• Oxygen titration therapy and hypercapnia risk in COPD

      Harding, Cecily; Hart, Lindsay (2019-09-11)
      Background: Estimated to be the third leading cause of death in the UK by 2030, chronic obstructive pulmonary disease (COPD) is a common presenting complaint requiring an emergency ambulance. It is recognised that patients with COPD are at high risk of developing hypercapnia with the main theory of causality being high-flow oxygen therapy. Therefore, current guidelines recommend titrating oxygen therapy to maintain oxygen saturation percentage (SpO2) of 88–92% to reduce this risk. Aim: The aim of this review is to analyse literature concerning oxygen therapy in patients with COPD and their potential risk of hypercapnia. Methods: Extensive literature searches with strict parameters were carried out in electronic databases. After filtration of results, eight core articles were selected for analysis, from which three themes were identified as particular topics of interest. Findings: Critical analysis of the core articles confirmed the increased risk of hypercapnia in patients with COPD, but it is unclear if the cause is high-flow oxygen therapy, rate of alveolar ventilation or a specific COPD phenotype. Conclusion: Methods of reducing hypercapnia are limited in the prehospital setting with the only method transferable to paramedic practice being air nebulisation. Clinical compliance with study protocols and current national guidelines is low, both in prehospital and in-hospital environments. Abstract published with permission.
    • Paramedic accuracy and confidence with a trauma triage algorithm: a cross-sectional survey

      Durham, Mark (2017-03)
      Abstract published with permission. Introduction – Since 2008, the UK has been developing trauma networks, with ambulance services adopting triage tools to support these. So far there has been no published work on how UK paramedics use these algorithms. This study aims to evaluate factors affecting the accuracy and self-perceived confidence of paramedics from one UK Ambulance Trust when applying the Major Trauma Decision Tree. Methods – A quantitative cross-sectional survey was e-mailed to every paramedic within the participating Ambulance Trust, asking for basic demographic data and presenting four case studies. Respondents applied the Major Trauma Decision Tree to the case studies, stating which algorithm steps (if any) they triggered, and their appropriate destination. A Likert scale was utilised to explore respondent views on the Major Trauma Decision Tree. Descriptive and inferential statistics were used to identify linked factors affecting accuracy/confidence. Results – Of the 1132 paramedics employed by the Trust, 178 completed the survey (16% response rate). Sensitivity with the Major Trauma Decision Tree was 77% (95% CI 72–81%) and specificity, 61% (95% CI 56–66%). The trigger most commonly missed was patient age of greater than 55 years. Respondents reported that transport time to a major trauma centre/trauma unit influenced compliance with the algorithm. Self-perceived confidence was low overall, but correlated positively with frequency of exposure to trauma (rs [178] = 0.323, p < 0.0005). Respondents’ concerns about the reception they would encounter from hospital staff correlated negatively with confidence (rs [178] = –0.459, p < 0.0005). Conclusion – Respondent sensitivity when using the Major Trauma Decision Tree was low, which may be due to paramedic concerns about transport time. The most commonly missed trigger was patient age. Future training may benefit from addressing these points. In addition, respondents’ confidence with the Major Trauma Decision Tree was also low and closely linked with exposure to trauma, and the reception anticipated from hospital staff.
    • Paramedic independent prescribing: a qualitative study of early adopters in the UK

      Stenner, Karen; Van Even, Suzanne; Collen, Andy (2021-05-01)
      Paramedics working in advanced practice roles in the UK can now train to prescribe medicine. This is anticipated to benefit patient access to medicines and quality of care where there is a national shortage of doctors, particularly in primary care. 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.
    • Paramedic practitioners

      Walter, Alex (2014-02)
    • 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.
    • Patient confidentiality and safety: a classic conundrum

      Vigar, Paul (2017-05)
      Abstract published with permission. Paramedics frequently have to balance patient confidentiality and patient safety. Patient information is subject to legal, ethical and professional obligations of confidentiality and should not be disclosed to a third party for reasons other than healthcare, without consent. Whilst there is an imperative to preserve the professional/patient relationship, there are occasions where this is not possible. This article considers circumstances when confidential patient information may be disclosed without the consent of the patient and discusses the legal, ethical and professional aspects of decision making in this context. A clinical example from practice is presented where an ambulance crew was called to a 50-year-old man with type I diabetes, which is normally well controlled with insulin. He is employed as a van driver, but has experienced two sudden hypoglycaemic episodes in 3 weeks rendering him unconscious. Once treated, he declines transport to hospital, any onward referral or to inform the Driver and Vehicle Licensing Agency (DVLA) through fear of having his driving licence suspended.
    • Patient positioning and airway management in the pre-hospital setting: an observational study

