Volume 10 Issue 10

What do influencers think?

‘Paramedics are a key component of the health system as the first point of contact for those in most need of our care. The changing role of paramedics has seen them take greater responsibility for clinical decision making and providing interventions that in the past would only have been undertaken by doctors. They make a valuable contribution to high quality patient care as inter-professional clinicians working in pre-hospital care settings in Northern Ireland and I welcome the fact that these enhanced roles are being underpinned by a move to higher education for paramedic practice. The ongoing development of the paramedic profession has led to the recent recognition of Northern Ireland paramedics as members of the Allied Health Professional Group, underlining the high quality and compassionate care they provide to patients. I look forward to continuing to work in partnership with the Ambulance Service and its dedicated paramedics as we deliver on the ambitious health transformation programme, including a transformed ambulance service which will enable resources to be targeted more effectively to those patients with the most urgent clinical need.’

Ketamine administration by HART paramedics: a clinical audit review

Hazardous Area Response Team (HART) paramedics from a single ambulance service Trust were trained to administer ketamine up to 0.5 mg/kg for analgesia in the pre-hospital environment. The Trust's special operations department felt that, in doing so, patient care could be improved in both hazardous areas and regular pre-hospital clinical situations. After completing a written examination and scenario training on the relevant Trust patient group directive (PGD), HART paramedics were authorised from 4 July 2016 to administer ketamine autonomously. HART paramedics then retrospectively self-reported on the details of administration using a computerised auditing application called iAuditor. Data from 1 year of usage were then collated and analysed using Microsoft Excel with the aim of identifying current practice and developing recommendations for the future. Despite encountering complications, safe independent use of ketamine was demonstrated and was shown to be an effective analgesic agent in the majority of incidents. Suggested methods for developing and improving ketamine use by paramedics are discussed. Furthermore, a number of recommendations for optimising the Trust's ketamine PGD and the iAuditor template were identified. This work has provided the foundations for future audit and research.

Outgrowing a role never looked so good

If you think that the month of September flew past, the last 10 years have certainly been a blur for me. We are celebrating the 10-year anniversary of the first edition of the Journal of Paramedic Practice. Times have changed and so too have the role and function of the paramedic. The role today resembles little of the role paramedics were practising some 10 years back: from a transport service, scoop and run, to a skilled, proficient pre-hospital care provider and, beyond that, staffed by confident and competent employees who are indeed much more than knowledgeable doers.

JPP Letters

Dear Editorial Team,In your latest issue of the Journal of Paramedic Practice (Volume 10, Issue 9; September 2018), there was an article titled ‘Recognising ECG Landmarks’ written by Karen Simpson-Scott. I would firstly like to state that this was a well written article, and an enjoyable read; however, there are some concerns with the information/images within, that I feel require your urgent attention.Figure 1, images 1 and 3 show incorrect limb lead/chest lead placements as otherwise correctly described in the article text. Where possible, upper limb leads should be placed proximal to the wrist and, ideally, on a bony prominence. Lower limb leads should be placed proximal to the ankle, again ideally, on a bony prominence. These standardised positions are ‘best practice’ as suggested by the Society for Cardiological Science and Technology (SCST) for obtaining an accurate electrocardiogram (ECG), but also as a standardised approach for serial ECG comparison, which may potentially be between different users and/or settings (i.e. hospital, ambulance, community, practice, etc). Ideally, any variation should be documented on the ECG trace. Image 3 shows incorrect chest lead placement. V1 and V2 are depicted proximal to the 2nd intercostal space, and too far from the border of the sternum. This therefore disrupts all other lead placements. Correct placement images can be found within SCST guidance.On page 397 in the ‘Chest Lead’ section, there is a sentence that states ‘the third intercostal space should be in line with the angle of louis’. This is incorrect information. The second intercostal space is lateral and slightly inferior to the sternal angle. Once the second intercostal space is palpated, it is then possible to palpate down to the third, and then to the fourth intercostal space. Where the fourth intercostal space meets the sternum, is where V1 and V2 are correctly placed respectively. As already identified in the article text, incorrect chest lead placement can present the clinician with abnormal morphologies, obscuring accurate interpretation of a 12-Lead ECG.I feel that this information should be reviewed and appropriately communicated in a subsequent issue (or other means) so that best practice for paramedics is continuously promoted, and that the images in this article support and reflect the hard work of the text written within.Should you require it, here is the link to the SCST Guidance for Recording a Standard 12-Lead Electrocardiogram (issued September 2017) for any further information and/or clarification: http://www.scst.org.uk/resources/SCST_ECG_Recording_Guidelines_20171.pdfSincerely yours,Philip Poskitt

