• ‘I wish there was CPAP in every box’: internet-based survey responses of clinicians recruiting to a pilot randomised controlled trial of continuous positive airway pressure (CPAP) for patients with acute respiratory failure

      Miller, Joshua; Keating, Samuel; Fuller, Gordon W.; Goodacre, Steve (2019-09-24)
      Background Continuous positive airway pressure (CPAP) is not in widespread use in UK ambulance services, but could benefit patients with acute respiratory failure (ARF). As a new treatment in this context, clinician acceptability is an important factor in the feasibility of conducting definitive research in the prehospital arena. Methods As part of a pilot randomised controlled trial (the ACUTE study), recruiting clinicians were emailed after enrolling patients to either the CPAP or standard-care arm, and were asked to complete an optional, anonymous, internet-based survey. The survey used a mixture of closed questions, Likert-scaled answers and free text to explore staff views on both the treatment and the trial procedures. Quantitative responses were analysed descriptively, and qualitative answers thematically. Results Recruiting clinicians for all 77 patients were sent survey links, with 40 email responses received. Respondents felt confident diagnosing ARF and determining trial eligibility. CPAP-arm respondents found the equipment easy-to-use and felt it did not delay transport to hospital. Most standard-care respondents said they would have liked CPAP to be available to their patients. Respondents described varying responses from receiving hospital staff. Conclusions Prehospital CPAP seems acceptable to clinicians. Limitations of this survey are that it was targeted only at clinicians who have already opted to take part in the trial, and so may exclude a body of staff who find the treatment unacceptable at face value. Not all clinicians who enrolled patients completed the survey, which could suggest a response bias or simply a reflection of its optional nature within the trial. Future pilot studies could mandate an acceptability survey, and also seek the views of staff not taking part in the interventional study. Trial teams may need to better explain the rationale of comparing a new intervention with standard care, and offer more widespread hospital staff awareness sessions., https://emj.bmj.com/content/36/10/e11.2 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.25
    • Identification of adults with sepsis in the prehospital environment: a systematic review

      Smyth, Michael A.; Brace-McDonnell, Samantha J.; Perkins, Gavin D. (2016-08)
      Objective: Early identification of sepsis could enable prompt delivery of key interventions such as fluid resuscitation and antibiotic administration which, in turn, may lead to improved patient outcomes. Limited data indicate that recognition of sepsis by paramedics is often poor. We systematically reviewed the literature on prehospital sepsis screening tools to determine whether they improved sepsis recognition. Design: Systematic review. The electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed were systematically searched up to June 2015. In addition, subject experts were contacted. Setting: Prehospital/emergency medical services (EMS). Study selection: All studies addressing identification of sepsis (including severe sepsis and septic shock) among adult patients managed by EMS. Outcome measures: Recognition of sepsis by EMS clinicians. Results: Owing to considerable variation in the methodological approach adopted and outcome measures reported, a narrative approach to data synthesis was adopted. Three studies addressed development of prehospital sepsis screening tools. Six studies addressed paramedic diagnosis of sepsis with or without use of a prehospital sepsis screening tool. Conclusions: Recognition of sepsis by ambulance clinicians is poor. The use of screening tools, based on the Surviving Sepsis Campaign diagnostic criteria, improves prehospital sepsis recognition. Screening tools derived from EMS data have been developed, but they have not yet been validated in clinical practice. There is a need to undertake validation studies to determine whether prehospital sepsis screening tools confer any clinical benefit. https://bmjopen.bmj.com/content/bmjopen/6/8/e011218.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/bmjopen-2016-011218
    • Identification of Sepsis among Ward Patients

      Smyth, Michael A.; Daniels, Ron; Perkins, Gavin D. (2015)
    • Impact of introducing a major trauma network on a regional helicopter emergency medicine service in the UK

