Excited delirium syndrome involves extreme agitation and aggression in a patient with an altered mental status; around one in ten cases ends in cardiac arrest. It has two main triggers: acute drug use and psychiatric illness. Patients display violent behaviour, increased pain tolerance and great strength; they pose significant risks to themselves and those around them. Maintaining safety on scene is paramount, which can be supported by a dual response by paramedics and law enforcement officers, and the patient is likely to need restraining or sedation. Treatment is non-specific and involves managing symptoms and complications such as hyperthermia, acidosis and rhabdomyolysis.
Evidence is growing that prone positioning may be a simple, safe, and effective technique to improve oxygenation in awake patients with COVID-19 who are unresponsive to initial therapy. However, there is little evidence about its use in the prehospital environment. This study explores clinician awareness and experiences of this in a large ambulance service in south east England.
An online survey was distributed to 3377 operational ambulance clinicians working for the South East Coast Ambulance Service NHS Foundation Trust to assess their awareness of using the prone position for patients with suspected COVID-19 and their experiences of its use in their practice.
A total of 278 respondents completed the survey, of whom 229 were aware of the use of the prone position for awake patients with COVID-19 and 18 had attempted to use it in their practice. Ten reported improvements in clinical observations and patient comfort, and six patients showed clinical improvement only. There were no reports of deterioration. The most common reason for not attempting prone positioning was the absence of formal training or guidance.
Ambulance clinicians are aware of the use of the prone position for patients with COVID-19 and a small number have used it. The majority of clinicians who were aware of the procedure did not use it because of the lack of guidance or concerns over patient safety. When attempted, prone positioning in prehospital practice may be an example of practice borne of ‘clinical courage’. Further research is needed before the prone position can be routinely used in prehospital practice.
Coronary heart disease is a leading cause of death worldwide. Paramedics are instrumental in the treatment, triage and transport of patients experiencing acute coronary syndromes and acute myocardial infarction (AMI). Paramedics currently rely on prehospital electrocardiography and patient symptomology to diagnose AMI, which may result in missed diagnoses. Point-of-care biomarkers such as cardiac troponin (cTnT) and copeptin may have the potential to increase the diagnostic capabilities of prehospital providers. Multiple electronic databases (MAG Online Library, Cochrane Library, PubMed and Embase) were searched to evaluate the feasibility and potential application of cardiac biomarkers cTnT and copeptin in the prehospital setting. Because of the paucity of evidence, this article explores the evidence on the dual-marker strategy of cTnT and copeptin to increase diagnostic capabilities of prehospital providers, and as an adjunct for decision-making and risk stratification for AMI. The evidence suggests that using the combined dual-marker strategy of cTnT and copeptin may counteract limitations of the ‘troponin-blind’ period of cTnT and the low cardiac specificity of copeptin. However, the research for this method is still in its infancy and requires investigation into its feasibility and affordability as well as into the training required to implement it in paramedic practice.
As Barry Costello looks beyond his time as an NQP, he reflects on what's next…
Vaccines are advocated as the best defence against COVID-19. While most NHS staff, including ambulance clinicians, have been vaccinated, some remain hesitant. All health and social care staff, with some exemptions, were originally expected to be fully vaccinated by 1 April 2022. However, this is currently on hold due to the recent reconsideration by the Secretary of State.There are ethical arguments against and in favour of mandatory vaccination. Arguments against include potential harm and loss of autonomy. Coercing staff may be interpreted by the public that health professionals do not trust vaccines. A mandate may also be seen as authoritarian, which may embolden the anti-vaccine movement. Compulsory vaccination is also opposed by Royal Colleges, professional bodies and trade unions. Arguments to support mandatory vaccination include that society has a legitimate interest in regulating behaviour that harms others, even if this limits individual choices and that people live in groups so their rights and powers are limited by the rights of others. Paramedics deal with a diverse population, and often encounter clinically vulnerable patients as well as those who are COVID-19 positive. It can be argued that patients' right to be safe from unnecessary risk usurps that of a practitioner to refuse vaccination. Having all health and social care staff fully vaccinated will increase the health service's resilience. Future decisions on any vaccine mandates must incorporate various ethical arguments and support with additional effort to address underlying issues related to vaccine hesitancy.
Survival rates for out-of-hospital cardiac arrest (OHCA) patients in the UK are low compared with other developed countries. UK ambulance services are in an important position to influence these survival rates by improving their ‘chain of survival’ (Nolan et al, 2006). A paramedic-led resource, with enhanced technical and non-technical skills specialising in OHCAs, has been shown to improve patient outcomes in this population group in the UK. The author proposes that this concept should be considered by all UK ambulance services to improve OHCA patient survival.