Volume 3 Issue 10

Adrenaline in out-of-hospital cardiac arrest: is the jury out?

Spotlight on Research is edited by Julia Williams, Principal Lecturer, Paramedic Science, University of Hertfordshire, Hatfield, Hertfordshire UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk (to avoid disappointment or duplication we recommend an initial email before beginning any writing).

Blended learning: conflict resolution training for ambulance first responders

In 2004, the NHS Counter Fraud and Security Management Service (CFSMS) were asked to provide training to raise awareness of conflict resolution techniques for all frontline NHS staff, including ambulance personnel. Specific ambulance guidance was published in 2007—this guidance sought to protect NHS workers from the perception that there was evidence of violence against health workers (NHS CFSMS, 2007). South Western Ambulance Service Foundation NHS Trust (SWASFT) trained, in a classroom setting, all members of its 999 frontline, patient transport and all other patient-facing staff during 2009–2010. Following this training, concerns were raised about how the Trust was to undertake the dissemination of this training to its 900 plus volunteer community responder staff, scattered across the community in Dorset, Somerset, Devon, Cornwall, and the Isles of Scilly. The team within SWASFT began work, with a partner company, to design a blended learning solution—combining e-learning with face-to-face training in order to teach community responders the theoretical concepts of conflict resolution. This project was undertaken in partnership with Solutions Training and Advisory Ltd, a specialist conflict resolution training company. This article aims to provide a detailed overview of the approach used by SWASFT when designing a suitable training programme for its community responders. In addition, it seeks to demonstrate the value of this type of educational approach when dealing with community based support workers who, by virtue of their role, do the training in their own time and in their own homes.

Paramedic clinical decision-making in mental health care: a new theoretical approach

This article aims to present a new theoretical approach for examining paramedic clinical decision-making in relation to mental health care. Recent theorizing has begun exploring key clinical decision-making approaches that are particularly relevant to paramedic practice. These approaches have also revealed some important factors that influence clinical decision-making behaviours among paramedics such as prior experience and clinical and tacit knowledge. The literature, however, provides very little insight into the clinical decision-making strategies paramedics draw on and use when dealing with mental health patients, in particular, those patients who are dealt with under involuntary provisions of mental health legislation. In addition, the literature provides limited coverage to account for how paramedics deal with and mitigate risk factors relating to patients experiencing a mental health emergency. Following these shortcomings, this article will propose the use of hermeneutic phenomenological methods as a suitable and innovative interpretive research approach for examining paramedic clinical decisionmaking in relation to prehospital mental health care. It is argued that this approach is well suited for exploring how paramedics make sense of their experience providing emergency mental health care, how they perceive their role within the clinician-patient relationship, and the particular circumstances in which paramedics exercise their legislative responsibilities under mental health legislation.

Glucagon treatment for symptomatic beta blocker overdose

Symptomatic beta blocker overdose is a relatively uncommon, but potentially life-threatening condition (Sheppard, 2006; Health Protection Agency, 2010). Current definitive treatment for these patients involves intravenous glucagon therapy, and as such, glucagon is considered both a first-line treatment and an antidote in cases of symptomatic beta blocker overdose (Joint Formulary Committee, 2011; National Poisons Information Service, 2011a; 2011b). This case report examines an intentional overdose of propranolol, including paramedic prehospital management, and subsequent in-hospital definitive treatment involving intravenous glucagon therapy. Paramedics have experience and knowledge of administering intramuscular glucagon as part of their formulary, and possess the necessary skills for obtaining intravenous access. Therefore, could intravenous glucagon be considered appropriate for administration by paramedics as a prehospital intervention in cases of symptomatic beta blocker overdose?

Book Review

This is another in the popular ‘ABC’ range of medical books. There is no disputing the central role which patient safety occupies within healthcare and a major plus with this offering is that it encompasses both primary and secondary care. The editors acknowledge that only the basic principles are covered here but as is consistent with other books in the ‘ABC’ series, this is effectively done.

