What duty of care do you have for your patients? We talk a lot about duty. It is embedded in our daily conversations. We talk about ‘off-duty’, we enquire when staff are ‘on duty’ or on a ‘duty roster’. It has become part of our everyday vocabulary, but failing to provide a duty of care is the most common reason for doctors to be sued for negligence. The law of negligence seeks to ensure that as individuals, we are responsible for both our actions and our inactions.
Guideline summaryIn general:
Oxygen is a treatment for hypoxaemia and not breathlessnessOxygen is a medicine which should only be administered to achieve a target oxygen saturationOxygen therapy should always be accompanied by an assessment of saturation and documented in the same way as any other prescribed medication.The guidelines identify four distinct categories of patient:
The critically ill patientThe seriously ill patientPatients with conditions requiring controlled or low-dose oxygen therapyPatients not requiring oxygen therapy unless they become hypoxaemic (low saturations).Target saturations for each patient should be determined from the presenting complaint, a history of hypercapnic episodes (a high partial pressure of carbon dioxide), or previous interventions with non-invasive ventilation:
Oxygen delivery devices and flow rates should be adjusted to keep the oxygen saturation within the desired rangeOxygen should be reduced in stable patients with satisfactory oxygen saturationIdeally, high-risk patients should be issued with oxygen alert cards by their physicians specifying an individualized saturation target and ideal method of oxygen delivery and dose.
OverviewThis CPD module is aimed to provide an overall and generic approach to wound management, since it is not possible to provide a detailed approach for each type of wound that a paramedic may be presented with. This module will detail a brief overview of the anatomy and physiology of skin, an overview of different types of wounds, a review of wound infections and, with an associated understanding of the wound healing process, present a range of wound management products that are suitable for different types of wounds, such as a bleeding or sloughy wound. By understanding the nature of wounds, through which aspect of the skin is damaged and the associated pathophysiology, the available wound management products will become logical. There is unfortunately scarce information regarding wound management in the current Joint Royal College Ambulance Liaison Committee (JRCALC) Guidelines (JRCALC, 2006). Ambulance Trusts will have some form of policy/procedure or guidelines documenting the management of wound care and this CPD module aims to supplement this guidance.Learning OutcomesAfter completing this module you will be able:• Review the anatomy, physiology and functions of the skin.• Provide an overview of the various types of wounds presenting in prehospital care.• Explore and describe the key concepts involved in wound healing.• Provide an overview of the different types of dressings available.• Suggest a wound management guide for prehospital care.
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 firstname.lastname@example.org (to avoid disappointment or duplication we recommend an initial email before beginning any writing).
Investigations into the trauma patient who suddenly deteriorates while in the care of paramedics, either on scene or during transport to hospital, is limited. The objective of the study was to determine the incidence, physiological criteria for sudden deterioration, and outcome of patients who suddenly deteriorated during paramedic care. Methods: this is a secondary data analysis of an existing prehospital-based trauma dataset. The sudden deterioration dataset had been created previously by linking twelve months (2002) of an Australian Ambulance Service's trauma data with a State Trauma Registry. The sudden deterioration dataset was interrogated using predefined criteria to identify patients who suddenly deteriorated in the presence of paramedics, either on scene or enroute to hospital. Results: there were 239 patients who met the criteria for sudden deterioration, amounting to 0.45% of the total number of trauma patients transported or seen by the Victorian Ambulance Services for 2002. Four patients who suddenly deteriorated did not meet the criteria for prehospital potential major trauma. Conclusion: this study suggests that the incidence of trauma patients suddenly deteriorating in the presence of paramedics is very low and that increasing the total out-of-hospital time to get these patients to an appropriate level trauma service does not adversely affect their mortality outcome.
Retail stores are often frequent sources of emergency medical service (EMS) calls responding to traumatic injuries. At risk populations for trauma due to falls are paediatric and elderly persons. Methods: the authors reviewed the English literature for incidence and outcomes of EMS response to retail store injuries in paediatric and elderly populations. Articles were chosen based on EMS response and emergency department (ED) visits for age ranges younger than 18 and older than 65. Injury patterns and mechanism of injury were reviewed and alcohol or assault related injuries were excluded from analysis. Results: 22 relevant articles from 5 countries, with the majority of studies from the US, were found; these included 7 descriptive national surveillance database reviews, 4 retrospective record reviews, 4 randomized trials, a survey based study, with the remainder case reports and editorials. Modes of conveyance are the sources for majority of injuries including trauma from the use of shopping carts, stairs, escalators, and elevators. Other areas of injury include trip hazards. Falls are the most common mechanism of injury for both populations and account for more than half of injuries associated with store environments. The use of safety devices and efforts to reduce injury risk are not universal in the retail industry and interventions have variable efficacy. Conclusion: retail stores are common settings responded to by paramedics for paediatric and elderly traumatic injuries. Scene management and extrication of injured persons is an issue for EMS personnel responding to these settings, with methods tailored to injury mechanism. There are several avenues for intervention with the focus on injury prevention though community education.
