Homelessness: implications for paramedic practice

Key facts on homelessnessThe full extent of homelessness and rough sleeping in the UK is difficult to describe. Homelessness is recorded differently in each nation, and not all homeless people show up in official statistics. However, it is clear that homelessness and rough sleeping have been increasing substantially since a low point between 2009 and 2010.Statutory homelessness statistics reported that the local authorities in England had duty to accommodate just over 59 000 households in 2016–2017. This is a 48% increase on the 40 020 reported in 2009–2010. In addition, the estimated numbers of people who sleep rough have increased by 169% since 2010 to 4751 (Ministry of Housing, Communities and Local Government, 2018a; 2018b).

Methoxyflurane (Penthrox®)—a case series of use in the prehospital setting

Methoxyflurane (Penthrox®) is a fluorinated hydrocarbon, which when first used in general anaesthesia was noted to have strong analgesic properties in subanaesthetic dosage. More than 5 million doses have been sold for use in Australia since 1978 and have been found to have an excellent safety profile. After rigorous review by the Medicines and Healthcare Regulatory Agency, methoxyflurane was granted a product licence in 2015 in the UK and Europe for the relief of pain in patients with moderate-to-severe trauma. This paper presents the first reported case series of patients treated with methoxyflurane in the UK and Ireland in the prehospital environment. The results show a statistically significant improvement in patient pain scores at 1, 2 and 5 minutes following administration of methoxyflurane. With its use increasing in prehospital care and emergency departments, methoxyflurane is recognised as a useful adjunct to the choice of analgesia for trauma patients with moderate-to-severe pain.

Military and civilian handover communication in emergency care: how does it differ?

There is a growing body of literature on handover communication between prehospital and hospital receiving teams in civilian emergency care settings but little is known about how this differs from handover in the UK military medical services. This literature review shows that civilian handover is a complex process conducted in less-than-ideal circumstances, and it is affected by human behaviour and patient factors. There is a debate around standardisation including the use of the Mechanism, Injury or Illness, Signs, Treatment (MIST) mnemonic. There is limited understanding of how this mnemonic was used by the UK military, how it was developed to deal with specific patient characteristics or in the context of military operations in Afghanistan within which it evolved. Advancements in clinical practice made during conflict are ancillary to military objectives and should be supported by an evidence base before being transferred to civilian health care.

A tactical analgesic option for Durham and Cleveland police firearms medics: the journey

Background:With an ever-increasing exposure to clinical situations, predominantly trauma, firearms medics at Durham and Cleveland police forces began to consider whether an increase in their scope of practice was needed; specifically, whether they could add analgesia administration to their clinical protocols.Considerations:The request was directed to the Tactical Medical Advisory Group (TMAG). This faculty comprises a clinical lead, emergency medicine doctors, military and civilian paramedics and tactical team medic (TTM) trainers. Analgesia in general was discussed, then potential analgesic agents were considered. The faculty agreed that the analgesic agent would have: to be available to all tactical team medics at all times, so should be highly portable); a minimal regulatory and training burden; a rapid effect with minimal side effects; and no conflict with prehospital medicine practice.Implementation:A 6-hour training course in methoxyflurane (Penthrox®) with summative assessments was designed and delivered by TMAG to all TTMs over a 4-week period. The chair of the TMAG agreed to be the signatory for the prescription-only medicine document and a standard operating procedure was drawn up. Sufficient stocks of methoxyflurane were then purchased and distributed across both police forces' armed response units, together with updated patient report forms, administration documents and feedback forms completed by TTMs after incidents.

Linking civilian and military care in a training exercise

In a collaborative exercise, the University of Cumbria's paramedic training team held a multidisciplinary training weekend at its Ambleside campus on 8–9 December 2018. In this feature comment, we hear from some of the key players involved in the training, which importantly linked civilian and military emergency care

Leadership in training: a Q&A with Ian Corrie

As well as the use of practical clinical scenarios, the training weekend was also used to provide leadership and development training for senior members of the regiment. In this special Question and Answer feature, the man in charge, Ian Corrie, provides a more in-depth insight into what the training involved

An essential resource for your back pocket

Three Key TakeawaysCommunication is key! Make eye contact and ensure pre-alert includes correct terminology of presenting complaintRefer to the patient as a ‘woman’ rather than a ‘patient’Suggestions of chapters to include in future editions: maternal mental health, safeguarding and women's experiences of emergency birth

New kid on the block: starting as an NQP

In 2018, our new Student Column shared perspectives from first, second and third year students across UK paramedicine programmes. This year, we will follow Abbygail Elsey, on a quarterly basis, as she takes the first steps of her journey as a newly qualified paramedic at South Central Ambulance Service after her recent graduation from Edge Hill University

The Brook Greenwich (1957)

Photograph courtesy of London Ambulance Service.

