Recent Submissions

  • Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project.

    Steel, Alistair; Haldane, Charlotte; Cody, Dan (2021-02-15)
    Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting. 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. DOI
  • A national survey of ambulance paramedics on the identification of patients with end of life care needs

    Eaton-Williams, Peter; Barrett, Jack; Mortimer, Craig; Williams, Julia (2020-12-01)
    Objectives: Developing the proactive identification of patients with end of life care (EoLC) needs within ambulance paramedic clinical practice may improve access to care for patients not benefitting from EoLC services at present. To inform development of this role, this study aims to assess whether ambulance paramedics currently identify EoLC patients, are aware of identification guidance and believe this role is appropriate for their practice. Methods: Between 4 November 2019 and 5 January 2020, registered paramedics from nine English NHS ambulance service trusts were invited to complete an online questionnaire. The questionnaire initially explored current practice and awareness, employing multiple-choice questions. The Gold Standards Framework Proactive Identification Guidance (GSF PIG) was then presented as an example of EoLC assessment guidance, and further questions, permitting freetext responses, explored attitudes towards performing this role. Results: 1643 questionnaires were analysed. Most participants (79.9%; n = 1313) perceived that they attended a patient who was unrecognised as within the last year of life on at least a monthly basis. Despite 72.0% (n = 1183) of paramedics indicating that they had previously made an EoLC referral to a General Practitioner, only 30.5% (n = 501) were familiar with the GSF PIG and of those only 25.9% (n = 130) had received training in its use. Participants overwhelmingly believed that they could (94.4%; n = 1551) and should (97.0%; n = 1594) perform this role, yet current barriers were identified as the inaccessibility of a patient’s medical records, inadequate EoLC education and communication difficulties. Consequently, facilitators to performing this role were identified as the provision of training in EoLC assessment guidance and establishing accessible, responsive EoLC referral pathways. Abstract published with permission.
  • A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

    Barrett, Jack (2019-03)
    Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). Abstract published with permission.
  • Ambulance clinicians’ perspectives of sharing patient information electronically

    Barrett, Jack (2019-12)
    Communication in the NHS is vital to patient care and safety. Government bodies are pushing for the digitisation of patient health records so that access and transfer of information is easier between patient care teams. Many ambulance trusts have issued their clinical staff tablet computers as a step in the transition from paper-based to electronic-based patient health records. This study aims to evaluate whether these ambulance clinicians perceive tangible benefits to digitisation, particularly regarding collaborative working with other healthcare professionals. Abstract published with permission.
  • Where's the Fire?

    Copson, Anne (2008-12)
    As the UK explores the potential for fire services to act as first-responders to medical incidents, it is interesting that this research focuses on a system where fire services have traditionally been utilized as first-responders and where questions are now being asked as to whether this resource is appropriate for all emergency health care calls. The study included a ‘before-after’ design and set out to examine whether a selective emergency medical dispatch (EMD) system could reduce the frequency of deployment of fire department first-responder units and, if it did, whether this compromised patient safety. Abstract published with permission.
  • Paramedic management of shock in trauma: unlocking the potential

    Hitt, Andy (2010-08)
    Globally, traumatic injury is a leading cause of death for patients under 45 years old. A consequence of serious or poorly managed trauma is shock—a clinical syndrome that is both preventable and treatable if spotted in time. Heightened pathophysiological awareness and a review of diagnostic methods may promote early circulatory support rather than aggressive resuscitation. This could reduce the risk of iatrogenic complications and avoid unnecessary delay. The aim of this article is to critically appraise the treatment options currently available to UK paramedics and postulate realistic improvements based on underlying pathophysiology. Abstract published with permission.
  • Acute stroke life support: a United States based training course; is it appropriate for and transferable to the English health care setting?

