Volume 11 Issue 1

Human factors, cognitive bias and the paramedic

The consequences of human factors and cognitive bias can be catastrophic if unrecognised. Errors can lead to loss of life because of the flawed nature of human cognition and the way we interact with our environment. Seemingly small mistakes or miscommunications can lead to negative outcomes for patients and clinicians alike. It is easy to see therefore why the College of Paramedics now recommends the teaching of human factors at higher education institutions. Using a problem-based approach, this article aims to inform prehospital clinicians about how human factors and cognitive bias can affect them and their practice, and how these can be mitigated.

Protecting the mental health of UK paramedics

It is estimated that the average member of the public within the UK will experience one or maybe two traumatic situations in a lifetime—whether that be through witnessing or being involved in an accident, natural disaster, collision, medical episode or traumatic event. Those working in frontline emergency ambulance services however are exposed to distressing and traumatic events on a much more frequent basis (Halpern et al, 2012).

Redefining the ‘news’

Researching complex topics and demysifying useful information, sharing the stories of real people, writing, editing, polishing—these are some of the reasons I went into my profession. But when I carried out my master's in journalism, the drawn out United States-led war on Iraq was front-page news, while stories in health care (which had always been my area of interest) tended to focus on sensationalising research and scaring people away from just about every food (though to be fair, a large majority of our food has in fact been tampered with to a worrying degree—but that's a discussion for another day).

Diagnosis in art: Dr Dorothy Hodgkin (1910–1994)

In 1985—the same year as Live Aid, the Broadwater Farm riots, the Bradford Football club fire and the Manchester Airport disaster—Dr Dorothy Hodgkin sat for this portrait. Dr Hodgkin was a pioneer in the field of chemistry, and was awarded the Nobel prize in 1964. As part of a vast body of work, she identified the chemical structure of penicillin, Vitamin B12 and insulin.

Building up a positive culture

In an unpredictable—and sometimes frightening—world, the few events that bring some normalcy can be really comforting. Christmas was never going to be white, New Year's Eve was always going to be busy and the question, ‘what's the worst thing you have ever seen?’ will forever follow social introductions to paramedics.

Student paramedics need funding too…

In 2018, a new student column shared perspectives from first, second and third year students across UK paramedicine programmes. This year, in a special quarterly feature, we will follow Eleanor Chapman, who has now graduated, on her journey as a newly qualified paramedic

Capnography: not just for cardiac arrest

‘The Basics’Chapter 1 entitled ‘The Basics’ provides an overview of the technology behind capnometry/capnography, the various available options of measuring EtCO2 levels and a detailed look at all phases of the respiratory cycle, and how they are presented in a waveform. Furthermore, Valente discusses causes of artefact that may alter the patient's waveform and how to deal with them.

Honouring inclusivity and support in paramedicine

Creating a brandIn a bid to create an identity for Proud@WMAS, the committee tried to design a new logo but quickly realised that the already established design had resonance with current staff and so it remained. The rainbow star of life, used by the National Ambulance LGBT Network, of which we are a contributing member, was agreed as it was felt that it would achieve uniformity across other ambulance organisations and enable the network to be recognised more easily. The committee sourced some funding to purchase 200 star of life pin badges which were distributed to staff across the Trust—they were so well received that a waiting list for badges had to be drawn! Why was the badge important? It allowed people to identify—not only as allies but also as advocates. When asked about the badge, people can spread the good work of the network.The network knew that work needed to be done to support not only our workforce, but also the diversity of the population we serve. A key part of this is the transgender community. The team began developing a Trans Awareness Programme for the Trust to increase awareness among operational staff, availability of information, training, and development of internal policy.It was on the back of this that a member of staff approached their line manager to notify them of their intention to transition from female to male. Their manager immediately contacted the network for support, not only to assist the manager but also to offer direct support to the staff member.

Brayden set to widen range of award-winning manikins

Brayden Baby: intuitive lights help improve CPR performanceCurrently under development, the Brayden Baby is designed with the help of key opinion leaders representing the ERC, national resuscitation councils and leading European paediatric institutions.Brayden Baby uses advanced sensors to detect and analyse the effectiveness of CPR. Sets of interrelated LED lights illuminate key performance indicators. Brayden Baby has intuitive lights to help guide the student to perform good quality ventilation, which is vital for successful resuscitation of an infant.Lights are also placed in the chest and illuminate to show correct compression depth, and blood circulation lights illuminate to represent the flow of blood from the heart to the brain. Additionally, it has a CPR-quality indicating light, which only illuminates when correct compression depth, compression rate and full chest release are performed—similar to the function in the award-winning Brayden manikin.