CPD on the move for student and newly qualified paramedics

Anatomy and physiologyPart 1 provides a solid overview of cardiac anatomy and physiology. Despite the authors managing to explain difficult concepts in a simple way, as well as using figures to illustrate what they are describing, I found this part of the book a bit overwhelming. Maybe I've just been out of higher education for too long though. Certainly, remembering back to my university days, I would have been grateful to find this information on cardiac anatomy and physiology succinctly presented as in this chapter rather than having to search through the entire library of anatomy and physiology books to find what I was looking for.

Peripheral IV cannulation

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this instalment, Kevin Armstrong discusses peripheral intravenous cannulation

Assault bill: incoming law aims to protect paramedics

While unacceptable, attacks on paramedics seem to have become commonplace. New legislation now promises to toughen sentences for assaults on emergency workers on duty. Alistair Quaile reports on the details of the assault bill, while our social media followers have their say as we highlight their comments throughout the article

Looking back to 2008—Looking forward to 2028

Clinical Practice Lens – ‘In the first edition of the Journal of Paramedic Practice, Roland Furber promised that the journal would hold relevance to the paramedic profession as a whole, and asked for paramedics to come together to contribute their experiences, opinions and research. We feel the last 10 years of the journal have lived up to this promise, with early clinical practice articles covering pulse oximetry, a feasibility study of pre-hospital arterial blood gas (ABG) analysis and research into ventilation during cardiac arrest. As a profession, we have come a long way in a decade, with specialist paramedics now undertaking thoracostomies, surgical airways and pre-hospital ultrasound, while using drugs to undertake nerve blocks, sedation and paralysis. Furthermore, paramedics are no longer confined to the pre-hospital setting, as their skills become universally recognised in the wider healthcare environment. Most recently, we have seen the roll-out of paramedic prescribing, which will undoubtedly facilitate the progression of paramedics in all domains, and pave the way for further specialist and advanced paramedic roles.’

A Guide to the Mental Capacity Act for Paramedics

The Mental Capacity Act 2005 is one of the key pieces of statutory legislation used in modern paramedic practice. To the unprepared, the Act can seem complex and daunting; but it is a powerful tool which helps paramedics to deal with often complex and challenging situations in a way which is both ethically and legally safe. What follows is a walk-through of the Act itself looking at the parts which are relevant to paramedic practice and discussing issues relating to them which, it is hoped, will enable paramedics and others involved in delivering pre-hospital emergency medical care to apply the Act with confidence in their practice.

A Larrey Society: needed now more than ever

As part of marking the celebration of the last 10 years of paramedic practice, Larrey Society founder, David Davis, speaks up in this short article about the history of the now-defunct Larrey Society, and why its relaunch, against the background of the recent Carter Report on Ambulance Productivity, has never been more urgently needed.

Paramedic leaders: past, present and future

In this article, Adam Layland, Registered Paramedic and Senior Lecturer in Leadership and Management from Coventry University, discusses the existing leadership in paramedic practice, and what elements are still needed.

Heart block as a complication of acute myocardial infarction: the anatomical and physiological mechanisms

OverviewHeart block (HB) is a recognised complication of acute myocardial infarction (AMI) and is often a marker for increased mortality and morbidity. An appreciation of the anatomical and physiological mechanisms associated with the development of HB in AMI is important for the prediction and management of complications when dealing with such cases. Certain forms of HB are classically linked to infarction of specific anatomical territories in AMI. However, variations in pre-morbid state and anatomy of the coronary vessels provide potential for the development of HB in any patient experiencing AMI, regardless of the territory affected.LEARNING OUTCOMESAfter completing this module, the paramedic will be able to:Understand heart block in the context of acute myocardial infarctionUnderstand the relevant anatomy and physiology of clinical presentations of heart block in acute myocardial infarctionIdentify types of heart block in order to determine appropriate treatment strategiesUnderstand the differences in the appearance of various forms of heart block on an electrocardiogramIf you would like to send feedback, please email jpp@markallengroup.com

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