    Davis, David; Crook, D.; Hargroves, D.; Miller, G.; South, A.; Jenkinson, D.; Smithard, D. (2009-12-01)
  • A Study to Assess the Use of Pre-Hospital Charcoal in South East England

    Dines, A. M.; Butler, C.; Taylor, I.; Ovaska, H.; Rowland, A.; Wood, D. M.; Dargan, Prinkeet (2009-06-03)
  • Vehicles and equipment for land-based neonatal transport

    Kempley, S. T.; Ratnavel, Nandiran; Fellows, T. (2009-08)
  • Phase shift in transmitted electrocardiograms: A cautionary tale of distorted signals

    Tayler, David; Hitt, Andy; Jolley, Brian; Sanders, Guy; Chamberlain, Douglas (2009-08-01)
  • Rudolf Juchems — A pioneer of cardiopulmonary resuscitation in Germany

    Böttiger, Bernd W.; Chamberlain, Douglas A.; Bossaert, Leo; Juchems, Markus (2009-10)
  • The primacy of basics in advanced life support

    Chamberlain, Douglas; Frenneaux, Michael; Fletcher, David (2009-06)
  • Prehospital neuromuscular blockade post OHCA: UK's first paramedic-delivered protocol

    Durham, Mark; Westhead, Pete; Griffiths, David; Lyon, Richard; Lau-Walker, Margaret (2020-05-05)
    Background: Since 2016, critical care paramedics from the South East Coast Ambulance Service have offered neuromuscular blockade to patients for ventilatory/airway control after cardiac arrest. Aims: To examine the first cases of paramedic-delivered neuromuscular blockade, and evaluate the prevalence of its use and safety. Methods: Retrospective service evaluation of patients receiving post-arrest paralysis during the study period from 1 April 2016 until 31 July 2017. Findings: The study included 127 patients. The mean age of administration was 63 years, mean weight was 80 kg (SD: 19 kg), dose was 1 mg/kg and median time from rocuronium administration to hospital was 32 minutes (IQR 20–43 minutes). Three patients (2.3%) experienced a minor adverse incident. There were no major airway complications, nor other significant adverse incidents. Thirty-seven patients (31%) survived to discharge. Conclusion: From this patient group, paramedic-administered rocuronium in intubated patients who have experienced a cardiac arrest and a return of spontaneous circulation appears to be safe, but further interventional research is required to determine whether this improves patient outcomes. Abstract published with permission.
  • Patient assessment: a reflective case study

    Hitt, Andy (2009-12-18)
    The three ‘C's of physical assessment—capacity, consent and communication—could be compared to the ‘ABCs' of resuscitation; without all three you will make very little, if any, progress. But do we give these aspects the attention they deserve, especially in time critical situations? This case study is based on a 76-year-old female who presented at Accident and Emergency (A&E) with central chest pain, diarrhoea and vomiting, productive cough and pyrexia. The aims of this case study are to discuss the impact of 21st century legislation on patient assessment, demonstrate the importance of objective, structured history taken and investigate the subjective nature of physical examination. In a world of waiting lists and litigation some argue that we should let technology do the leg work—ultrasound, chest x-rays, magnetic resonance imaging (MRI) and computed tomography (CT)—why use a stethoscope? Abstract published with permission.
  • Exploring paramedic perceptions of feedback using a phenomenological approach

    Eaton-Williams, Peter; Mold, Freda; Magnusson, Carin (2020-06-01)
    Abstract published with permission. Objectives: Despite widespread advocacy of a feedback culture in healthcare, paramedics receive little feedback on their clinical performance. Provision of ‘outcome feedback’, or information concerning health-related patient outcomes following incidents that paramedics have attended, is proposed, to provide paramedics with a means of assessing and developing their diagnostic and decision-making skills. To inform the design of feedback mechanisms, this study aimed to explore the perceptions of paramedics concerning current feedback provision and to discover their attitudes towards formal provision of patient outcome feedback. Methods: Convenience sampling from a single ambulance station in the United Kingdom (UK) resulted in eight paramedics participating in semi-structured interviews. Interpretative phenomenological analysis was employed to generate descriptive and interpretative themes related to both current and potential feedback provision. Results: The perception that only exceptional incidents initiate feedback, and that often the required depth of information supplied is lacking, resulted in some participants describing an isolation of their daily practice. Barriers and limitations of the informal processes currently employed to access feedback were also highlighted. Formal provision of outcome feedback was anticipated by participants to benefit the integration and progression of the paramedic profession as a whole, in addition to facilitating the continued development and well-being of the individual clinician. Participants anticipated feedback to be delivered electronically to minimise resource demands, with delivery initiated by the individual clinician. However, a level of support or supervision may also be required to minimise the potential for harmful consequences. Conclusions: Establishing a just feedback culture within paramedic practice may reduce a perceived isolation of clinical practice, enabling both individual development and progression of the profession. Carefully designed formal outcome feedback mechanisms should be initiated and subsequently evaluated to establish resultant benefits and costs.
  • Tension pneumothorax: are prehospital guidelines safe and what are the alternatives?

