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 to 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 the gastrointestinal system, gives an overview of initial examination considerations.
Convulsive status epilepticus (CSE) is a medical emergency that is commonly encountered in the prehospital setting. In almost all prehospital settings, treatment is limited to benzodiazepines even though the standard of care in emergency departments includes second-line agents such as phenytoin.
A literature search was conducted using PubMed and Google Scholar using the search terms ‘phenytoin’, ‘seizure’ or ‘convulsive’ and ‘prehospital’, ‘EMS’ or ‘ambulance’ or ‘emergency department’. Five articles were analysed and a narrative review formed.
Phenytoin is an effective and commonly used second-line anti-epileptic agent but there is a distinct lack of evidence on prehospital phenytoin. Phasing the introduction of phenytoin into practice while simultaneously running a well-designed research trial could provide data for prehospital providers and the wider health community.
Management of CSE will continue to present challenges to prehospital providers. Promoting the introduction of phenytoin to select patients, administered by advanced clinicians, could be an excellent opportunity to generate much-needed clinical data and potentially reduce morbidity and mortality in CSE.
The second part of the series on child public health explores the levels of prevention implemented in order to hinder diseases from affecting the lives of children, and how paramedics implement prevention strategies in their practice both in prehospital and primary care settings.
Having just completed her final year as a student paramedic, Ellie Daubney shares some surprising lessons learned and her recent shifts in perspective towards patient care as she undertakes a new role as a temporary newly qualified paramedic during COVID-19
Primary percutaneous coronary intervention (PPCI) is the gold standard for treating patients experiencing ST-elevation acute myocardial infarction (STEMI). More than 30 000 patients experience cardiac arrest out of a hospital setting in the UK every year and may be some distance from a PPCI facility.
To analyse and consider if a better outcome could be achieved for patients if PPCI was an adjunct to thrombolytic therapy, where delays of ≥60 minutes are inevitable or unavoidable.
The current review examined a range of articles, research materials and databases.
Some studies suggested the use of prehospital thrombolysis while others compared the effectiveness of drug-eluting stents. While the ‘gold standard’ for the treatment of patients experiencing a myocardial infarction is still PPCI, several factors can delay patients from receiving this treatment at an appropriate facility within the recommended time frame.
Patients may not be able to access PPCI within 60, 90 or 120 minutes for reasons including increasing urbanisation, population growth and NHS hospital funding cuts. If the PPCI unit is some distance away, ambulance crews could start thrombolysis treatment and transmit clinical findings to a specialist cardiologist in the PPCI facility, or stop at a local hospital that could provide thrombolysis.
Awareness is increasing that health behaviours, which are a part of a person's lifestyle, have significant effects on emotional and physical wellbeing. Ambulance workers are at a higher risk of poorer psychological health outcomes than the general population. This begs the question whether lifestyle could play a role in emotional and physical health outcomes, which is an understudied area in this population. This paper reviews health behaviours in paramedics and assesses the impact they may have on their emotional and physical wellbeing.
PRISMA guidelines were adhered to and seven online bibliographic databases (MEDLINE, CINAHL, PsychArticles, PsychINFO, Web of Science, PubMed and Google Scholar) and reference lists of eligible articles were searched. Papers were systematically extracted and selected by title, then by abstract using inclusion and exclusion criteria.
The papers included in this review (n=6) cover a range lifestyle factors (physical activity, smoking, alcohol use and sleep) that potentially affect wellbeing outcomes (weight/body mass index and post-traumatic stress symptoms) of ambulance workers across the Western world. They have various limitations.
Ambulance workers engage in negative health behaviours that have some bearing on their emotional and physical wellbeing. Further research could explore the role of health behaviours and lifestyle in ambulance workers using validated measures. The findings could support the development of an evidence-based, occupation-specific intervention.
Caring for patients who are approaching the end of life is an important part of the paramedic's role. Patients' circumstances are individual; for some, death is expected and may even a welcome (albeit sad) relief from a long period of pain and distress, while for others it is a tragic, unexpected outcome after every effort to prevent it has been exhausted. Regardless of circumstances, paramedics have to make wide-ranging clinical decisions, underpinned by a complex legal and regulatory framework. Paramedics generally have to obtain a patient's informed consent before proceeding with any intervention. They may be challenged if a dying patient refuses life-sustaining treatment or no longer has the mental capacity to consent and need to know the law on decision-making in these cases. This article discusses issues around capacity and consent at the end of life. The next article in this series considers issues such as advance decisions to refuse treatment and do not attempt CPR decisions.