      Plumbley, Stuart; Parkhe, Emma; Lambert, Ruth (2017-03)
      Abstract published with permission. Background – Pre-hospital airway management is often carried out in unconventional and challenging settings. The position of the patient requires the clinician to adjust the working position in order to get optimal visualisation. Aim and objective – This study aims to determine whether patient positioning affects the time to ventilation by tracheal intubation and the insertion of a supraglottic device in order to optimise airway management and reduce the period of hypoxia. The objective is also to compare the results of paramedics with the results of specialised critical care paramedics in order to ascertain whether additional training affects the time to ventilation in different positions. Methods – A sample of seven paramedics and seven critical care paramedics was recruited on a voluntary basis. The paramedics were timed while intubating with an endotracheal tube and inserting a supraglottic device, i-gel, from three different positions: lying down on the floor, kneeling in front of an ambulance trolley and standing with the trolley adjusted to the paramedic’s preferred height. Results – On average, both paramedics and critical care paramedics intubated from a lying down position in 26 seconds. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The quickest paramedic intubation attempt was from a lying down position in 26 seconds, whereas the quickest critical care paramedic intubation attempt from a standing position by a height-adjusted trolley took 20 seconds. Conclusion – Both paramedics and critical care paramedics intubate from a lying down position in the same time. The critical care paramedics were on average quicker than the paramedics from the kneeling and standing positions. The critical care paramedics were more consistent in all their attempts, with less of a performance gap among themselves. The variation in time to ventilate among paramedics showed huge differences in the paramedics’ overall performance.
    • Perceived areas for future intervention and research addressing conveyance decisions and potential threats to patient safety: stakeholder workshops

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2016-09)
      Background As part of a study examining systemic influences on conveyance decisions by paramedics and potential threats to patient safety, stakeholder workshops were conducted with three Ambulance Service Trusts in England. The study identified seven overarching systemic influences: demand; priorities; access to care; risk tolerance; training, communication and resources. The aim of the workshops was to elicit feedback on the findings and identify perceived areas for future intervention and research. Attendees were also asked to rank the seven threats to patient safety in terms of their perceived importance for future attention. Methods A total of 45 individuals attended across all the workshops, 28 ambulance service staff and 17 service user representatives. Discussions were audio-recorded, transcribed and thematically analysed. A paper based paired comparison approach was used to produce an ordinal ranking to illustrate the relative prioritisation of issues. Analysis included testing for internal consistency and between-rater agreement for this relatively small sample. Findings The two highest ranking priorities were training and development, as well as access to care. The areas for intervention identified represent what attendees perceived as feasible to undertake and relate to: care options; cross boundary working; managing demand; staff development; information and feedback; and commissioning decisions. Perceived areas for research specifically address conveyance decisions and potential threats to patient safety. 17 areas for research were proposed that directly relate to six of the systemic threats to patient safety. Conclusions Feedback workshops were effective in the validation of findings as well as providing an opportunity to identify priorities for future interventions and research. They also facilitated discussion between a variety of Ambulance Service staff and service user representatives. Ongoing collaboration between members of the research team has enabled some of the research recommendations to be explored as part of a mutually agreed research agenda. https://emj.bmj.com/content/emermed/33/9/e7.3.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-2016-206139.25
    • Phase shift in transmitted electrocardiograms: A cautionary tale of distorted signals

      Tayler, David; Hitt, Andy; Jolley, Brian; Sanders, Guy; Chamberlain, Douglas (2009-08-01)
    • A pilot study evaluating the use of ABCD2 score in pre-hospital assessment of patients with suspected transient ischaemic attack: experience and lessons learned

      Munro, Scott F.S.; Rodbard, Sally; Ali, Khalid; Horsfield, Claire; Knibb, Wendy; Holah, Janet; Speirs, Ottilia; Quinn, Tom (2016-08)
    • 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.
    • PP19 Use and impact of the pre-hospital 12-lead electrocardiogram in the primary PCI era (PHECG2): mixed methods study protocol

