This month, Ellie Daubney reflects on a difficult patient case she encountered on placement and the need for emotional resilience, support networks and self-care as a paramedic
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, Rory McKelvin discusses the application of splints to fractures and sets out a best practice step-wise approach to assessment, decision-making and application in prehospital settings
Background:Paramedics new to research need to know how to optimise the quality of proposed research studies. A prehospital mixed-methods study design required guidance, not only from an academic perspective but also from experts within paramedicine. Paramedic engagement was defined as an exercise where paramedic researchers and paramedic clinical academics could be involved as advisory professionals.Aim:The aim of this paramedic engagement was the revision of a proposed research design on how senior clinical advisers determine futility in pulseless electrical activity in out-of-hospital cardiac arrest.Method:Five research paramedics and four clinical academics were interviewed by email using semi-structured questions. A generic qualitative inquiry with inductive content analysis was applied.Results:Paramedic engagement identified five themes: rewording the proposed study title; acknowledging that paramedics withdrew resuscitation; the implications of prolonged futile resuscitation; the need for autonomous paramedic decision-making; and improving research methodology.Conclusions:Professional paramedic engagement meant a number of complexities were identified within prehospital research and and pragmatic solutions were provided to the limitations in the proposed design. Novice researchers within paramedicine would benefit from early paramedic engagement to facilitate the design of research studies, provide guidance on methodology and identify limitations to improve the overall quality of prehospital research proposals.
Background:Cerebral oximetry allows non-invasive, real-time monitoring information of cerebral blood flow to be carried out. It has recently been used to provide information about cerebral perfusion during resuscitation efforts in cases of cardiac arrest and may give an indication of neurological survival. Most of this information has been obtained during the hospital phase of treatment and little is known about cerebral flow in the prehospital phase.Methods:A systematic review was carried out, with the PubMed and EMBASE databases searched to identify clinical trials where cerebral oximetry monitoring was performed in the prehospital phase of out-of-hospital cardiac arrest. It aimed specifically to answer the following questions: is cerebral oximetry monitoring feasible in the prehospital environment? Can cerebral oximetry be used as a useful marker of the quality of cardiopulmonary resuscitation in the prehospital setting? Can cerebral oximetry be used to assist decisions around prognostication and futility for out-of-hospital cardiac arrest?Results:Five studies were identified for review. Feasibility was demonstrated in four of these. The usefulness of cerebral oximetry in monitoring cardiopulmonary resuscitation has not been well explored in out-of-hospital cardiac arrest. Similarly, data linking intra-arrest cerebral oximetry values and prognosis in out-of-hospital cardiac arrest is sparse.Conclusions:cerebral oximetry is feasible in out-of-hospital cardiac arrest but its usefulness in guiding resuscitation attempts in this environment remains largely unknown.
Trauma is the leading cause of death for people in the UK and North America, especially for those aged 15–24 years. However, if early management regimes of permissive hypotension, high-flow oxygen and administration of tranexamic acid are applied, mortality risk can be reduced significantly. Acute traumatic coagulopathy (ATC) is an internal process that is initiated by significant or massive trauma because of hypoperfusion resulting in hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx. ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy—the ‘lethal triad’ of trauma. This article discusses the pathophysiology of ATC and treatment strategies via the management of the lethal triad.
A note on peer review from our team…High quality peer review is essential to any reputable academic journal and the Journal of Paramedic Practice (JPP) is no exception. However, it's not only the journal that benefits from the process; the peer reviewer gains too. Peer review allows you to see some of the latest articles before they are published and provides an opportunity for you to shape those articles. Carefully constructed feedback can help newer authors develop their submissions from promising to publishable, and help to cultivate the next generation of paramedic authors. The JPP also grants you access to the views of the other peer reviewers from the same article so you can learn from their comments and develop your own reviewing skills.If you are planning on writing for publication, understanding peer review provides insight into how other authors have formulated their articles, presented their key points, organised their data and discussed any limitations in their work. You will understand what editors and other reviewers are looking for, which will enhance the likelihood of your article being published. Peer review enhances your CV and may provide opportunities for joining an editorial board.The JPP employs a ‘double blind’ peer review process to ensure that the evaluation of submitted manuscripts is not biased. Peer reviewers have a central role to play in scholarly publishing across the range of health and social care and peer reviewing in the JPP is no different.Peer reviewers and the robust system associated with peer review is there to authenticate our academic work—it helps us to improve the quality of published work as well as increase networking opportunities in our varied professional communities.The JPP relies on the peer review process to uphold the quality and validity of individual articles as well as the standard of the journal in which they are published. The JPP considers peer review to be the gold standard, the best form of scientific evaluation, as we strive to demonstrate rigour and coherence. Without peer reviewers, we would not have a journal that is respected by the profession and further afield, so it is hats off to our peer reviewers who do an outstanding job, even while holding down their day job!The peer review process is an essential element of any professional journal. At the inception of the JPP, we wanted to establish a robust publication that acted as a voice for the growing profession of paramedics and prehospital care.Since 2008, we have witnessed the JPP mature and develop with an increasing diversity of articles, reflecting the breadth of the profession's roles. We have had the wonderful opportunity to serve as one of the professional voices in paramedic practice—to offer a platform for developing clinical practice and care.We would not have been able to achieve our development without the work of our fantastic reviewers who not only apply their professional, expert opinion based on their years of experience in reviewing publications, but also support our potential authors in further developing their writing skills.Our reviewers achieve this in addition to their full-time jobs and, for many, a number of other professional roles. To our reviewers—we say a huge thank you!
I had an interesting conversation the other day with a former nurse who claimed that my work, publishing research and clinical articles for providers of health care, affects theoretical professional knowledge—but doesn't have an impact on real people. Of course a person's knowledge is going to affect the way they provide care to a person; but besides that, in today's era of evidence-based practice, we are all working together in a cycle to not only advance the profession of paramedics and other prehospital care providers, but to improve the standard of care being delivered to patients.
Why an ‘outsider’?The literature around the ambulance services is rapidly increasing. However, at present, the lack of research around topics like patient safety means that a majority of the available research is based on data from primary care settings, like hospitals, where the context is remarkably different (Altman et al, 2004; Rust et al, 2008; Fisher et al, 2015). While the ambulance services grow their research profile and continue pairing with universities, implementing roles like the research paramedic, this problem is bound to be temporary (McClelland, 2013).The Research Activity League Table published by the National Institute for Health Research (NIHR) demonstrates that from 2014/15–2016/17, the total number of large-scale studies conducted in the ambulance services expanded substantially from only 9, up to 46. Equally, the number of participants recruited increased from 270 to over 8300 (NIHR, 2018).While this growth in research is remarkable and the transition to a research-literate care setting is fundamental to their success, the ambulance services still have a long way to go (Wood, 2012). As the services continue to deliver more and more research ‘in-house’, and increase the amount of research led by paramedics, in the meantime, some of the work is currently being carried out by external researchers, like myself (McClelland, 2013).
Snippets of paramedicineFrom this introduction, I am sure you have gathered that this book is aimed at the healthcare manager looking for innovative ways to improve services to make them more efficient and effective. Nevertheless, there are some snippets related to the work of the paramedic and, on rare occasions, the paramedic in the UK.
OverviewThis article presents an overview of the additional aspects of history-taking that need to be considered when assessing patients presenting with a rash. This relies on strong underpinning anatomy and physiology knowledge to correlate the skin presentation to what may be happening pathophysiologically within the patient's skin. Four case studies are presented, with leading questions which are then explained. The overall aim of this article is to provide an introduction to key dermatological presentations for the paramedic as a starting point for more thorough reading and exploration on the subject.