Volume 14 Issue 1

Recognising, assessing and managing chest pain

Chest pain is a common medical symptom that paramedics attend to in the out-of-hospital environment. The causes of chest pain and the signs and symptoms are explained in this article, alongside tools that could be useful in diagnosis, such as clinical risk scores and troponin testing. Finally, pain management strategies that use a balanced approach for optimal patient care are referred to, with some specificity for cardiac chest pain explained.

Intravenous ketamine as an analgesia in prehospital adult trauma patients

Background: Prehospital traumatic pain is common, but the quality of pain management in these patients is poor. Current practice recommends morphine as the first-line analgesia in major trauma but this carries high risks and is often contraindicated. Alternative paramedic-administered analgesia does not provide adequate pain relief or may be contraindicated. As a result, many patients remain in pain. Analgesic ketamine is used safely and effectively in international civilian and military settings and by paramedics with additional training, education and qualifications. Aim: The study had two aims. Namely, these were to find out whether intravenous ketamine: provides effective relief of prehospital traumatic pain in adults; and is safe for prehospital administration by non-specialist paramedics. Method: Three databases, CINAHL, MEDLINE and AMED, were searched to identify articles published between 2009 and 2021. Exclusion criteria were applied and results subjected to critical appraisal and evaluation. Findings: Four studies were included in the review. Two themes were identified for thematic analysis: therapeutic effectiveness; and the safety of IV ketamine administration by paramedics. The evidence drew predominantly homogenous conclusions, but was substandard regarding external validity, which limited the quality of these conclusions. Conclusion: Ketamine provides effective pain relief in line with morphine and is safe for paramedics to administer. However, clear gaps in the evidence mean the research questions are not fully answered, so changes to current paramedic practice cannot be recommended.

Taking meaningful steps

‘Five hundred twenty five thousand six hundred minutes, how do you measure a year in the life?’ - Seasons of Love, Jonathan Larson

Burnout in frontline ambulance staff

Background: Staff retention is a significant issue for ambulance services across the globe. Exploratory research, although minimal, indicates that stress and burnout, in particular, influence attrition within the paramedic profession. These need to be understood if their impact on retention is to be addressed. Aims: To determine the presence of and contributory factors for burnout in the ambulance service to inform recommendations for positive change. Methods: A two-phased survey approach was adopted using an adapted Maslach Burnout Inventory and Copenhagen self-assessment burnout questionnaire, to measure levels of burnout, depersonalisation (cynicism) and personal achievement. Open-ended questions explored factors that influenced these. Demographic and comparative analysis identified trends and thematic analysis was carried out on the qualitative data. Results: Ninety-four per cent of ambulance staff in this study (n=382) reported a sense of personal achievement within their professional role; however, more than 50% were experiencing varying levels of burnout with 87% displaying moderate or high levels of depersonalisation towards their work. Causes of stress were complex: themes attributed were a perceived lack of management support, the public's misuse of the ambulance service, involuntary overtime and a poor work-life balance. Conclusions: Burnout poses a genuine threat to retention in the ambulance service and needs addressing. Proactive screening, better communication between practice staff and management and access to counselling services are recommended. This problem of burnout is beginning to be acknowledged but further evidence is needed to understand it in more depth in order for effective solutions to be developed.

Identifying and managing hyperkalaemia in the prehospital environment

Hyperkalaemia is defined as a high level of potassium within the blood. Potassium concentration is normally tightly regulated at 3.5–5.5 mmol/litre. Hyperkalaemia can have major consequences for muscle, nerve and cardiac function, leading to arrhythmias and cardiac arrest. It has many causes, including disease states, trauma and medication; a tourniquet can lead to pseudohyperkalaemia. Some patients are at a greater risk of developing it. Hyperkalaemia is most accurately identified through blood tests but results of these may not be available prehospitally. Paramedics need to take a thorough history and carry out an electrocardiogram (ECG) to diagnose hyperkalaemia. ECG results can indicate the severity of the condition, and a guide to the ECG changes corresponding to serum potassium levels could help paramedics in diagnosis. Nebulised salbutamol is recommended as the first-line management of hyperkalaemia in several healthcare areas but there are no protocols that enable UK paramedics to provide this, even though emergency vehicles carry the drug and paramedics administer it for other conditions. Establishing such protocols would allow paramedics to treat patients effectively at the scene and en route to hospital.

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