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction: part 1

Cardiogenic shock associated with ST-segment elevation myocardial infarction (STEMI) is a potentially devastating complication. This type of shock consists of left ventricular dysfunction causing haemodynamic instability and end-organ hypoperfusion resulting in multi-organ dysfunction syndrome. Despite advances in the management of STEMI, especially in the realm of reperfusion strategies, mortality rates remain high. The pathophysiology is complex and multifactorial, resulting in a clinical presentation of hypotension and signs of hypoperfusion. Patient assessment comprises a targeted history and a thorough physical examination to detect signs of decompensation and end-organ hypoperfusion. Upon arrival in hospital, an echocardiograph is essential in the process of identifying a cause.Learning OutcomesAfter completing this module the paramedic will be able to: Define cardiogenic shockUnderstand the pathophysiology of a person in cardiogenic shockRecognise the clinical presentation and features of cardiogenic shockUnderstand patient assessment of a person who appears to be in cardiogenic shock

The Brook Greenwich (1957)

Photograph courtesy of London Ambulance Service.

New kid on the block: starting as an NQP

In 2018, our new Student Column shared perspectives from first, second and third year students across UK paramedicine programmes. This year, we will follow Abbygail Elsey, on a quarterly basis, as she takes the first steps of her journey as a newly qualified paramedic at South Central Ambulance Service after her recent graduation from Edge Hill University

An essential resource for your back pocket

Three Key TakeawaysCommunication is key! Make eye contact and ensure pre-alert includes correct terminology of presenting complaintRefer to the patient as a ‘woman’ rather than a ‘patient’Suggestions of chapters to include in future editions: maternal mental health, safeguarding and women's experiences of emergency birth

Leadership in training: a Q&A with Ian Corrie

As well as the use of practical clinical scenarios, the training weekend was also used to provide leadership and development training for senior members of the regiment. In this special Question and Answer feature, the man in charge, Ian Corrie, provides a more in-depth insight into what the training involved

Linking civilian and military care in a training exercise

In a collaborative exercise, the University of Cumbria's paramedic training team held a multidisciplinary training weekend at its Ambleside campus on 8–9 December 2018. In this feature comment, we hear from some of the key players involved in the training, which importantly linked civilian and military emergency care

Military and civilian handover communication in emergency care: how does it differ?

There is a growing body of literature on handover communication between prehospital and hospital receiving teams in civilian emergency care settings but little is known about how this differs from handover in the UK military medical services. This literature review shows that civilian handover is a complex process conducted in less-than-ideal circumstances, and it is affected by human behaviour and patient factors. There is a debate around standardisation including the use of the Mechanism, Injury or Illness, Signs, Treatment (MIST) mnemonic. There is limited understanding of how this mnemonic was used by the UK military, how it was developed to deal with specific patient characteristics or in the context of military operations in Afghanistan within which it evolved. Advancements in clinical practice made during conflict are ancillary to military objectives and should be supported by an evidence base before being transferred to civilian health care.

A tactical analgesic option for Durham and Cleveland police firearms medics: the journey

Background:With an ever-increasing exposure to clinical situations, predominantly trauma, firearms medics at Durham and Cleveland police forces began to consider whether an increase in their scope of practice was needed; specifically, whether they could add analgesia administration to their clinical protocols.Considerations:The request was directed to the Tactical Medical Advisory Group (TMAG). This faculty comprises a clinical lead, emergency medicine doctors, military and civilian paramedics and tactical team medic (TTM) trainers. Analgesia in general was discussed, then potential analgesic agents were considered. The faculty agreed that the analgesic agent would have: to be available to all tactical team medics at all times, so should be highly portable); a minimal regulatory and training burden; a rapid effect with minimal side effects; and no conflict with prehospital medicine practice.Implementation:A 6-hour training course in methoxyflurane (Penthrox®) with summative assessments was designed and delivered by TMAG to all TTMs over a 4-week period. The chair of the TMAG agreed to be the signatory for the prescription-only medicine document and a standard operating procedure was drawn up. Sufficient stocks of methoxyflurane were then purchased and distributed across both police forces' armed response units, together with updated patient report forms, administration documents and feedback forms completed by TTMs after incidents.