The nearness to death effect and why NHS pressures are going to intensify

Nearness to death effectSo, what have deaths to do with capacity pressures? There is a very simple answer: the nearness to death effect. The nearness to death effect has been documented for around four decades and shows that healthcare demand escalates with nearness to death and not with age, per se (Payne et al, 2007). Around half of a person's lifetime hospital inpatient admissions and bed occupancy is compressed into the last year of life (Hanlon et al, 1998). Hence, the marginal changes in deaths are intimately linked to the marginal changes in medical admissions (Jones, 2018a). If you ignore the nearness to death effect, you get the entirely false impression that it is all of those older people consuming the resources.For those who have been in the ambulance service for many years, have a moment's reflection around how Figure 1 may have influenced the marginal changes in the proportions of male and female ambulance journeys, especially since 2003. I think you have probably gathered the point.However, the issue regarding older people consuming all of the resources is addressed in Figure 2 where the age at death in 1974 is compared with that in 2017. Deaths in 1974 have been adjusted down to the same total as in 2017. As can be seen, in 1974, the bulk of deaths occurred below the age of 80; while in 2017, it is above age 80. The age of death has increased; hence, the nearness to death effect makes it seem that older people are clogging up the ambulances, etc. Nothing has changed. It has always been that the dying people (in their last year of life), irrespective of their age, drive the marginal pressures on NHS capacity.Figure 2.Age at death in 1974 compared with that in 2017Clearly, non-end-of-life NHS demand pressures are also age-related and Figure 3 attempts to disentangle how many admissions in the medical group of specialties may be a result of each source. Figure 3 makes such an estimate by assuming that every person has seven admissions (emergency and elective, including day case) in the last year of life. As is demonstrated, the proportion of admissions which are end-of-life-related rises with age except in the oldest old (age 90+). It is likely that the number of admissions in the last year of life may vary with age (especially in the oldest old). However, the principle is that the total admissions, ambulance journeys etc, rise in proportion to the speed of change in the population age-structure, relative to the rate of change in deaths.Figure 3.Calculated proportion of all admissions in England in 2017/18 which may be related to the end of lifeRegarding the rate of change in deaths, between 1991 and 2011, deaths in the UK were decreasing by around 4940 per annum. However, since 2011, they have been increasing by around 8840 per annum, and deaths have continued to increase throughout 2018 (Jones, 2018b). Hence, the end-of-life-based winter pressures in 2018/19 will indeed be worse than ever before—irrespective of whether or not there is an influenza outbreak! Influenza would only make a bad situation worse.

Prehospital care in isolated neck of femur fracture: a literature review

Around 65 000 people experience a fractured neck of femur (NOF) each year in the UK. It is estimated that one in 10 patients with an NOF fracture will die within 1 month, and one in three will die within 1 year. The bill for NOF fracture, excluding substantial social care costs, is £1 billion per year. Given the exposure that ambulance services have to these patients, several aspects of NOF fracture care could be improved in the prehospital environment, which could also generate significant savings for the NHS. This article reviews the literature regarding NOF fracture care, and highlights aspects that affect ambulance services and prehospital care. A variety of these, including pain management, fast-track systems, fluid therapy and renal impairments, can be improved, but evidence specific to the prehospital environment is lacking.

Human factors in student paramedic practice

Human factors affect paramedic practice and training. However, although there are frequent references to human factors in the literature, little evidence on this is available on those that influence student paramedic development. A personal experience as a student paramedic highlighted certain human factors unique to the role, most notably how interactions between students and mentors can affect a student's practice. Following this, the awareness and effect of human factors within the student paramedic role were investigated. Discussions regarding human factors that influence a student paramedic's development on practice placements remain in their infancy. The student paramedic role is unique and challenging, and involves developing a level of resilience that continues post registration. Because of the role's emotive nature, students need to increase their awareness and management of human factors to prevent them from affecting their practice. Equally, educators need to have a greater focus on encouraging and teaching coping strategies. Practitioners who work with students do so whether they choose to be a mentor or not and many may feel unprepared for the role. Interactions between students and clinician mentors are complicated and future research will be required to determine the best approach to aid student development in the placement environment.

Hypothermia: exploring causes and treatment options

The regulation of a patient's body temperature is a key part of a paramedic's duty during treatment. Preventing hypothermia by keeping a core body temperature above 35°C and providing sufficient warming devices to prevent changes in body temperature requires careful assessment, monitoring and training. Critical factors in achieving this include assessment of the patient's exposure to the cold, and understanding of the risks linked to hypothermia—especially in older patients who are at risk of a fatal reaction if the body's temperature drops.

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