• The secrets of success

      First, Sue; McGregor, Erica (2006-12-01)
    • The future of air ambulance services in trauma care

      Davies, Douglas (2009-12-18)
      This article explores the development of air ambulances from being vehicles for inter-hospital transfers to being the modern frontline resources for prehospital care. The service models currently utilised by the various air ambulance charities are explored, as is the influence each of these may have on the delivery of patient care. The organizational structure of air ambulance charities is addressed, as it also impacts upon service delivery and the governance of clinical practice. This area gives rise to an exploration of the potential for air ambulances to offer a unique platform for the development of the paramedic profession and an expanded scope of clinical practice. The article also explores the effect of wider changes within health care and how this impacts upon the services provided by air ambulances. Analysis of potential future developments based upon a number of factors is made and conclusions drawn with regard to both current and future practice development. Abstract published with permission.
    • NWAS Library and Information Service

      Holland, Matt (2009-12-18)
      Matt Holland is Outreach Librarian in the North West Ambulance Service. Here he explains his unique role, and the steps involved in the development of a Library Information Service. Abstract published with permission.
    • COPD: an overview of prehospital care

      Scholes, Steven; Hedges, Nicola (2009-12-18)
      Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. It is a debilitating airways disease which presents to the ambulance service with varying severity and is characterized by airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months. It may coexist with other comorbidities such as cardiovascular disease, making diagnosis of exacerbations difficult. COPD management in the prehospital environment is focused on effective recognition and the early application of pharmacological intervention to alleviate symptoms using current Joint Royal Colleges Ambulance Liaison Committee Guidelines. Abstract published with permission.
    • Stroke knowledge and awareness: an integrative review of the evidence

      Jones, Stephanie P.; Jenkinson, Amanda J.; Leathley, Michael J.; Watkins, Caroline L. (2010-01)
    • Joint Royal College Ambulance Liaison Committee Airway Working Group commentary

      Jackson, Mike (2010-03)
      The publication of the paper by the Joint Royal College Ambulance Liaison Committee Airway Working Group (JRCALC AWG) will no doubt start a fierce debate among the paramedic and medical professions about prehospital intubation. Prehospital intubation performed by paramedics is a profession-defining skill, has been practised by paramedics in the UK for over 20 years, and has been a mainstay of prehospital airway management. In a survey of paramedics in the USA, prehospital intubation was ranked as a more important skill than defibrillation and patient assessment.1 Most of the literature reviewed by the JRCALC AWG was from the USA and included studies of drug-assisted intubation. Wang and associates2 examined 592 attempts at intubation in one year and found 536 of these to be successful (90.5%); another study of 264 paediatric prehospital intubations reported a much higher success rate of 99%,3 Bulger and colleagues4 in Seattle reported a success rate of 98.4% and in Bellingham, Washington, Wayne and Friedland5 reported a 95.5% success rate. It must be said that there are significant differences in the training and education of paramedics between the USA and the UK. The national standard curriculum for emergency medical technicians in the USA6 states that paramedics require only five successful intubations before graduation, whereas in the UK until recently paramedics needed to achieve 25 successful intubations. It is recognised that achieving intubation of the trachea does not necessarily mean the individual is proficient or competent in the skill of intubation. However, it must also be noted that achieving 25 intubations provides the paramedic with a higher degree of proficiency and competency than those achieving five. Limited capacity in the clinical placement circuit and the increased use of supraglottic devices for anaesthetic procedures in hospital means that paramedics are having difficulty in achieving the target of 25; as a result the accreditation bodies no longer demand that the 25 target is met, although there is still a need to learn the skill. In the future it is likely that training opportunities will be even more difficult to secure, and so the profession now finds itself at a crossroads. We need to look at what is right and what is safe for the patient, and importantly what is achievable by the profession. This will mean looking for alternative ways of achieving competence, for example, human simulation laboratories or looking at alternative airways. Recent evidence suggests that increasing the intubation experience of paramedics leads to better prehospital outcomes.7 Further evidence suggests there is no difference between experienced paramedics and doctors in performing successful intubation in prehospital cardiac arrest.8 Therefore, rather than removing the skill of intubation for all paramedics the focus should be on ensuring a proportion, for example, those in senior or advanced roles, are given the opportunity to acquire the necessary experience. If we adopt this approach the more exposure these clinicians will have the more proficient they will become, and this will result in improved outcomes. The JRCALC AWG has recognised this as a possible solution to the current problem. Ambulance services would be able to structure their response model to reflect this clinical provision and use these senior clinicians appropriately, not only to provide the expertise but also to supervise and lead on patient care at critical incidents. By using these senior clinicians the impact upon operational performance and resources will be minimised. With the training and revalidation problems we face the time is right for newly qualified paramedics and existing ones unable to maintain their intubation skills to adopt an alternative to intubation. Supraglottic airway devices are an alternative to intubation, but the suggestion by the JRCALC AWG that we should simply replace prehospital intubation by paramedics with supraglottic devices needs to be debated and researched. There is little evidence to support the effectiveness of supraglottic devices in prehospital non-fasted patients. Research to date has focussed primarily on the use of these devices in hospitals. We have no evidence to suggest that these devices are safe outside of hospitals; thus we need further research about their effectiveness. It is a gold standard in trauma that drug-assisted intubation is the best way to intubate the patient, and it is accepted that this should only be done by skilled operatives who perform the procedure regularly. However, although the JRCALC AWG agrees there is little evidence that prehospital intubation without anaesthetic drugs improves patient outcomes, there is also little evidence (especially from the UK) that prehospital intubation in patients in cardiac arrest is harmful. There are many examples in medicine in which treatment is given when it has not been proved to be effective, but the treatment continues as there is no evidence it is harmful. As there is no UK evidence that prehospital intubation by paramedics is harmful, the profession needs to continue this practice for patients in cardiac arrest—but with the skill performed by experienced senior and advanced paramedics working in a robust governance framework to ensure revalidation and maintenance of these skills. In the meantime, we need to explore the use of alternative devices including supraglottic devices, to decide if they are safe as an alternative to prehospital intubation especially for cardiac arrest, and to see if they will improve patient outcomes., https://emj.bmj.com/content/27/3/171.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/ DOI http://dx.doi.org/10.1136/emj.2009.090381
    • Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature

