• 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.
    • Falls: nine things to consider before dialling 999

      Hayes, Catherine; Scott-Thomas, Jeanette; Mains, Jacqueline; Barrigan, Marie; Graham, Yitka (2019-06)
    • Feasibility of phenytoin as a paramedic-led second-line anti-epileptic drug

      Morrison, Luke (2020-09-07)
      Background: Convulsive status epilepticus (CSE) is a medical emergency that is commonly encountered in the prehospital setting. In almost all prehospital settings, treatment is limited to benzodiazepines even though the standard of care in emergency departments includes second-line agents such as phenytoin. Methods: A literature search was conducted using PubMed and Google Scholar using the search terms ‘phenytoin’, ‘seizure’ or ‘convulsive’ and ‘prehospital’, ‘EMS’ or ‘ambulance’ or ‘emergency department’. Five articles were analysed and a narrative review formed. Results: Phenytoin is an effective and commonly used second-line anti-epileptic agent but there is a distinct lack of evidence on prehospital phenytoin. Phasing the introduction of phenytoin into practice while simultaneously running a well-designed research trial could provide data for prehospital providers and the wider health community. Conclusion: Management of CSE will continue to present challenges to prehospital providers. Promoting the introduction of phenytoin to select patients, administered by advanced clinicians, could be an excellent opportunity to generate much-needed clinical data and potentially reduce morbidity and mortality in CSE. Abstract published with permission.
    • The frequency, characteristics and aetiology of stroke mimic presentations: a narrative review

      McClelland, Graham; Rodgers, Helen; Flynn, Darren; Price, Christopher (2019-02)
    • Hangings attended by emergency medical services: a scoping review

      Shaw, Gary; Thompson, Lee; McClelland, Graham (2021-03)
      n the United Kingdom (UK) there were 6507 deaths by suicide in 2018, with hanging being the most common method. Hanging will normally result in emergency medical services (EMS) being called and may result in resuscitation being attempted. Trauma audits conducted by North East Ambulance Service NHS Foundation Trust have identified an increased trend in hanging cases, which were also reported in national data. The aim of this scoping review was to explore the literature around EMS attendance at hangings to inform further research and clinical practice. Abstract published with permission.
    • The head injury transportation straight to neurosurgery (HITS-NS) randomised trial: a feasibility study

      Lecky, Fiona; Russell, Wanda; Fuller, Gordon W.; McClelland, Graham; Pennington, Elspeth; Goodacre, Steve; Han, Kyee; Curran, Andrew; Holliman, Damian; Freeman, Jennifer; et al. (2016-01)
    • How do paramedics learn to intubate?

      McClelland, Graham; Younger, Paul; Haworth, Daniel (2016-05)
      Abstract published with permission. A short cut review was carried out to establish what education and training are required for paramedics to gain initial competence in the skill of endotracheal intubation. Nineteen studies were identified with relevance to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is difficult to isolate intubation from the wider subject of airway management and the range of skills and techniques necessary to safely secure the airway in the prehospital setting. The evidence presented suggests that at least 25–35 intubations are necessary, as part of a wider programme of training, to gain initial competence in this skill.
    • Identifying pre-hospital factors which influence outcome for major trauma patients in a regional Trauma Network: an exploratory study

      Thompson, Lee; Hill, Michael; Davies, Caroline; Shaw, Gary (2016-09)
      Background Major trauma is often life threatening or life changing and is the leading cause of death in the United Kingdom for adults aged≤45 years. The aim of this exploratory study was to identify pre-hospital factors influencing patient outcomes for major trauma within the Northern Trauma Network. Method Secondary data analysis of a combined data set of pre-hospital audit data and patient outcome data from the Trauma Audit Research Network (n=1033) was undertaken. Variables included mechanism of injury, age, physiological indices, timings and skill mix. Principle outcome measures included Mortality data and Glasgow Outcome Scales. Results Glasgow Coma Scores proved a significant predictor of mortality in major trauma (p<0.00). Amongst other physiological indices, systolic blood pressure ≤90 mm Hg. was associated with both increased mortality (p≤0.004) and poorer morbidity (p≤0.021). Respiration rate <14/minute was also significantly predictive of morbidity (p≤0.03) and mortality (p<0.00). Prolonged response times to the most critically injured patients (p<0.031), and increasing casualty age were significantly associated with poorer outcomes. The attendance of a Doctor was significantly associated with increased mortality (p≤0.036) perhaps validating existing resource despatching practices. Predictors of positive outcomes included the presence of a Doctor when on-scene time ≤50 minutes (p≤0.015), crew arrival on-scene ≤10 minutes (p<0.046) and on-scene time ≤50 minutes (p<0.015). Conclusion These findings validate GCS, BP and Respiratory Rate values as valid triggers for transport to a Major Trauma Centre. Analysis of the interactions between arrival time, time-on-scene, skill mix and age demand further exploration but tentatively validate the concept of a ‘Golden Hour’ and suggest the potential value of a ‘load and go and play on the way’ approach. https://emj.bmj.com/content/emermed/33/9/e5.1.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/ 10.1136/emermed-2016-206139.18
    • The impact of introducing real time feedback on ventilation rate and tidal volume by ambulance clinicians in the North East in cardiac arrest simulations

      Charlton, Karl; McClelland, Graham; Millican, Karen; Haworth, Daniel; Aitken-Fell, Paul; Norton, Michael (2021-05-10)
    • Impact of the COVID-19 lockdown on hangings attended by emergency medical services

