People in rubber suits and how to treat them: decompression injuries in divers

The majority of our planet is covered in water and millions of people around the world enjoy exploring what lies beneath the surface of our seas and lakes. Diving is a popular activity, with a long history, that allows people to visit—for pleasure or for business—a different world. Diving is a sport with inherent risks. The hazards and potential for injuries, ranging from the minor to the life-threatening, are an unavoidable part of the activity. The factors involved in diving injuries and the signs and symptoms divers may present with, are many and varied. Decompression injuries are one of the potential injuries that will respond to appropriate treatment and may have the longest lasting effects. Confident treatment of decompression injuries is made easier by understanding the physics involved in breathing gases underwater. The definitive treatment involves recompression that should be provided at a specialist hyperbaric facility.

Europe gets serious about minimizing needlestick injuries

More than one million needlestick injuries are suffered in Europe each year. New legislation was recently passed by the EU to protect Europe's healthcare workers from potentially fatal blood-borne infections such as HIV and hepatitis B and C, resulting from injuries with used needles. Here, John Bowis, Health First Europe (HFE) Honorary President and former UK Minister of Health and MEP, comments on the new directive and its significance to paramedic practice.

Will a new election bring change?

At the time of writing, only 3 weeks remain until a general election that could see a major shift in the political landscape of the UK. The first ever live television prime ministerial debate has just taken place and more than 9 million viewers witnessed the emergence of the Liberal Democrat leader, Nick Clegg, as a serious political voice in the election. Yet, does the political landscape of the UK really matter to the frontline practitioner who is faced with an ever-increasing demand upon already stretched services? Do we really need to be sitting down and reading the manifestos of the main protagonists? In reality, the answer has to be yes because as public servants, the policies of the government of the day will have a very significant impact upon the way we work, the way we are measured and the level of remuneration we receive for our efforts.

Prehospital induction techniques: mild hypothermia during advanced life support

The use of therapeutic hypothermia has been proposed as a potential treatment for a number of medical conditions including head injury and cerebral vascular accidents. This article aims to explore the different techniques used to induce hypothermia during prehospital cardiovascular arrest.The review of the necessary literature has been made in order to answer the question ‘What are the possible cooling methods to reach therapeutic hypothermia in out-of-hospital cardiac arrest?’. The research took place between May–November 2008.Ovid database was examined/questioned initially and the research was carried out simultaneously using Ovid Medline, Pubmed and CINAHL. The research showed that inclusion and exclusion criteria were similar in all the analysed studies. The chosen patients were aged 18–70 years. Only one article included patients older than 70 years who were affected by extra-hospital cardiocirculatory arrest and were treated with therapeutic hypothermia with infusion of cold liquids or use of correspondent remedies.A total of 627 620 articles were found during the search term research. Boolean operators were used to review the research. ‘AND’ was used to combine to the operator limit. ‘OR’ was used to include orthographic alternatives.All this reduced the research to four articles. Cutting off and mesh researches were used in ‘include relative terms’ within the Ovid control panel.The analysis of the four studies showed the effectiveness of introducing hypothermia in prehospital treatment dealing with the reduction of the oesophageal temperature. In all studies, the temperature reduction is relevant, presenting values of −1–4°C. The infusion of cold solutions is a technique that is easy to apply and has low costs. Infusion with cold pads, on the other hand, proves more difficult and requires greater attention and daily maintenance.

ECPs: avoiding emergency department attendance or hospital admission?

The aim of the literature review was to identify and appraise studies that have compared the effectiveness and decision-making of emergency care practitioners with other health professionals.There is no ‘gold standard’ for determining whether the actions of an emergency care practitioner (ECP) results in a patient avoiding attendance at an emergency department (ED) or hospital admission. Consequently, reporting on the cost effectiveness of ECPs is potentially spurious, especially as the cost difference between ED attendance and hospital admission is considerable.Medline and EMBASE databases were searched for publications relevant to the study area. Additional searches were carried out using the online search function offered by the Cochrane Library and the Emergency Medicine Journal.Twenty-nine publications met the inclusion criteria. Nineteen of these papers were considered suitable for background information only. Ten studies were analyzed in further detail and three main themes identified: non-conveyance rates, decision-making and admission avoidance.Studies show that patients assessed by ECPs are less likely to be conveyed to the ED, than when attended by a traditional ambulance response. The Department of Health (DH, 2005) refer to a traditional ambulance service response to a 999 call as sending a double-crewed paramedic ambulance to the patient, provide any necessary life support to stabilize the patient and transport to the ED.The decision-making of ECPs compares favourably with other health professionals when deciding whether a patient can be treated at home, or requires ED attendance or hospital admission. No studies were found that determined whether an ECP is able to accurately decide whether their intervention results in patients avoiding ED attendance or admission. There is a need to evaluate the validity of data collection methods which differentiate between emergency department and admission avoidance as a result of the actions of ECPs.