      McQueen, Carl; Crombie, Nicholas; Perkins, Gavin D.; Wheaton, Steve (2014-10)
      Introduction In the West Midlands region of the UK, the delivery of prehospital trauma care has recently been remodelled through the introduction of a regionalised major trauma network (MTN). Helicopter emergency medical services (HEMS) are integral to the network, providing means of delivering highly skilled specialist teams to scenes of trauma and rapid transfer of patients to major trauma centres. This study reviews the impact of introducing the West Midlands MTN on the operation of one its regional HEMS units. Methods Retrospective review of the Midlands Air Ambulance clinical database for the 6 months after the launch of the West Midlands MTN. The corresponding period for the previous year was reviewed for comparison. The contribution of trauma cases to overall workload, mission outcome data and the number of interventions performed at the scene were compared. Results The proportion of HEMS activations for trauma cases was similar in both cohorts (70.84% before MTN vs 71.57% after MTN). The proportion of mission cancellations was significantly lower after the launch of the network (23.71% vs 19.03%). Significantly more scene attendances resulted in interventions by HEMS crews after the MTN launch (44.66% vs 56.92%). Conclusions Since the introduction of the West Midlands MTN, tasking of HEMS assets appears to be better targeted to cases involving significant injury, and a reduction in mission cancellations has been observed. There is a need for more detailed evaluation of patient outcomes to identify strategies for optimising the utilisation of HEMS assets within the regional network. https://emj.bmj.com/content/emermed/31/10/844.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-2013-202756
    • Improving data quality in a UK out-of-hospital cardiac arrest registry through data linkage between the Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project and NHS Digital

      Rajagopal, Sangeerthana; Booth, Scott J.; Brown, Terry P.; Ji, Chen; Hawkes, Claire A.; Siriwardena, Aloysius; Kirby, Kim; Black, Sarah; Spaight, Robert; Gunson, Imogen; et al. (2017-09)
    • Incidence of acute respiratory failure cases in West Midlands Ambulance Service (WMAS) – sub-study of ACUTE (ambulance CPAP: use, treatment effect and economics) trial

      Gunson, Imogen M.; Herbert, Esther; Fuller, Gordon W. (2019-09-24)
      Background Acute respiratory failure (ARF) is a life-threatening emergency and pre-hospital CPAP may improve outcomes. A CPAP cost-effectiveness determinant is the incidence of eligible patients with ARF. This sub-study of the ACUTE trial aimed to determine the number of adults with ARF potentially suitable for CPAP, presenting to WMAS. Methods This observational study was conducted between 1stAugust 2017 and 31st July 2018. Adult patients presenting with SpO2 <94% were identified from WMAS electronic patient records. Electronic filters applied ACUTE trial inclusion and exclusion criteria, with subsequent manual clinical review by a research paramedic. A second research paramedic checked a sub-sample for inter-rater agreement. Overall and monthly incidence rates were calculated, census data provided the population denominator. Results 108,391 potential patients were identified from electronic patient records (EPR), after filter application 4,526 cases were eligible for review (Figure 1). After review, 1017 cases were considered CPAP candidates. Inter-rater agreement was 86%. Overall incidence was 17.35 per 100,000 population per year (95%CI 16.3–18.5). Marked seasonal variation was present, increasing over winter (Figure 2). Urban areas had the highest proportion of eligible patients (67.6% v 18.3% Rural v 14.2% semi-rural); and 53.0% of all eligible were male. Conclusions The incidence of eligible ARF patients impacts on the cost-effectiveness of pre-hospital CPAP, but previous reports have been variable, using sub-optimal methods or from non-UK settings. We report a valid NHS estimate of 17 patients per 100,000 who do not respond to current pre-hospital ARF management and could be candidates for CPAP., https://emj.bmj.com/content/36/10/e11.3. 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.26
    • Infrastructure and operating processes of PIONEER, the HDR-UK Data Hub in Acute Care and the workings of the Data Trust Committee: a protocol paper

      Gallier, Suzy; Price, Gary; Pandya, Hina; McCarmack, Gillian; James, Chris; Ruane, Bob; Forty, Laura; Crosby, Benjamin; Atkin, Catherine; Evans, Ralph; et al. (2021-04)
      Health Data Research UK designated seven UK-based Hubs to facilitate health data use for research. PIONEER is the Hub in Acute Care. PIONEER delivered workshops where patients/public citizens agreed key principles to guide access to unconsented, anonymised, routinely collected health data. These were used to inform the protocol. https://informatics.bmj.com/content/28/1/e100294 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/10.1136/bmjhci-2020-100294
    • ‘Interception’: a model for specialist prehospital care provision when helicopters are not available

      McQueen, Carl; Apps, Richard; Mason, Fay; Crombie, Nicholas; Hulme, Jon (2013-11)
      The deployment of specialist teams to incident scenes by helicopter and the delivery of critical care interventions such as Rapid Sequence Induction of anaesthesia to patients are becoming well-established components of trauma care in the UK. Traditionally in the UK, Helicopter Emergency Medical Services (HEMS) are limited to daylight operations only. The safety and feasibility of operating HEMS services at night is a topic of debate currently in the UK HEMS community. Within the West Midlands Major Trauma Network, the Medical Emergency Response Incident Team (MERIT) provides a physician-led prehospital care service that responds to incidents by air during daylight hours and by Rapid Response Vehicle during the hours of darkness. The MERIT service is coordinated and supported by a dedicated Major Trauma Desk manned by a HEMS paramedic in the ambulance service control room. This case illustrates the importance of coordination and integration of specialist resources within a major trauma network to ensure the expedient delivery of HEMS-level care to patients outside of normal flying hours. https://emj.bmj.com/content/emermed/30/11/956.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-2013-202989
    • Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial

      Nolan, Jerry P.; Deakin, Charles D.; Ji, Chen; Gates, Simon; Rosser, Andy; Lall, Ranjit; Perkins, Gavin D. (2020-01-30)
    • An introduction to CPD for paramedic practice

      Sibson, Lynda (2008-11)
      This article outlines the concept of continuing professional development (CPD) and its application to the paramedic. CPD has long been an aspect of other health care professions, but is relatively new to the paramedic profession. The Health Professions Council (HPC) standards mean that paramedics will have to provide evidence of CPD from August 2009. The standards apply not only to those in clinical practice, but also to those working in research, management or education. CPD can initially appear daunting. However, it can, and should be, an enjoyable aspect of developing yourself and your professional practice. This article therefore aims to suggest some CPD activities for paramedic practice, with reference to some of the HPC guidelines and learning from other health care professionals. Abstract published with permission.
    • An introduction to reflective practice

      Sibson, Lynda (2008-12)
      This article aims to describe the process and theory of reflective practice and outline some reflective practice models for consideration for paramedic practice. Reflective practice is not just about writing an assignment, it is about looking back (reflecting) on a situation and taking another objective view of the incident. Reflective learning is a process where examination and exploration of an issue of concern, triggered by a specific experience, is clarified into some form of meaning, thus changing the individuals' perspective. Four reflective models have been presented—each with similar steps—so that readers can chose which one suits their practice. If undertaken well, it can enhance and develop new knowledge, initiate changes to practice and ultimately, improve patient care. Abstract published with permission.
    • Is IV paracetamol as effective an analgesic as IV morphine for patients in non-cardiac pain? A literature review

      Duplessis Grimson, Samuel (2016-01)
      Abstract published with permission. Since the introduction of IV paracetamol to UK ambulance services in 2012 there has been some debate as to which is the better analgesic, IV paracetamol or IV morphine. This literature review was designed to compare the effectiveness of IV paracetamol and IV morphine and consider whether IV paracetamol has any morphine sparing effects. A clinical question was constructed asking: ‘Is IV paracetamol as effective an analgesic as IV morphine for patients in non-cardiac pain?’ and inputted into a variety of journal databases. This returned 2 952 articles, of which 60 abstracts were read and 9 were reviewed, after relevant exclusions were made. It was found that IV paracetamol is as effective as IV morphine and consistently causes fewer adverse reactions, if given as a standalone medication. The review suggests that IV paracetamol could significantly reduce the dose of IV morphine required for post-operative patients. The review recommends that paramedics should favour administering IV paracetamol rather than IV morphine, if the clinician is faced with a choice. Current guidelines need to be updated in line with current research that demonstrates the effectiveness and safety of IV paracetamol.
    • Keeping the beat: does music improve the performance of chest compression by lay persons?

      Rawlins, Lettie; Woollard, Malcolm; Hallam, Phil; Williams, Julia (2011-03)
      Background Early bystander cardiopulmonary resuscitation (CPR) increases survival from out-of-hospital cardiac arrest. Simplifying training can improve skill retention and confidence. A recent pilot study suggested music may help health professionals perform CPR. The song ‘Nellie the Elephant’ (tempo 100 bpm) is sometimes used to encourage compression rates in accordance with Resuscitation Council guidelines. This study investigates whether music helps lay persons perform compressions at 100 per minute. Methods This randomised cross-over trial opportunistically recruited lay volunteers who performed three sequences, pre-randomised for order, of one minute of continuous chest compressions on a recording manikin accompanied by no music (NM) and repeated choruses of ‘Nellie the Elephant’ (Nellie), and ‘That's The Way (I Like It)' (TTW). Results Of 130 participants, 62% were male, median age was 21 (IQR 20 to 25), 72% had no previous CPR training. Mode and IQR for compression rate were NM 111 (93 to 119); Nellie 106 (98 to 107), (TTW) 109 (103 to 110). Within-groups differences were significant for Nellie vs NM and Nellie vs TTW (p<0.001) but not NM vs TTW (p=0.055). A compression rate of 95 to 105 was achieved with NM, Nellie, and TTW for 15/130 (12%), 42/130 (32%) and 12/130 (9%) attempts respectively. Differences in proportions were significant for Nellie vs. NM and Nellie vs TTW (p<0.0001) but not for NM vs TTW (p=0.55). Relative ‘risk’ for compression rate between 95 and 105 was 2.8 for Nellie vs NM (95%CI 1.66 to 4.80), 0.8 for TTW vs NM (95% CI 0.40 to 1.62), and 3.5 for Nellie vs. TTW (95% CI 1.97 to 6.33). Conclusion and recommendations ‘Listening to Nellie’ (vs TTW or no music) significantly increased the proportion of lay persons achieving compression rates close to the 100 bpm guideline. Playing it during training and ‘real’ CPR may help rescuers deliver correct compression rates. https://emj.bmj.com/content/emermed/28/3/e1.18.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.2010.108605.6
    • Leadership within the ambulance service: rhetoric or reality?