    Simons, Phil (2011-02)
    Abstract published with permission. Tension pneumothorax is a life-threatening complication of chest injury. It can cause rapid physiological decompensation, cardiac arrest and death. The Joint Royal Colleges Ambulance Liason Committee (JRCALC) provide guidelines on the prehospital diagnosis and treatment of this condition. The aim of this article is to ask whether or not these guidelines are effective and if there are feasible alternatives to the management of tension pneumothoraces in the prehospital environment.
  • Polytrauma: a case report

    Hitt, Andy (2011-01)
    Abstract published with permission. In the prehospital setting, the ‘foot of the bed inspection’ becomes an ‘over the ambulance dashboard inspection’. A mangled wreck at the foot of a tree is usually a good indication that someone has been injured and that timely clinical intervention may be required. By considering the mechanisms involved and performing a thorough primary survey, time critical patients can be triaged and treated with efficiency. As paramedics’ assessment skills continue to improve and doctors gain prehospital experience, it is anticipated that a well balanced team will emerge. A team that is aware of their limitations and limit their interventions to the time permitted to intervene. This case study is based on the young male driver of a vehicle that has been involved in a high speed collision with a tree. It aims to identify the probable pathologies, explain the pathophysiology of clinical signs and discuss, with evidence, the treatment options and appropriate destination for the patient.
  • Predictors of survival from out-of-hospital cardiac arrest

