) serving differing population distributions in northeast England (urban/suburban/rural). The transport time from scene to ED for all the highest priority dispatches between 1 October 2009 and 30 September 2010 was compared with predictions made by generic GIS software. Results For 10 156 emergency ambulance journeys, the mean prediction discrepancy between actual and predicted journey times across all EDs was an underprediction of 1.6 min (SD 4.9). Underprediction was statistically significant at all population densities, but unlikely to be of clinical significance. Ambulances in urban areas were able to exceed general traffic speed, whereas, the opposite effect was seen in suburban and rural road networks. There were minor effects due to travel outside the busiest traffic times (mean overprediction 0.8 min) and during winter months (mean underprediction 0.4 min). Conclusions It is reasonable to estimate emergency ambulance journey times using generic GIS software, but in order to avoid insufficient regional ambulance provision it would be necessary to make small adjustments because of the tendency towards systematic underprediction. https://emj.bmj.com/content/emermed/31/9/758.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-2012-202246
    • Evaluation of pre-hospital point-of-care testing for lactate in sepsis and trauma patients

      Younger, Paul; McClelland, Graham (2014-10)
      Abstract published with permission. Objective: Lactate is a significant marker of critical illness and mortality in sepsis and trauma patients. The purpose of this study is to evaluate point-of-care lactate testing by paramedics in a UK ambulance service. Methods: Selected enhanced care paramedics were trained to use the lactate meter in patients with suspected sepsis and patients who trigger the major trauma bypass protocol. Feedback was collected on the practicalities of using the meter and the potential impact on the diagnosis of sepsis. Results: Data were collected on 114 patients, 96% had suspected sepsis (n=109) and 4% (n=5) were patients who had sustained trauma. The participants found that the ability to take lactate readings was useful and increased their confidence in their clinical decision making. Conclusions: Point-of-care lactate measurement is feasible in pre-hospital care and appears to support paramedics in their decision making.
    • Paramedic initiated Lisinopril for acute stroke treatment (PIL-FAST): results from the pilot randomised controlled trial

      Shaw, Lisa; Price, Christopher; McLure, Sally; Howel, Denise; McColl, Elaine; Younger, Paul; Ford, Gary A. (2014-12)
      Background High blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited. Methods We conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT. Results In 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST paramedic. Conclusions It is possible to conduct a paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained paramedics across several ambulance services would be needed to recruit the number of patients likely to be required. https://emj.bmj.com/content/emermed/31/12/994.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-2013-202536
    • A retrospective observational study to explore the introduction of the National Early Warning Score in NEAS

      McClelland, Graham (2015-02)
      Abstract published with permission. Background: The National Early Warning Score (NEWS) is a simple, rapid assessment tool compiled from respiratory rate, oxygen saturations, supplemental oxygen, temperature, systolic blood pressure, heart rate and level of consciousness developed by the Royal College of Physicians. NEWS was introduced into practice at North East Ambulance Service NHS Foundation Trust (NEAS) between April 2013 and March 2014. This paper will examine the use of NEWS in pre-hospital practice and seek to describe the patient population in terms of NEWS. Methods: Cross-sectional samples of patient records from NEAS attendances over two 24-hour periods were examined for NEWS usage, completeness of necessary observations and outcomes that may be linked to NEWS. A primary sample from 8 July 2013 included 100% of patients. A secondary sample of 10% of patients was taken from 1 April 2014. Results: Although 90% of all cases may be suitable for NEWS <1% (n=6) of patients attended had NEWS recorded. Of the NEWS elements only temperature was not consistently recorded. 95% of sets of observations included >4 NEWS elements. A consistent pattern emerged when the sample population was described according to NEWS using three methods of accounting for missing items of data. Pre-alerting based on NEWS was examined with little agreement between NEWS and current practice found, although this does not take into account practical reasons for pre-alerting such as underlying condition or local pathways. Conclusions: NEWS is not being documented by ambulance crews although the majority of the necessary elements are being recorded. This largely descriptive account of the use of NEWS within NEAS indicates that NEWS has not been adopted by ambulance crews.
    • Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC) : a pragmatic, cluster randomised controlled trial

      Perkins, Gavin D.; Lall, Ranjit; Quinn, Tom; Deakin, Charles D.; Cooke, Matthew W.; Horton, Jessica; Lamb, Sarah E.; Slowther, Anne-Marie; Woollard, Malcolm; Carson, Andy; et al. (2015-03)
    • Development and impact of a dedicated cardiac arrest response unit in a UK regional ambulance service