      Taylor, James; Armitage, Ewan (2012-08)
      Abstract published with permission. Just as part 1 of this article (Armitage and Taylor, 2012) introduced the concept of management and leadership, specifically within the context of the ambulance service, part 2 will stimulate further discussion in connection with the development of leadership related knowledge, skills, experience and behaviours among paramedics. Throughout the piece, the need for leadership development at an organisational and professional level will be promoted, and the authors will explore why leadership and leadership development is a key component to paramedic practice, as well as considering how ‘human factors’ and ‘non-technical’ skills are central to a sucessful process of leadership. The NHS Leadership Framework will be reviewed and the authors will consider how it can be used by individuals, organisations and the paramedic profession as a whole to drive leadership development in the future.
    • Lecture notes: emergency medicine

      Armitage, Ewan (2011-12)
    • Legal and professional boundaries: a case study

      Hodgson, Ruth (2016-02)
      Abstract published with permission. There are multiple legal issues which dominate the work of paramedics and healthcare professionals alike. For those professionally registered, such as paramedics, there is an added obligation of professional boundaries. This article will examine possible legal and issues within a hypothetical case study and discuss the possible conflicts associated with these issues. The article considers a range of legal and professional aspects which may crop up in the pre-hospital care environment including capacity to consent, informed consent, acting in the best interests of a patient, rights of a foetus, infant preservation, duty of care and negligence. Within pre-hospital care there is a necessity to make rapid decisions based upon these laws, and therefore it is important that all practitioners consider these.
    • Lights, camera, disciplinary action?

      Mursell, Ian (2012-02)
      Abstract published with permission. There seldom appears to be a day go by without the opportunity to watch ourselves or colleagues in the latest episode of ‘Emergency Hero Rescues’ or similar ‘real life’ television programmes. However, the growth of such shows and inherent public interest in the emergency services brings to light the question of whether such media coverage is of benefit or risk to our profession. For many of us, watching such programmes is a guilty pleasure, we don't want to watch, but are strangely drawn to them. How many times have you found yourself ‘tutting’ at the TV or shaking your head pointing out the error of our peer's actions? Regardless of our reactions to such programmes, public interest is difficult to deny and as such, television coverage of prehospital care is a subject for careful consideration.
    • Locations of out-of-hospital cardiac arrests and public-access defibrillators in relation to schools in an English ambulance service region

      Benson, Madeleine; Brown, Terry P.; Booth, Scott; Achana, Felix; Price, Gill; Ward, Matthew; Hawkes, Claire A.; Perkins, Gavin D. (2018-09)
    • Management of the ruptured abdominal aortic aneurysm: challenges facing paramedics

      Smith, Neil (2011-07)
      Abstract published with permission. An abdominal aortic aneurysm (AAA) is a localized dilatation of the abdominal aorta resulting from degenerative cardiovascular disease. Such aneurysmal arteries pose few problems for many patients and are simply monitored and managed conservatively within the community. However, the ruptured abdominal aortic aneurysm is a time-critical medical emergency requiring timely surgical intervention in order to offer any chance of survival. Even when recognized early, 90% of patients will suffer an out-of-hospital cardiac arrest before arriving at the emergency department and of those who reach theatre, only 40% will survive. This article aims to increase the paramedic practitioner's knowledge and understanding of AAA through a holistic discussion of the prehospital recognition and early management. Particular emphasis will be placed on fluid replacement therapy and analgesia with specific reference to the issues associated with aggressive fluid resuscitation, and the potential benefits elicited through the use of opiate analgesia and subsequent pharmacologically induced hypotension. This article further aims to set the prehospital management into the wider context, thus providing paramedic practitioner's with an insight into how prehospital interventions affect the patients’ ultimate outcome and postoperative quality of life.