A review of trauma patients taken to hospital by air ambulance

IntroductionDoctors are being introduced on air ambulance services in the UK. Meaningful assessment of air ambulance services is difficult owing to inter-service variation. County air ambulance (CAA) (rebranded as Midland's Air Ambulance after this article was written) progressively introduced doctors into their service from 2006 providing an opportunity to gather data and quantify the sample size that will be required to assess their impact on patient survival.MethodCAA trauma alerts to Selly Oak Hospital (the main receiving hospital for the service) between 1 January 2006-30 June 2007 were reviewed. Crew composition, mission data and patient notes were examined and the abbreviated injury score 98 and injury severity score were used to calculate the probability of survival. Survival outcome was ascertained at 90 days. Data analysis included survival analysis; Cox regression; logistic regression; tests for association (CI 95%, P<0.05). Post-hoc power calculations were undertaken.Results299 cases were identified, 186 met the inclusion criteria. The probability of survival ranged between 5.56-99.48%. There was no statistically significant association found between crew composition and survival (P=0.355) and post-hoc power calculations showed 54 258 events would be required to assess this. If accepting 80% power and assuming our proportion of 14% mortality ± 5%, 800 events would be required in each arm of future studies.ConclusionsOur post-hoc power calculations revealed that a national or multi-centre study is needed to assess this aspect of aircrew composition in order to prove or discount associations between crew composition and survival at 90 days. Now that a power estimate is available, designing adequately powerful studies will be possible; enabling monitoring the increasing deployment of this expensive resource and examining the effect of doctors on air ambulances. This is of increasing importance to assess as medically-led air ambulance missions increase.

Spotlight on Research

Current evidence is not clear as to whether people who sustain a head injury while on anticoagulant and antiplatelet medication are at increased risk of intracranial haemorrhage (ICH). This 2-year study provides a retrospective analysis of all adult patients who attended the emergency department (ED) with a head injury and were admitted as an inpatient, and who were taking anticoagulant (warfarin) and/or antiplatelet (aspirin, clopidogrel, dipyridamole) treatments prior to admission (n=399).

Continuing Professional Development: Assessment of the acutely or seriously ill child or young person in the prehospital setting

OverviewChildren and young people (CYP) have distinctive needs within emergency and urgent care. Clinical presentations can often be confusing with non-specific symptoms and numerous potential diagnoses which may require a variety of assessment, management and treatment strategies. For the inexperienced practitioner, assessing CYP can be daunting. Applying clinical reasoning to these situations requires the practitioner to have an understanding of child-specific anatomy, physiology, pathophysiology and psychology; as well as the ability to consider other contributing factors such as the child's ability to communicate.Furthermore, it has been recommended that every professional who is involved in the care of a child and/or young person, should, as a minimum, be competent in: recognition of the sick child; basic lifesupport skills; initiation of treatment using protocols for the management of common conditions; recognition of rare but treatable conditions; effective communication; recognition of and response to any concerns about safeguarding and understanding the need for play and recreation activities.In this article, a case presentation will be used to demonstrate how initial observations require critical thinking in order to identify alternatives to the most obvious rationale for the presenting signs and symptoms.Learning OutcomesAfter completing this module you will be able to:• Have an understanding of the factors involved in critical thinking and clinical reasoning and begin to further develop these.• Recognition of different models of assessment that can be incorporated into your practice. Have an understanding of the importance of using a structured approach to assessment of children and young people.• Further develop your knowledge and understanding of key anatomical and physiological differences in children and young people and how these impact on their clinical presentation.• Use a case presentation to explore the numerous potential diagnoses for paediatric presentations.• Have an appreciation of the current NICE guidelines and how these should impact upon your practice.

Making the most of your journal articles

I will never forget the Autumn months of 2008. The JPP editorial team were putting the finishing touches to our first issue. Hundreds of paramedics from all over the UK had even subscribed in advance of seeing a copy of the journal.