Changes in vital signs of trauma victims from prehospital to hospital settings

The objective of this article is to characterize changes in vital signs of trauma victims from prehospital to hospital settings, their associations with injury severity, and the need for an emergency operation. Methods: a prospective cohort included 601 patients admitted to a level one trauma centre from 1 July to 30 September 2007. All prehospital and hospital admission values of Glasgow coma score (GCS), systolic blood pressure (SBP), heart rate (HR), respiratory rate (Resp) and oxygen saturation (SpO2) were recorded. All urgent major surgical procedures were graded in real-time as: emergency, urgent, or not urgent. Injury severity score (ISS) was calculated following completion of all the diagnostic work-up. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those who needed an urgent intervention or intensive care. Vital signs trends were analyzed using the students' T—test. Associations with injury severity and the need for an emergency operation were analyzed using chi-squared test. The statistical significance level was set at 5% (P ≤ 0.05). Results: 243(40%) patients were classified as major trauma. 39(6.5%) patients required an emergency operative intervention—29 for active bleeding and 10 for imminent cerebral herniation. The time from injury to hospital arrival was 44.8 ± 17.63 minutes (mean±standard deviation), the time did not differ for those needing an emergency operation. Prehospital GCS ≤12 and SBP ≤90 were associated with a severe injury (a relative risk(RR) of 4.95, 95% confidence interval(CI) 3.25–7.58 for low GCS and 4.60, 2.67–7.94 for low SBP) and emergency surgical procedures (RR, 95% CI 4.43, 2.28–8.58 for low GCS and 11.69, 5.85–23.36 for low SBP). These values changed significantly from the field to the hospital with the mean GCS increasing 1.65 points and the mean SBP decreasing 7.23 mmHg (p<0.001). One patient out of 473 with a GCS ≥14 in the field and no one out of 483 patients with a GCS ≥14 on admission needed a neurosurgical procedure. 15/533(2.8%) patients with a prehospital SBP >90, and only 2/542(0.4%) patients with a SBP >90 on admission required emergency bleeding control (P<0.005). HR ≥120 and changes in HR of 20 beats per minute (bpm) or more were not associated with injury severity. The respiratory rate and the SpO2 did not change significantly, and were not associated with injury severity. Conclusion: prehospital vital signs values are expected to change significantly over time. Prehospital GCS ≤12 and SBP ≤90 predict major trauma, while the HR is not a good indicator of haemodynamic status. When these parameters normalize on admission, an emergency operation is rarely needed.

Ketamine: a unique drug with several potential uses in the prehospital setting

Ketamine is an anaesthetic agent that does not depress a patient's respiratory drive, setting it apart from other sedatives such as benzodiazepines. It has historically been used in austere environments with few resources for close monitoring under anaesthetia. More recently, it has found frequent use in paediatric specialties to facilitate painful procedures, but also seen use in adults. Commonly used in emergency departments by physician-level providers, it has found a use in the prehospital setting. Case reviews, as well as retrospective and prospective studies, have examined its use by physicians and paramedics in the prehospital setting. Ketamine offers several potential uses for paramedics including analgesia, sedation, and airway management; but thorough understanding of the drug and its unique effects is critical for safe use.

Epinephrine and its use in acute life-threatening asthma in adults

Epinephrine (adrenaline) is commonly used by paramedics in a range of clinical scenarios. Its role in cardiac arrest scenarios is well established, but the indications for use in acute severe or life-threatening asthma are less well defined. This article reviews the evidence for the use of epinephrine in acute severe asthma and uses a case study to highlight some of the potential side-effects that clinicians need to be aware of.

Innovation but precious little evaluation: time for more IDEAL-ism in prehospital care?

Recognized uncertaintyThere are many examples in prehospital care of innovations introduced with enthusiasm, but where the supporting evidence-base is lacking. To name but a few here: non-invasive pacing (Sherbino et al, 2006), mechanical chest compression devices (Brooks et al, 2011), and oxygen administered to the patient with acute myocardial infarction (Cabello et al, 2010). Evidence that benefit exceeds harm for these interventions has yet to be established in a well conducted study (high-quality research is now underway addressing most of these issues). That is not to say these interventions do not work, but there is recognized uncertainty.Contemporary enthusiasm for mild therapeutic hypothermia (MTH) following cardiac arrest has recently been challenged (Nielsen et al, 2011) and while there is some evidence for this intervention, it is considered low-level (Walters et al, 2011); supporting this author's view that it would be premature for ambulance services to introduce MTH outside of a well-designed, ethically approved research study.Two more examples that were published as this commentary was being written include a randomized trial of 8718 patients comparing the impedance threshold device (ITD) with a sham device (Aufderheide et al, 2011). Contrary to an earlier, non-randomized UK study (Thayne et al, 2005) suggesting that the ITD improved short-term survival, the ITD did not significantly improve survival with satisfactory function in this recent high-quality study. Moreover, another prehospital study in the same edition found no difference in outcomes with either a brief period of basic life support (BLS) compared with two minutes of BLS provided by ambulance personnel prior to first analysis of cardiac rhythm (Stiell et al, 2011) differing from more optimistic assessments from lower quality, UK observational series (Fletcher et al, 2011). These should serve as yet more reminders that robust evaluation is required before widespread adoption of innovative treatments. Using treatments before we have a robust evidence-base could be described as experimenting on patients, we need to go about it the right way through well-designed, ethically approved research that gives a fair assessment of the value of a therapeutic intervention.It is not just about treatments either. There has been enthusiasm for introducing strategies for risk assessment in patients with suspected transient ischaemic attack (TIA), but modelling has suggested using ambulance services to expedite TIA care was unlikely to be cost effective (Mant et al, 2008). The ABCD2 score has not proven useful in the emergency department setting (Perry et al, 2011). Critical care paramedics are an attractive proposition (NHS Confederation, 2011) but there is no good evidence yet of their value to patients or the NHS, and the research underpinning the NHS Confederation report has been criticized for its poor quality (Hughes, 2011). It is possible to do such research well, see for example the work from Sheffield on paramedic practitioners (Mason et al, 2007).