      McClelland, Graham; Shaw, Gary; Thompson, Lee; Wilson, Nina; Grayling, Michael (2020-10-24)
    • Improving pressure ulcer risk identification: a pilot project by ambulance staff

      Mains, Jacqueline; Graham, Yitka; Hayes, Catherine (2020-03-10)
      Background: A quality improvement initiative was designed to identify patients at risk of compromised tissue viability before they were admitted to hospital. Paramedics were educated to better identify patients with pressure ulcers or pressure damage, or those at risk of compromised tissue viability, and these patients were fitted with a pressure ulcer alert bracelet so that emergency department staff could identify them. Aims: The aims of the current initiative were to educate paramedics to better identify patients with pressure ulcers or those at risk of compromised tissue viability to emergency department staff, and fit them with a pressure ulcer alert bracelet to highlight them to emergency department staff so they would receive prompt intervention. Methods: A plan, do, study, act improvement methodology was used, and data from a 3-month period were retrospectively analysed. Patients identified as being at risk of compromised tissue viability were flagged as requiring assessment via a pressure ulcer risk assessment tool to enable prevention. Results: Paramedics identified 130 at-risk patients (aged 23–100 years), and data from 127 patients were analysed. Most at-risk patients fitted with pressure ulcer alert bracelets were aged 70 years or over, and there was an even female/male division. More than half (53%) of patients were found to have a pressure ulcer and alerted to emergency department staff. More than one in four (27%) patients who were identified as being at risk of pressure ulcers lived in nursing or residential homes, and 43% lived alone or in warden-controlled accommodation. Conclusions: Paramedics effectively identified potential risk factors for pressure ulcer development, indicating a need for immediate intervention. This study gives insight into how pressure ulcer risk assessment using an alert bracelet may be used in paramedic practice in emergency department handovers. Success depends on hospital staff acting upon paramedic recommendation. Abstract published with permission.
    • Improving systems for research management and governance

      McLure, Sally; Dorgan, Sharon; Smith, Justine (2010-02)
      The North East Ambulance Service NHS Trust (NEAS) is committed to the implementation of a number of nationally proposed initiatives following the introduction of the research strategy Best Research for Best Health (Department of Health, 2006). The ambitious strategy introduces several measures to improve the research environment and ensure that studies commence more efficiently. This article provides an overview of the national initiatives, i.e. the Research Passport Scheme and the National Institute for Health Research Coordinated System for gaining NHS Permissions. These initiatives aim to strengthen and streamline research management and governance across England, which NEAS are actively embracing. Abstract published with permission.
    • Improving the prehospital safety of steroid-dependent patients in northern England: A hospital-initiated ambulance service registration pathway

      Mitchell, Anna L.; Devine, Kerri; Lal, Vikram; Galloway, Paul; House, Matthew; White, Katherine; Watson, Julie; Parry, Steve; Miller, Margaret; Morris, Margaret; et al. (2017-12)
    • Incidence of peri-opiate nausea and vomiting in the pre-hospital setting: an intermediate analysis

      Campbell, Gareth; Woollard, Malcolm; McLure, Sally; Duckett, Jay; Newcombe, Robert; Clarke, Tom (2011-03)
      Background Intravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide is common. In the absence of pre-hospital data to support this practice, we sought to determine the incidence of peri-opiate nausea and vomiting in an ambulance service which does not administer anti-emetics. Methods This prospective observational study is currently assessing the incidence of emesis in 400 patients attended by the North East Ambulance Service, aged above 17 years and receiving morphine, using a patient-scored Nausea and Vomiting Score (NVS: 0=no nausea or vomiting, 1=slight nausea, 2=moderate nausea, 3=severe nausea, 4=vomited once, 5=vomited twice or more). Results To date 145 patients have been recruited. Median NVS before morphine was 0 (range 0 to 6, inter-quartile range (IQR) 0 to 1): 54/141 (38%) of patients had some degree of nausea or vomiting. Median NVS on hospital arrival (after morphine) was 0 (range of 0 to 6, IQR 0 to 1): 54/130 (42%) patients had some degree of nausea or vomiting. The differences pre- vs. post-morphine in median NVS (p=0.98) and proportion of patients suffering nausea and vomiting are not statistically significant (p=0.98 and p=0.54 respectively). There were no significant correlations between pre-morphine pain score and pre-morphine NVS; post-morphine pain score and post-morphine NVS; pre-morphine NVS and total morphine dose; and post-morphine NVS and total morphine dose (Spearman's rank correlation 0.09, p=0.274; 0.07, p=0.44; 0.10, p=0.25; and 0.10, p=0.24 respectively). Conclusion and recommendations To date this study has found no evidence that pre-hospital administration of morphine is associated with an increased incidence or severity of nausea and vomiting and therefore does not appear to support the routine co-administration of metoclopramide. https://emj.bmj.com/content/emermed/28/3/237.2.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/emj.2010.108597.2
    • The influence of paramedic assessment on emergency transportation of stroke patients

      Price, Christopher; Duckett, Jay; Cessford, C.; Ford, Gary A. (2008-09-01)
    • Intravenous versus oral paracetamol in a UK ambulance service: a case control study

      Charlton, Karl; Limmer, Matthew; Moore, Hayley (2020-06-01)
      Abstract published with permission Objectives: To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. Methods: We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. Results: 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. Conclusion: Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.
    • 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