Reducing unnecessary conveyances to hospital can help relieve pressure on emergency departments. Making decisions about conveyance in rural areas is particularly challenging because of the travel distances involved.
To explore perceptions of paramedics in a rural setting about how they make decisions regarding conveyance and non-conveyance for patients categorised as ‘amber’ (serious but not life-threatening).
Data were collected through interviews with 17 paramedics working in rural areas, which were analysed using inductive thematic analysis.
Paramedics perceive hospitals as places of safety for themselves (psychological safety) and for patients (patient safety). Lower levels of psychological safety (e.g. because of an organisational blame culture) and perceived increased risks to patient safety (e.g. because of a lack of health resources in the community) influence paramedic decision making on conveying patients to hospital.
Current practice contributes to increasing pressures on emergency departments. Ambulance services should work towards a non-punitive culture of safety where paramedics feel they can make decisions based on their experience and expertise rather than to protect themselves.
Lactate devices offer the potential for paramedics to improve patient triage and escalation of care for specific presentations. There is also scope to improve existing prehospital tools by including lactate measurement.
A literature search was conducted using the Medline, CINAHL, Academic Search Premier, Sciencedirect and Scopus databases.
Acquiring prehospital lactate measurement in trauma settings improved triage and recognition of the need for critical care. Within a medical setting, studies offered mixed results in relating prehospital lactate measurement to diagnosis, escalating treatments and mortality. The accuracy of prehospital lactate measurements acquired varies, which could impact decision making.
Prehospital lactate thresholds could aid decision making, although the literature is limited and evidence varies. Lactate values of ≥4 mmol/litre in medical and ≥2.5 mmol/litre in trauma patients could signify that care should be escalated to an appropriate facility, and that resuscitative measures should be initiated, particularly with sepsis, as reflected by standardised lactate values that guide treatment in hospitals. Similarly, a lactate value of <2 mmol/litre could mean de-escalating care into the community, although further research is warranted on this.
Reflection is embedded in a variety of higher education healthcare programmes, and is a continuing professional development requirement for paramedics (Health and Care Professions Council, 2012; 2014). The listed benefits of reflection include incorporation and exploration of an evidence base into a clinician's practice; avoidance of routine practice; identification of shortfalls in knowledge; and identification of learning needs by the reflector (Jasper et al, 2013). Nine nearly qualified student paramedics took part in this qualitative study. The findings showed a positive attitude towards reflection among the students. Various barriers to reflection were identified. There appeared to be a lack of reflection and reflective practice in some sections of the paramedic workforce. Analysis of the findings have implications for both paramedic practice and paramedic education. This article is a summarised version of a research piece; therefore not all findings will be discussed.
In this month's issue on decision making, Ellie Daubney shares how her decision-making responsibilities have changed from first to second year, and the lessons she has learned
Diabetes is a group of metabolic diseases characterised by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic complications of diabetes include accelerated development of cardiovascular disease, end-stage renal disease, loss of visual acuity, and limb amputations. However, in the acute situation, diabetes can result in conditions such as diabetic ketoacidosis and hyperosmolar hyperglycemic state, both of which have the same cause: insufficient insulin. This article explores the physiology of glucose control, the pathophysiology of diabetes and the role of the paramedic in the prehospital treatment of the diabetic emergencies, diabetic ketoacidosis and hyperosmolar hyperglycemic state.