Discussing therapeutic hypothermia and the ‘Cool it’ study

What about the ambulance services?Despite recommendations for early induction of TH within the 2005 and 2010 European Resucitation Council Guidelines (Nolan et al, 2005; 2010), there has been no published, high quality research performed by any UK ambulance trust into the effectiveness of TH in the prehospital setting.Some services have ‘dabbled’ with ice cold saline and cold packs, but not one single service in the UK has a prehospital therapeutic hypothermia standard protocol for use following return of spontaneous circulation (ROSC) after sudden cardiac arrest.‘The results from the ‘Cool it’ trial may well be a starting point to accelerate implementation into the prehospital arena’For those practitioners who are aware of the pathophysiology of therapeutic hypothermia and the outcome effects that cooling a patient can have, it becomes a frustration that these interventions are not becoming a common and rapidly introduced standard within the emergency setting. It can almost make one seem evangelical in their support of TH when trying to share the benefits that it can bring and persuade clinical managers to introduce the intervention into everyday guidelines.There has yet to be the momentum created for change in the ambulance service, but the results from the ‘Cool it’ trial published in August may well be a starting point to accelerate implementation into the prehospital arena (Mooney et al, 2011).

Principles of research ethics

The Health Professions Council Standards of Proficiency for paramedics expect registrants to be competent in practising evidence-based practice. Although the treatments a paramedic can provide are steered by the Joint Royal Colleges Liaison Committee (JRCALC) Guidelines, it is important we can access good quality relevant research to ensure the care we provide our patients is based on the best available evidence. As paramedic education continues to evolve, it is likely more paramedics will wish to become involved in proposing and conducting research relevant and accessible to our own unique profession. The Department of Health's Research Governance Framework outlines the standards and responsibilities expected to be recognized by those wishing to propose and conduct research, and sets out the key ethical issues that are expected to be addressed as part of the research process.

Open University awards in paramedic sciences

What can the OU offer paramedics?So what can the OU offer to people in the emergency care area? It might seem counterintuitive to teach such a hands-on subject at a distance, but the OU achieves this by entering into partnerships with employers who can deliver face-to-face the practical aspects of the subject. In this way, students learn theoretical material at the same time as improving their practical skills, and so have the opportunity to underpin practice with theory—this is a central tenet of the awards. Students must be employed in a relevant field while they are studying, and this benefits both the students themselves, who can earn while they learn, and the employers, who can select their most promising employees for career development by this route. The OU offers a foundation degree (FD) in paramedic sciences, and a diploma of higher education (DipHE) in paramedic sciences. The content and structure of these awards is identical, but for various cultural and financial reasons some employers favour one or the other—for example, foundation degrees are not recognized in Scotland, so Scottish students undertake the diploma version of the award. From the student's point of view, the learning experience is the same regardless of the name.Both awards are accredited by the UK's Health Professions Council (HPC), and any graduate of either award is eligible to apply to the HPC for registration as a paramedic. Thus, these awards are most suitable for people currently working at ambulance technician or emergency care assistant level, and wishing to become a paramedic. The FD has also proved popular with paramedics who already have HPC accreditation but who wish to obtain higher education qualifications to strengthen their knowledge base.

Continuing Professional Development: Risks and benefits of paramedic-initiated shoulder reduction

OverviewA dislocated shoulder is a painful injury that requires early reduction to reduce pain and restore mobility. Anterior dislocations are the most common type, and techniques used to achieve reduction have a high rate of success and low rate of complications. While this procedure is commonly performed by physicians, a delay to care may be associated with unnecessary pain and complications associated with delayed reduction. As such, this module investigates the conditions under which paramedic management of these injuries may be appropriate.Learning OutcomesAfter completing this module you will be able:• Recognize the typical clinical features associated with anterior shoulder dislocation.• Describe the anatomical structures that maintain shoulder stability.• Contrast the risks of shoulder reduction in the field with risks associated with delayed reduction.• Describe circumstances where paramedic reduction of shoulder dislocation may be indicated in the field.

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