Methoxyflurane (Penthrox®)—a case series of use in the prehospital setting

Methoxyflurane (Penthrox®) is a fluorinated hydrocarbon, which when first used in general anaesthesia was noted to have strong analgesic properties in subanaesthetic dosage. More than 5 million doses have been sold for use in Australia since 1978 and have been found to have an excellent safety profile. After rigorous review by the Medicines and Healthcare Regulatory Agency, methoxyflurane was granted a product licence in 2015 in the UK and Europe for the relief of pain in patients with moderate-to-severe trauma. This paper presents the first reported case series of patients treated with methoxyflurane in the UK and Ireland in the prehospital environment. The results show a statistically significant improvement in patient pain scores at 1, 2 and 5 minutes following administration of methoxyflurane. With its use increasing in prehospital care and emergency departments, methoxyflurane is recognised as a useful adjunct to the choice of analgesia for trauma patients with moderate-to-severe pain.

Homelessness: implications for paramedic practice

Key facts on homelessnessThe full extent of homelessness and rough sleeping in the UK is difficult to describe. Homelessness is recorded differently in each nation, and not all homeless people show up in official statistics. However, it is clear that homelessness and rough sleeping have been increasing substantially since a low point between 2009 and 2010.Statutory homelessness statistics reported that the local authorities in England had duty to accommodate just over 59 000 households in 2016–2017. This is a 48% increase on the 40 020 reported in 2009–2010. In addition, the estimated numbers of people who sleep rough have increased by 169% since 2010 to 4751 (Ministry of Housing, Communities and Local Government, 2018a; 2018b).

What is your ‘normal’?

I'm not convinced that a week can be normal when working in health care. The potential for an unusual or unexpected situation, outcome or presentation is ever present. In my previous column, I proffered that there is something comforting about the feeling of normality. Perhaps then, we attempt to comfort ourselves with thoughts of the mythical normal week? Is it perhaps possible that we have normalised the unusual? I suspect most of us still relish the diversity and variation associated with a role like ours. So as I settle down to write this column, I thought I'd review my past week and share some of my experiences.

Ignorance isn't bliss: behind the unequal distribution of end-of-life demand and cost

Variance in deaths and pressureClearly, some areas have more deaths than others, and Figure 1 shows the distribution of deaths per 1000 population across local government areas in the UK. Data are for 2017 and are from the Office for National Statistics (ONS) (2018a). The fewest deaths per 1000 population occur in London with the 14 lowest local authorities in the UK. Slough (5.3 deaths per 1000 population) comes in at number 15. At the other end, the top five local authorities (East Lindsey, Christchurch, Inverclyde, Rother, Tendring) all have more than 14 deaths per 1000 population. Of the four countries of the UK, Northern Ireland has the youngest population with only 8.6 deaths per 1000 population compared with 10.7 in Scotland. This inherent 5-times difference in deaths per 1000 population (as per Figure 1) therefore places markedly different end-of-life pressures on NHS organisations.Figure 1.Deaths per 1000 population in 2017 for local government areas and regions throughout the United KingdomThe last year of life is characterised by functional and cognitive decline and increasing dependence on carers for the activities of daily life (Rabbit et al, 2008; Kalbarczyk-Steclik and Nicinska, 2015; Aaltonen et al, 2017). Symptoms of anorexia, dyspnoea, fatigue and pain all increase (Singer et al, 2015); hence increasing numbers of falls and accidents resulting in fractures and other injuries along with indicators of failing immune function such as respiratory and other infections (Jones and Goldeck, 2014). Any forecast of future demand therefore must take trends in deaths into account along with the usual effects of age alone (Moore et al, 2017).

What is the long-term plan?

Acash- and resource-strapped NHS, repeatedly tasked with finding tens of billions in efficiency savings, and where funding gaps and cuts (alongside a rising demand) seems to have become a norm over the last decade. Now as we approach Brexit without any sign of a deal, a whole new string of problems are on the horizon for health care, health professionals and the patients you serve.

Management of cardiogenic shock complicating ST-segment elevation myocardial infarction: part 1

Cardiogenic shock associated with ST-segment elevation myocardial infarction (STEMI) is a potentially devastating complication. This type of shock consists of left ventricular dysfunction causing haemodynamic instability and end-organ hypoperfusion resulting in multi-organ dysfunction syndrome. Despite advances in the management of STEMI, especially in the realm of reperfusion strategies, mortality rates remain high. The pathophysiology is complex and multifactorial, resulting in a clinical presentation of hypotension and signs of hypoperfusion. Patient assessment comprises a targeted history and a thorough physical examination to detect signs of decompensation and end-organ hypoperfusion. Upon arrival in hospital, an echocardiograph is essential in the process of identifying a cause.Learning OutcomesAfter completing this module the paramedic will be able to: Define cardiogenic shockUnderstand the pathophysiology of a person in cardiogenic shockRecognise the clinical presentation and features of cardiogenic shockUnderstand patient assessment of a person who appears to be in cardiogenic shock