      Younger, Paul; McClelland, Graham; Fell, Paul (2015-05-19)
      Background Survival rates from out-of-hospital cardiac arrest (OHCA) vary, with figures from 2% to 12% reported nationally. Our ambulance service introduced a dedicated cardiac arrest response unit (CARU) as a trial in order to improve local patient outcomes by focussing training, extending the scope of practice and increasing exposure to cardiac arrests. CARU launched in January 2014 using a rapid response car staffed by senior paramedics responding to cardiac arrests within a 19 minute radius of their location⇓. VIEW INLINE VIEW POPUP Methods This work describes the development and impact of CARU during the initial six months (10/01/14 to 09/07/2014) of operations using prospectively collected data on all cases attended. Results CARU activated to 165 calls and attended 65% (n=107). 50% (n=54) of the cases attended were cardiac arrests where resuscitation was attempted. Return of Spontaneous Circulation (ROSC) was achieved during pre-hospital resuscitation in 52% (n=28) of cases. Patient outcomes are reported compared with service data for January to June 2014 inclusive and one year of historical data from the regional OHCA registry: Conclusions Based on these figures CARU appears to have a positive impact on ROSC and a significant impact on survival to discharge rates compared with the rest of the service (p<0.01, Fisher's exact test). Further work is needed to explore how CARU delivers this impact and how the CARU model can be implemented beyond the trial setting in a sustainable fashion. https://emj.bmj.com/content/32/6/503.2. 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/ DOI http://dx.doi.org/10.1136/emermed-2015-204979.2
    • The challenges of conducting prehospital research: successes and lessons learnt from the Head Injury Transportation Straight to Neurosurgery (HITS-NS) trial

      McClelland, Graham; Pennington, Elspeth; Byers, Sonia; Russell, Wanda; Lecky, Fiona (2015-08)
      Head Injury Transportation Straight to Neurosurgery was a cluster randomised trial studying suspected severe head injury treatment pathways conducted in the North East Ambulance Service NHS Foundation Trust and North West Ambulance Service NHS Trust between January 2012 and March 2013. This was the world's first large scale trial of any trauma bypass and was conducted as a feasibility study. This short report will describe some of the lessons learnt during this ground breaking and complex trial. https://emj.bmj.com/content/32/8/663.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-2014-203870
    • Moving sepsis care to the front line: knowledge and views of pre-hospital clinicians

      Roebuck, Elizabeth (2015-09)
      Abstract published with permission. Background: Previous in-hospital studies have highlighted the opportunity pre-hospital clinicians have to recognise sepsis at an early stage. Left untreated, mortality in septic shock increases rapidly. Sepsis screening tools have been developed to assist recognition; however, current knowledge of sepsis, effectiveness of previous training and attitudes towards implementation of a screening tool is unknown. Methods: A survey was emailed to 529 paramedics and 131 advanced technicians in the North of England to determine their current knowledge of sepsis, views around previous training and the use of a screening tool. Case studies were included to investigate current management of patients with history of infection. Results: 144 clinicians completed the survey, gaining a 21.8% response rate. 54% (95% CI 46%, 62%) of clinicians felt like they had good knowledge, leaving 46% of clinicians feeling a lack of knowledge. 94% (95% CI 89%, 97%) thought emergency departments should treat sepsis immediately or within the first hour. Case studies highlighted variability in the management pathways chosen and 98% (95% CI 94%, 99%) of clinicians required further training. 97% (95% CI 92%, 99%) agreed a screening tool would assist in the identification of septic patients and 98% (95% CI 95%, 99%) would use the tool. Conclusions: Severity level and importance of quick recognition and management are acknowledged among clinicians. Although response rate is a limitation of this study, knowledge levels differentiate greatly among the cohort and nearly all state they require further education. Clinicians agreed a screening tool would help identify septic patients and would use it alongside clinical acumen.
    • A pilot study exploring the accuracy of pre-hospital sepsis recognition in the North East Ambulance Service

      McClelland, Graham; Jones, Jacqui (2015-09)
      Abstract published with permission. Background: Over the past decade there has been a focus on improving pre-hospital recognition and treatment of patients with sepsis. This pilot study investigates pre-hospital sepsis recognition, including the use of a Sepsis Screening Tool (SST), treatment and whether timely identification influenced the time to treatment and outcome at the receiving unit. Methods: A cross-sectional sample of patients with a documented suspicion of sepsis by North East Ambulance Service NHS Foundation Trust (NEAS) was combined and cross referenced with patients coded for sepsis at The James Cook University Hospital (JCUH) to generate a sample of sepsis patients seen within January 2014. NEAS sepsis recognition was compared with SST identification by retrospectively examining patients’ medical records. Sensitivity and specificity for NEAS diagnosis were calculated by comparing NEAS identification with JCUH diagnosis using the hospital SST. Results: The sample included 49 patients from January 2014. NEAS correctly identified 18/42 patients with sepsis (43% sensitivity, 14% specificity). NEAS correctly identified 8/27 patients with severe sepsis (30% sensitivity, 77% specificity). Conclusions: It is evident that NEAS clinicians diagnose sepsis without consistently using the SST. Use of the SST would improve the ability of NEAS clinicians to identify patients with sepsis.
    • Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis.

      Gates, Simon; Quinn, Tom; Deakin, Charles D.; Blair, Laura; Couper, Keith; Perkins, Gavin D. (2015-09)