• 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
    • Just don't call me sir!

      Smith, Daniel (2019-06-08)
    • 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.
    • Knowing our specialist roles

      Smith, Daniel (2019-08-07)
    • 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.
    • Medical pharmacology at a glance

      Armitage, Ewan (2016-11)
    • 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.
    • Packing an academic punch

      Romano, Vincent (2018-06)
    • 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.
    • 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
    • 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 attitudes towards DNACPR orders

      Armitage, Ewan; Jones, Colin (2017-10)
      Abstract published with permission. Background: Qualitative research involving paramedics and their involvement in end-of-life (EoL) care has already been published, but there have been no published attitudinal studies specifically relating to do not attempt cardiopulmonary resuscitation (DNACPR) orders and paramedics working in the pre-hospital setting in the UK. Objective: To gain an understanding of paramedic attitudes towards an increasingly common aspect of paramedic practice, focusing specifically on the pre-hospital environment and identifying any corelation between gender, length of service, and level of educational attainment. Design: A paper-based questionnaire was distributed to all paramedic grades, operational out of two ambulance stations of a regional NHS ambulance service in March 2017. The questionnaires were designed using a combination of free-text boxes and Likert scales. A total of 33 questionnaires were issued and 11 completed questionnaires were returned. Results: Respondents indicated the importance of communication in relation to DNACPR orders, as well as the role of allied health professionals and family members in the process. Respecting the patient’s wishes was considered paramount, as was educational provision surrounding DNACPRs. Conclusion: The majority of respondents reported that they were comfortable incorporating DNACPR orders in their clinical practice, although more modest responses were returned regarding the level of education received in this area of paramedicine.
    • Paramedic clinical leadership

      Martin, John; Swinburn, Andy (2012-03)
      Developing the paramedic profession is at the heart of the mission for the College of Paramedics. As any profession develops it evolves to take leadership and responsibility for a growing body of knowledge that informs practice. Back in 2008 the College published the second edition of the curriculum framework for paramedics clearly outlining the need for the development of roles at a variety of clinical levels. Having these levels populated creates a clinical framework that will deliver patient benefit and develop future paramedic practice. At its recent Council meeting the College outlined the need to develop education standards, clinical guidelines, and voluntary regulation for these emerging elements on the career framework, and is set to do this over the coming year. In this article Andy Swinburn the College Council representative for NW region outlines how the North West Ambulance Service NHS Trust has put into place a structured career development spanning the professional roles from first registration to consultant practice. https://www.magonlinelibrary.com/doi/full/10.12968/jpar.2012.4.3.181 ] 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/10.12968/jpar.2012.4.3.181