Volume 12 Issue 4

Epilepsy in pregnancy: an emergency care context

Epilepsy is a heterogeneous neurological condition that manifests clinically in seizure, and diagnosis depends on seizure duration, frequency and characteristics. Seizures can lead to injury and poorly controlled epilepsy can cause sudden death. Women with epilepsy have a small but significant risk of adverse pregnancy outcomes such as antepartum and postpartum haemorrhaging, miscarriage, preterm birth or needing an induced birth or a caesarean section; two-thirds will not experience an increase in the severity or number of seizures during pregnancy. Paramedics should be aware that women with pre-eclampsia and eclampsia may have seizures, and that women may stop taking their anti-epileptic drugs or reduce dosage because of concerns over congenital malformation. Multidisciplinary care is essential for these women.

Effect of blood pressure on stroke severity and outcomes in acute cases

Background: Stroke results in impairment of cerebral autoregulation. Systemic blood pressure (BP), whether low or high, may affect cerebral blood flow and cause damage to brain tissue, so is important in the context of stroke. Effective management of BP may result in less severe strokes and better outcomes for patients. Methods: A literature search was performed to answer the research question, using the CINAHL Complete and MEDLINE Complete databases. Inclusion and exclusion criteria were applied. Full texts were reviewed for eligibility and 15 quantitative articles were selected and discussed. Results: Fifteen international quantitative primary research articles were selected and grouped into four themes: admission blood pressure; BP indexes/BP variability; active treatment of BP; and prehospital care. The articles were randomised controlled trials, cohort studies and one post-hoc analysis. Conclusion: In patients with acute ischaemic stroke (AIS), systolic BP in the 140–160 mmHg range on admission to hospital is associated with higher rates of positive outcome and lower stroke severity. BP-lowering therapy in AIS is safe and does not affect stroke severity, but also does not alter patient outcome. In the context of intracerebral haemorrhage (ICH), intensive BP-lowering therapy to a target of 140 mmHg and maintenance of this value for 7 days produces high rates of positive long-term outcomes in terms of quality of life and Modified Rankin Scale scores. Furthermore, early initiation of BP management, namely in the prehospital environment, is beneficial. These results provide evidence that antihypertensive treatment should be provided in the prehospital environment, and support early administration of treatment to reduce systolic BP to a target of 140 mmHg, which is a beneficial value for patients experiencing ICH and AIS.

A comparison of handover communication in NHS and military emergency care

Background: There is a gap in the literature comparing communication during handover between military and NHS emergency care settings. Objectives: This study aimed to explore differences in handover communication in the NHS and the military, and to understand how paramedics manage the transition between settings. Design: This was a qualitative study for which 13 paramedics were interviewed. It focused on handover communication in NHS emergency care settings and Camp Bastion Hospital, Afghanistan. Methods: Interviews were conducted with regular and reservist paramedics serving in the Royal Air Force who had undertaken a deployment with the Medical Emergency Response Team. Semi-structured interviews were recorded, transcribed, coded and subjected to a thematic analysis. Results: Three principal themes were identified: differences between handover communication; standardisation; and the challenge of transition. Conclusion: Participants were most concerned about standardisation. Transition theory and resilience may account for the difficulties encountered when transitioning between different care settings.

Nearly qualified but learning is for life

In her final column as a student paramedic, third year Ellie Daubney shares how COVID-19 is affecting her final year of her paramedic science degree and her plans to fill in any gaps in experience before embarking on her official career as a newly qualified paramedic

The paramedic profession: disruptive innovation and barriers to further progress

The paramedic profession in the UK evolved from a small number of pilot programmes in the early 1970s that focused on training selected NHS ambulance crews in advanced resuscitation techniques. Similar initiatives occurred almost simultaneously in the United States, Australia, New Zealand and Canada. This case study focuses primarily on the UK, and England in particular. The purpose of the initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity and became fully professionally recognised and regulated as allied health professionals, becoming an example of the phenomenon termed ‘disruptive Innovation’; this is something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in NHS ambulance services which, in comparison, have lagged behind and also failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, and hampered these practitioners' ability to make full use of their skills. The consequence of this has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover. Parallel developments in medical personnel deployment have increased the quantity of medical labour available to patients with serious or life-threatening injuries, with medical staff added to helicopter emergency medical crews. While many patients with urgent conditions would have benefited from general practitioners being available out of hours, proportionally fewer doctors are available to fulfil this role today and those that are attracted to working with the ambulance service often prefer to respond to cases involving major injury. For these reasons and given the reality that the ambulance service is morphing into primarily an urgent care organisation, de-emphasising the transport aspect of the service, changes are needed to its model of operation and to staff management and support.

Cardiovascular examination

The clinical examination is an important part of any patient consultation. After the primary survey and taking the patient history, a more in-depth examination is sometimes required to aid making a working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient and may not be possible in time-critical circumstances. However, clinical examination is an increasing part of paramedic practice owing to the continued expansion of the scope of the paramedic role in both urgent and emergency care. Education on clinical examination concerning each of the main body systems is now an integral part of undergraduate paramedic curricula.This clinical examination series provides a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians to maintain and demonstrate that they are staying up to date and advancing in their roles.This series gives an overview of each type of examination to support students, newly qualified paramedics and paramedics wishing to use these articles as a CPD development activity and an aide-memoire for clinical practice. This article, which explores the cardiovascular system, gives an overview of initial examination considerations, including first impressions.

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