Jonathan Fox of the Association of Professional Ambulance Personnel outlines the need for the provision of a complete package of safety measures, including personal protective equipment, to protect the front-line paramedic from assault and injury.
Obtaining a prehospital 12-lead electrocardiograph (ECG) in cases of suspected acute myocardial infarction is routine practice in UK prehospital care and is key to early diagnosis and activation of a primary percutaneous coronary intervention (PCI) team. This two-phase prospective observational study took place in the USA to establish whether independent paramedic interpretation of the 12-lead ECG has appropriate positivepredictive value (PPV) to justify activation of the PCI team, or whether there is benefit to using telemetry for physician review. In Phase I, paramedics looked for ECG evidence of ST-elevation and were responsible for mobilizing the PCI team; in Phase II the ECG was transmitted to the emergency department and reviewed by an emergency physician (EP) before mobilizsing the PCI team. Cardiologist confirmation of a STEMI on the prehospital 12-lead ECG was 42/54 (78%) in Phase I and 54/56 (96%) in Phase II. Disposition to emergent PCI occurred in 38/54 (70%) Phase I patients and 51/56 (91%) Phase II patients. This suggests that transmission to an emergency physician improves the PPV of the prehospital 12-lead ECG. The study limitation of greatest importance for extrapolation to UK practice was that unlike UK paramedics, these paramedics had no previous experience of looking for ST-elevation on a 12- lead ECG. It would be expected that the PPV of UK paramedics should be higher but a UK-based study is necessary to answer the question.
Stroke is the brain equivalent of a heart attack. With 1.9 million neurons being lost every minute, early access to acute care is critical. Ambulance clinicians have a vital role in ensuring the rapid assessment and transfer of patients to an acute stroke centre, as the principle barrier to delivering thrombolysis is enabling treatment within the narrow therapeutic time window. Timely management of transient ischaemic attacks (TIAs) reduces mortality, morbidity and use of precious NHS resources. Ambulance services need to develop pathways that embrace the vision of the National Stroke Strategy, risk stratifying patients and facilitating immediate hospital admission or referral to timely clinics.
In his first article on consent, Richard Griffith outlines the elements of a valid consent and how important obtaining consent is to the appropriateness of a paramedic's practice.
Early management of hypoperfusion in the field has included the use of patient postures that are believed to increase venous return and to subsequently increase cardiac output, resulting in an improvement in perfusion. These postures are usually a Trendelenburg (head down position with the lower body elevated approximately 30 centimetres) or a raised leg posture with the torso horizontal. Despite apparent acceptance of these postures in the management of hypotension due to hypovolaemia there is conflicting advice in paramedic textbooks regarding the use of these postures, and as such this study sought to locate and evaluate evidence relating to the efficacy of these postures in the early management of hypoperfusion. The results of the review failed to find evidence of efficacy arising from the prehospital setting. Evidence from other health settings was subsequently reviewed to synthesise recommendations for paramedic practice. No evidence of significant clinical benefit was located, and the use of these postures by paramedics to improve perfusion should be reviewed on the basis of these findings.
Paramedics have made a significant contribution to reductions in mortality for the time-critical conditions of acute myocardial infarction (AMI) and major trauma (Myocardial Ischaemia National Audit Project (MINAP), 2008), and they will be instrumental in helping to reduce stroke mortality in the near future (Department of Health 2006). These improvements have, and will be achieved by pre-hospital diagnosis and prompt aggressive treatment. There is however another time critical condition that is currently not being targeted, in which pre-hospital staff could significantly improve the patient's chances of survival. This condition is severe sepsis. This article presents a case study of a patient with severe sepsis who is transported from a nursing home to the emergency department (ED), and explores how paramedics can diagnose severe sepsis by use of a screening tool, and discusses the practicalities of delivering evidence-based care en route to hospital (high concentration oxygen, intravenous fluid challenges, intravenous antibiotics, measuring blood lactate). The benefits of alerting the receiving hospital of a patient with severe sepsis are also discussed.
Time is of the essence in the assessment and management of stroke patients. The timeframe in which to successfully administer effective thrombolysis treatment is short—3 hours—and therefore paramedics and technicians need to keep the time spent ‘on-scene’ with the patient to the bare minimum, focusing instead on rapid accurate assessment and transfer to the appropriate health care facility.