      Brooke, Mike; Walton, Julie; Scutt, Diane (2010-07-28)
      ABSTRACT Objectives Recently, attempts have been made to identify the utility of ultrasound in the management of patients in the prehospital setting. However, in the UK there is no directly relevant supporting evidence that prehospital ultrasound may reduce patient mortality and morbidity. The evidence available to inform this debate is almost entirely obtained from outside the UK, where emergency medical services (EMS) routinely use doctors as part of their model of service delivery. Using a structured review of the literature available, this paper examines the evidence to determine ‘Is there a place for paramedic ultrasound in the management of patients in the prehospital setting?’ Method A structured review of the literature to identify clinical trials which examined the use of ultrasound by non-physicians in the prehospital setting. Results Four resources were identified with sufficient methodological rigour to accurately inform the research question. Conclusion The theoretical concept that paramedicinitiated prehospital ultrasound may be of benefit in the management of critically ill patients is not without logical conceptual reason. Studies to date have demonstrated that with the right education and mentorship, some paramedic groups are able to obtain ultrasound images of sufficient quality to positively identify catastrophic pathologies found in critically ill patients. More research is required to demonstrate that these findings are transferable to the infrastructure of the UK EMS, and in what capacity they may be used to help facilitate optimal patient outcomes. https://emj.bmj.com/content/27/9/702.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/ doi: 10.1136/bmj.h535
    • Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature

      Brooke, Mike; Walton, Julie; Scutt, Diane (2010-07-28)
      Objectives Recently, attempts have been made to identify the utility of ultrasound in the management of patients in the prehospital setting. However, in the UK there is no directly relevant supporting evidence that prehospital ultrasound may reduce patient mortality and morbidity. The evidence available to inform this debate is almost entirely obtained from outside the UK, where emergency medical services (EMS) routinely use doctors as part of their model of service delivery. Using a structured review of the literature available, this paper examines the evidence to determine ‘Is there a place for paramedic ultrasound in the management of patients in the prehospital setting?’ Method A structured review of the literature to identify clinical trials which examined the use of ultrasound by non-physicians in the prehospital setting. Results Four resources were identified with sufficient methodological rigour to accurately inform the research question. Conclusion The theoretical concept that paramedic-initiated prehospital ultrasound may be of benefit in the management of critically ill patients is not without logical conceptual reason. Studies to date have demonstrated that with the right education and mentorship, some paramedic groups are able to obtain ultrasound images of sufficient quality to positively identify catastrophic pathologies found in critically ill patients. More research is required to demonstrate that these findings are transferable to the infrastructure of the UK EMS, and in what capacity they may be used to help facilitate optimal patient outcomes. https://emj.bmj.com/content/27/9/702. 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/emj.2010.094219
    • Managing neck breathing patients in the prehospital setting: review of best practice