      Munro, Scott; Gavalova, Lucia; Halter, Mary; Snooks, Helen; Gale, Chris P.; Weston, Clive; Watkins, Alan; Davies, Glenn; Hampton, Chelsey; Driscoll, Timothy; et al. (2019-09-24)
      Background The pre-hospital 12-lead electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found PHECG was associated with improved 30-day survival, but a third of ACS patients under EMS care did not have PHECG. Such patients tended to be female, older and/or with comorbidities. This previous study was undertaken when thrombolytic treatment was the main treatment for ST segment elevation myocardial infarction (STEMI); practice has since shifted to a predominant interventional strategy – primary percutaneous coronary intervention (pPCI). Moreover, the previous study relied solely on data collected by the Myocardial Ischaemia National Audit Project (MINAP), which does not include information on symptoms, EMS personnel gender, and other factors that may influence decision-making. The PHECG2 study addresses the following research questions: a) Is there a difference in 30-day mortality and reperfusion between those who do and do not receive PHECG? b) Has the proportion of eligible patients who receive PHECG changed since the introduction of pPCI networks? c) Are patients that receive PHECG different from those that do not in social and demographic factors, and in pre-hospital clinical presentation? d) What factors do EMS clinicians report as influencing their decision to perform PHECG? Methods Explanatory sequential Quan-Qual mixed methods study comprising 4 Work Packages (WPs): WP1 a population based, linked data analysis of MINAP from 2010–2017 (n=510,000); WP2 retrospective chart review of EMS records from 3 EMS; WP3 focus groups with personnel from 3 EMS. WP4 will synthesise findings from WP1-3. Conclusions Gaining an understanding into the clinical and non-clinical factors influencing EMS clinicians’ decisions to record PHECG will enable us to develop (and later test through a randomised trial) an intervention to improve PHECG uptake and patient outcomes following an ACS event., https://emj.bmj.com/content/36/10/e9.1. 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-2019-999abs.19
    • Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

      Bootland, Duncan; Rose, Caroline; Barrett, Jack; Lyon, Richard M.; Kent, Surrey and Sussex Air Ambulance Trust (2019-02)
      Objectives Patients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury. Design A retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS. Setting A mixed urban and rural area of 4.5million people in South East England. Participants GCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital (‘Escorted’), and those that were ‘Assisted’ but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set. Primary outcome measure Significant brain injury. Secondary outcome measure Recognition of patients requiring prehospital anaesthesia for head injury. Results Of 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04). Conclusion In patients attended by a UK HEMS service with a head injury and a GCS of 13–15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging. https://bmjopen.bmj.com/content/9/2/e023307.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/bmjopen-2018-023307
    • Pre-hospital resuscitation INtra-arrest cooling effectiveness survival – the PRINCESS study

      Nordberg, Per; Taccone, Fabio; Truhlar, Anatolij; Ortiz, Fernando R.; Vermeersch, Nick; Goldstein, Patrick; Cuny, Jerome; Vrankx, Marc; Jimenez, Francesco C.; Lyon, Richard M.; et al. (2015-11)
    • 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., https://heart.bmj.com/content/96/22/1785. 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/hrt.2010.207076
    • Prehospital amputation: a scoping review

      Gander, Bradley (2020-01)
      Abstract published with permission. Background: Where limbs or extremities become entrapped and it is not possible to extricate a patient in time to prevent death, or because of a deterioration or scene safety emergency, prehospital amputation is an option to enable extrication. Aims: This study aimed to analyse accounts of prehospital amputation and identify factors that may influence practice as well as areas for further research. Methods: A search of multiple databases (AMED, BNI, CINAHL, EMCARE, Google Scholar and PubMed) and additional literature for accounts of prehospital amputation was carried out. Results: Thirteen sources of evidence describing 20 cases of prehospital amputation (18) or dismemberment (2) in a variety of settings between 1975 and 2019 were identified. Prehospital amputation was reported following structural collapse (8), industrial accidents (6), road traffic crashes (5) and rail incidents (1). The procedure was undertaken for a range of reasons, including unsuccessful traditional extrication attempts (7), time-critical patient condition (6), a risk of further extrication attempts causing structural destabilisation (5) and dismemberment of deceased victims (2). The equipment used to perform the amputation was not reported in 14 cases. Outcomes were reported in 17 accounts, with all patients surviving to hospital. Conclusion: Prehospital amputation is performed extremely rarely and accounts in the literature are limited. The situations and environments in which prehospital amputation is reported vary and specialist teams are often required. Further review of guidance and studies on techniques may be beneficial.