    Chamberlain, Douglas (2010-10-21)
    This year is the 50th anniversary of the introduction of modern resuscitation from cardiac arrest, made possible by the combination of closed chest compressions with external defibrillation and effective artificial ventilation.1 Inevitably this was restricted initially to hospitals, but within a few years the need to counter sudden death in the community led to the development of cardiac ambulances. The appreciation that lethal cardiac arrhythmias are not only due to acute myocardial infarction but can also occur unpredictably from a myriad of causes led to more complex responses. In most developed countries we now have public education on the need for rapid access to help, widespread training in cardiopulmonary resuscitation (CPR), means of early defibrillation where relevant and skilled aftercare—the so-called ‘chain of survival’.2 But daunting problems markedly limit success, irrespective of knowledge and training within the community. Even when death strikes suddenly and prematurely, many cases are complicated by severe underlying pathology that is not always amenable to prompt treatment. Even more importantly, only a very few minutes are available for effective resuscitation before apparently irreversible cerebral and cardiac changes make recovery impossible. Survival from out-of-hospital cardiac arrest (OOHCA) is therefore achieved only in a small minority, even of those ‘too young to die’. Investigating the predictors of success can help to prioritise efforts to improve results that are currently so dire. They have also been used as a guide for recognising futility, with the aim of curtailing resuscitation attempts that may have no chance of success. Many studies have been published on the predictors of success for resuscitation of out-of-hospital cardiac arrest (OOHCA), including a recent review.3 As with all data relating to survival from major prehospital events, this topic is bedevilled by difficulties that may lead to inaccurate or misleading data and also to discrepancies that may be more apparent than real. Accurate record keeping in prehospital care of emergencies is challenging; even the identity of victims is often not known initially. Collation of data from emergency services with those from hospitals in order to ascertain discharge status can be very difficult, especially in the UK because of confidentiality rules. Some well-organised groups—particularly in Sweden4 and North America5—have largely overcome such problems and have been able to contribute greatly to our knowledge. But, criteria for inclusion of data vary widely between reports, ranging from all cases in which a resuscitation effort has been made to identifiable subgroups chosen for comparator purposes, designed to eliminate as far as possible variables that cannot be influenced by emergency services. The international Utstein group recommended in 19916 the use for this purpose of only bystander-witnessed adult arrests of presumed cardiac origin in which ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was the first recorded rhythm. A later review from the same source placed more emphasis on less restrictive data that are of more value in terms of epidemiology.7 The purpose for which data are collected can lead to appreciable differences in inclusion criteria that will have some influence on predictors of a successful outcome. Most predictors of success are widely agreed, however, and are valid for most prehospital cardiac arrest data irrespective of the inclusion criteria. The response interval of the emergency service is an obvious one, although a recent publication highlighted the non-linear effect of delay8; the penalty of time lost in the first 4 min is slight because all short delays are favourable, but the additional penalty when delays are long is also slight because they are all unfavourable. Herlitz et al9 found that the first recordable rhythm scored even more highly than the response interval; VF is favourable because it can usually be reversed, it tends to occur where the underlying pathology is not inevitably fatal, and it also acts as a surrogate for response interval since asystole ensues in all cases within minutes. The same authors listed other factors achieving high statistical significance for success: cardiac arrest outside the home; witness by bystander; CPR given before the arrival of the ambulance; and age. Both the site of the arrest and the availability of a witness also relate to delay to the onset of treatment, so are not totally independent. Age is important principally as a marker of likely comorbidity. As an independent predictor, it seems relatively unimportant when allowance is made for the lower incidence of VF as the first recorded rhythm.10 Several accepted predictors are thus very interdependent but fundamentally reflect the times to effective first aid (CPR) or definitive treatment, together with comorbidity and underlying pathophysiology for which first observed rhythm is a surrogate. Other potential predictors of success depend on observations available only during the resuscitation attempt. Complex analysis of the fibrillatory waveform11 can reveal characteristics that have a strong relationship to the chances of a return of spontaneous circulation (ROSC); the possibility has been explored of its use to determine the appropriate timing of an automated defibrillator shock. More importantly, the occurrence of ROSC during an attempted resuscitation is a variable of clinical significance. If ROSC cannot be achieved at least transiently, then the likelihood of eventual recovery is low; failure in cases presenting with VF has been suggested as an indication for terminating resuscitation efforts. In Ontario12 a guideline designed for terminating an attempt by those qualified to practise only basic life support and defibrillation was found also to be suitable for those who had advanced life support skills. This depended on no ROSC prior to transport, no shock having been required, the arrest unwitnessed by emergency medical services personnel or bystander and no CPR. Many might be uneasy with such guidance even after a careful study of its validity. The Swedish group have made major contributions over at least 12 years to our understanding of the predictors of a successful outcome for resuscitation after cardiac arrest. This issue of the journal contains their latest study13 that differs from others in that it focuses on the survivors of OOHCA rather than on the totality of victims (see page 1826). This new perspective has some important implications that merit attention. The first is the need to be less pessimistic about patients with non-shockable rhythms at first contact; they comprise 20% of this series of nearly 2200, and two-thirds never received a shock. The attitude of professional rescuers has not been investigated as a predictor of success, but its importance should not be doubted. Second and less encouragingly, the outcome in terms of cerebral function tended to be less good for asystolic arrests. This may have been due to longer resuscitation attempts, but one might also speculate on possible effects of adrenaline which has been shown in an animal model to have important adverse effects on cerebral capillary flow.14 Also important is the finding that a third of all survivors had arrests witnessed by ambulance staff; this highlights powerfully the continuing requirement to educate the public in the need to call promptly for unaccustomed chest pain. Less surprisingly, in these new data 79% of survivors had a cardiac aetiology and 90% were witnessed. Women accounted for only 28% of survivors; they were more likely to be at home, less likely than men to have VF and had less CPR. The underlying reasons are understandable and will be hard to counter. We now understand most of the predictors of success in the treatment of OOHCA, but one important lesson is never to equate a lower chance of survival with no chance. This can have a powerful demotivating effect on management, both pre- and in-hospital, with the result that we have fewer successes than our present knowledge base can justify., 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: DOI

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