      Brooke, Mike; Brown, Andrea (2010-11)
      An increasing number of patients with long-term tracheostomies or laryngectomies are being managed in the community. However, recent evidence suggests that many clinicians from both the hospital and prehospital setting lack sufficient skills and knowledge to safely manage them in emergency situations. This article describes the anatomical and pathophysiological variations that may be encountered in tracheostomy and laryngectomy patients, and relates them to the adaptations that may be required when managing this group of patients in the prehospital setting. Abstract published with permission.
    • Potential applications of capnography in the prehospital setting

      Percival, David (2012-01)
      Abstract published with permission. End-tidal carbon dioxide (ETCO2) monitoring is well established in hospital theatre and critical care settings (Lah and Grmec, 2010), employed for observation and monitoring in anaesthesia. Its application has now extended to the prehospital environment, primarily for the verification of endotracheal tube (ETT) placement, endeavouring to reduce the occurrence of oesophageal intubations (Grmec and Malley, 2004). In recent times, technological advances, coupled with an increased appreciation of the importance of prehospital interventions, has resulted in the production of additional equipment capable of monitoring ETCO2 in non-intubated, self-ventilating patients via a non-invasive nasal cannula. Despite having an extensive range of potential uses, the apparatus is widely underused (Langhan and Chen, 2008). In this article, potential applications in the prehospital setting will be discussed via a review of contemporary literature.
    • Acquisition and interpretation of focused diagnostic ultrasound images by ultrasound-naive advanced paramedics: trialling a PHUS education programme

      Brooke, Mike; Walton, Julie; Scutt, Diane; Connolly, Jim; Jarman, Bob (2012-04)
      Objective This trial investigated whether advanced paramedics from a UK regional ambulance service have the ability to acquire and interpret diagnostic quality ultrasound images following a 2-day programme of education and training covering the fundamental aspects of lung ultrasound. Method The participants were tested using a two-part examination; assessing both their theoretical understanding of image interpretation and their practical ability to acquire diagnostic quality ultrasound images. The results obtained were subsequently compared with those obtained from expert physician sonographers. Results The advanced paramedics demonstrated an overall accuracy in identifying the presence or absence of pneumothorax in M-mode clips of 0.94 (CI 0.86 to 0.99), compared with the experts who achieved 0.93 (CI 0.67 to 1.0). In two-dimensional mode, the advanced paramedics demonstrated an overall accuracy of 0.78 (CI 0.72 to 0.83), compared with the experts who achieved 0.76 (CI 0.62 to 0.86). In total, the advanced paramedics demonstrated an overall accuracy at identifying the presence or absence of pneumothorax in prerecorded video clip images of 0.82 (CI 0.77 to 0.86), in comparison with the expert users of 0.80 (CI 0.68 to 0.88). All of the advanced paramedics passed the objective structured clinical examination and achieved a practical standard considered by the examiners to be equivalent to that which would be expected from candidates enrolled on the thoracic module of the College of Emergency Medicine level 2 ultrasound programme. Conclusion This trial demonstrated that ultrasoundnaive practitioners can achieve an acceptable standard of competency in a simulated environment in a relatively short period of time. https://emj.bmj.com/content/emermed/29/4/322.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.2010.106484
    • From trade to profession-the professionalisation of the paramedic workforce

      First, Sue; Tomlins, Lucy; Swinburn, Andy (2012-07)
      Abstract published with permission. How do we achieve professionalisation of the paramedic? The Trait theory identifies professions as having 1. An exclusive body of knowledge 2. Self regulation and 3. Registration. Becoming a profession leads to improved remuneration and greater respect and knowledge, but this does not lead to a change in personal conduct. Professionalism however, is connected to behaviour, attitudes, accountability and responsibility. The behavioural changes and attitudes required of a ‘professional’ are brought about through the combination of higher education and clinical leadership. Academic input integrates clinical leadership with the career structure and all staff at all levels. Clinical leaders are at the coal face, accessible during and after the event, for training and clinical supervision and are therefore transforming practice at every level. However, clinical leadership is ineffective with an uneducated workforce and an uneducated workforce is ineffective without clinical leadership, the two go hand in hand So... What is the way forward for the ambulance service? What are paramedics doing to develop and maintain the profession and professional behaviours?
    • The art and science of mentorship in action

      Jones, Paul; Comber, Jason; Conboy, Adrian (2012-08)
      Abstract published with permission. The authors have collaborated to produce this article bringing together more than 60years of combined experience of paramedic practice, education and management. All maintain their paramedic registration and have among their goals the advancement and development of knowledge, skills and professionalism to promote an effective contemporary paramedic who continues to meet the care needs of the communities they serve. Practice mentors are pivotal to the success of a modern, fit-for-purpose paramedic curriculum that requires a significant proportion of learning and assessment to take place in the practice setting. This article focuses on the support that is needed for mentors during major professional and organisational change. Change which is aligned to localised multifaceted organisational strategies and change which includes supporting mentors, enabling them to carry out their function professionally, effectively and with confidence. This article discusses experiences of a collaborative, structured approach to mentorship support which is achieved through organisational, educational and professional alliances. It also explores other approaches and suggests a way forward in terms of a national governance framework.
    • Paramedic administration of glycoprotein inhibitors for ST elevation myocardial infarction

      Dykes, Simon (2012-08-16)
      Abstract published with permission. Until recently, paramedics were routinely delivering out-of-hospital thrombolysis for ST segment elevation myocardial infarction (STEMI). Now that primary percutaneous coronary intervention (PPCI) is the favoured reperfusion strategy, STEMI patients are by-passing the local emergency department and taken directly to the catheterisation laboratory via ambulance. STEMI patients within a rural setting are facing the prospect of extended transfer times for reperfusion of an already ischaemic myocardium, a potentially perilous strategy. Empirical research conducted outside the UK has identified that the pre-hospital administration of a glycoprotein inhibitor improves clinical outcome for STEMI patients. Glycoprotein naturally helps to build the fibrin mesh essential within the clotting process. Inhibition of this process by glycoprotein inhibitors IIb/IIIa (GPI IIb/IIIa) prevents aggregation at receptor sites on platelets. Original research supports the notion that GPI IIb/IIIa involvement improves patient clinical outcome for STEMI in the out-of-hospital phase. Paramedics are typically the first contact for the STEMI patient and it is tangible that paramedics have the appropriate skill and knowledge to diagnose the out-of-hospital STEMI. With this in mind, it is the purpose of this article to discuss the use of pre-hospital GPI IIb/IIIa administration and to argue that this intervention should be administered by paramedic personnel.
    • Kerbside consultations: advice from the advanced paramedic to the frontline

      Jackson, Mike; Jones, Colin (2012-09)
      Abstract published with permission. Aim To observe the issues, benefits and challenges of providing dynamic telephone clinical advice to frontline clinicians by advanced paramedics of the North West Ambulance Service NHS Trust. Method In order to focus on the key issues the study used a mixed method approach. A group of 11 advanced paramedics took part in two focus groups which was then followed up with a questionnaire to frontline clinicians. Using focus groups in the research not only allows for the possibility of multiple realities but also for participant validation. Using a qualitative approach allowed theory to develop and emerge which was then codified into themes and the data was then used to develop a questionnaire for frontline clinicians who had received clinical advice in the past in order to provide an element of quantitative data. Findings Five themes emerged from the stud: function, responsibility, barriers, education and support. Conclusion The study finds that clarity is required in relation to responsibilities and clinicians would benefit from a structured model to communicate information over the telephone—we believe the introduction of remote advice has improved patient safety and support to staff and has created opportunity for additional learning.
    • Pre-hospital coronary heart disease: analysing performance indicators

      Fletcher, David (2013-01)
      Abstract published with permission. The prevalence of coronary heart disease is massive within the UK and is the leading cause of myocardial infarction. Between a third and two thirds of associated deaths occur in the pre hospital setting, many within the first few minutes of symptom onset. Immediate quality treatment is proven to improve patient survival however recent evidence suggests patients are not receiving all the elements of a quality care bundle. Pain management has been identified as one area which requires national improvement to meet standards directed by the National Service Framework for Coronary Heart Disease. In response, Ambulance services nationally have used clinical performance indicators to address quality issues in order to enhance practice and achieve target. This article reviews the importance of pain relief in the treatment of acute coronary syndrome and analyses the use of clinical performance indicators in the pursuit of best practice within the North West.
    • Community service

      Byrom, Sarah (2013-04)