Objectives: The National Infarct Angioplasty Project (NIAP) pilots were set up in 2005 to test the feasibility of implementing a countrywide primary angioplasty (PCI) service for patients with ST-elevated myocardial infarction in England. The authors undertook an evaluation of these pilot sites along with a small number of control sites to assess the workforce and staff implications, patient and carer experience and the cost-effectiveness of primary angioplasty-based care in the real world. Methods: this was a mixed methods study, incorporating four main components: description of models of service delivery, evaluation of workforce and organizational issues, patient and carer evaluation and economic evaluation. Results: pilot sites varied considerably in size and configuration. Many offered ambulance bypass for patients within the catchment for nearby feeder (non-PCI) hospitals or received transfers from these non-PCI hospitals. During the pilot year, 70% (1449/2072) of patients were admitted directly to a PCI site, with a further 21% (435/2072) being transferred from a non-PCI site. Median call-to-balloon times (CTB) were 120 minutes for patients taken directly to a PCI site and 161 minutes for patients who went via a non-PCI site. CTB times can be reduced considerably by improving pathways so that ambulances can bypass non-PCI sites and bypass emergency departments by taking patients directly to the catheter laboratory for assessment. The use of telemetry to enable ECGs to be examined by staff within the coronary care unit can also reduce the number of patients being wrongly transferred to primary angioplasty centres. Time delays that incurred from transferring patients from non-PCI sites to PCI sites indicated that promptly administered thrombolysis may be more cost-effective than PCI in certain circumstances. Patients reported very high levels of satisfaction with care and reported higher levels of satisfaction with speed of treatment and the ambulance journey at NIAP site than control sites. Conclusion: primary PCI was found to be a cost-effective and feasible service, providing CTB times can be minimized by streamlining patient pathways.
Patients who experience an acute ST-elevation myocardial infarction (STEMI) present a common clinical problem. While the treatment for this condition has undergone various changes in recent years, the underlying pathophysiology has remained the same. The patient experiences an acute coronary atheromatous plaque which fissures or ruptures, leading to the development of thrombus associated with the acute plaque causing occlusion of the vessel. This causes the typical symptoms of acute STEMI of chest pain, breathlessness, sweating and nausea/vomiting, as well as the classical changes on the resting electrocardiogram (ECG). Once the coronary artery is blocked, the myocardium supplied by the vessel is at risk of necrosis, unless the vessel can be reopened and the blood supply is restored. Time is of the essence, since the quicker the vessel can be reopened, the less myocardial damage occurs. In this article, the use of thrombolysis to treat patients with STEMI is described. This covers its administration within the hospital setting and its use prehospital. The treatment of patients with STEMI using coronary angioplasty/stenting is addressed, including the assessment of the patient, the procedure itself and also the care of the patient following the procedure.
End tidal carbon dioxide (etCO2) measurements enable accurate monitoring of airway patency, ventilation (self or assisted) and metabolism. It is mandatory in current in-hospital anaesthetic practice and now recommended in the prehospital setting. Traditional methods of capnography have used either mainstream or sidestream devices, but both are not without their disadvantages, which may be potentiated in the prehospital environment. Portable devices either display a waveform (capnography) or a numerical reading alone (capnometry). Waveform capnography is often the preferred mode of CO2 detection in prehospital practice (mirroring experiences from in-hospital), however, there is no published evidence comparing the superiority of either method. The most recent advancement in prehospital capnometry is the introduction of a compact, light-weight, battery powered, self-contained mainstream capnometer. This device has been shown to be accurate when compared with anaesthetic equipment and appears to meet all the qualities required for inclusion as a tool for the improved care of the prehospital patient. It displays only a numerical reading as opposed to some new defibrillators used by certain ambulance services which include waveform capnography. The authors feel this difference would have very little detrimental effect on patient management out-of-hospital. This, coupled with the advantages gained by greater access to etCO2 monitoring, related to both cost and training, considerations have enabled the conclusion that this type of mainstream capnometer should be considered more often for prehospital care.
Sickle cell disease is a genetic blood disorder resulting in the sickling of red blood cells (RBC) when exposed to certain conditions. Historically, sickle cell care has been poor and often delayed, but in recent years, several key publications have helped provide guidance and uniformity on how to manage acute crises, ensuring all patients receive a high level of care. The sickling of RBC can lead to acute complications, some of which are potentially life-threatening. The sickling can occur anywhere in the body, producing a wide array of symptoms. For this reason, it is paramount that prehospital clinicians conduct a thorough assessment and, where appropriate, initiate treatment prior to arrival at the hospital. The most common symptom that clinicians will need to manage is severe pain. Many patients will have an individualized treatment plan detailing how they are best managed following an acute crisis and where possible it should be followed.
Meningitis Research FoundationThe Meningitis Research Foundation (MRF) provides resources for health professionals to help diagnose and treat meningitis and septicaemia. Recently, MRF re-launched its life-saving series of algorithms for the management of meningococcal disease and bacterial meningitis in children and young people. These protocols are aimed at doctors in emergency medicine, paediatrics, paediatric intensive care units, anaesthetics and general medicine in the UK.
BasicsThe British Association For Immediate Care (BASICS), founded in 1977, have held three day training courses for years in order to provide the PhEC (prehospital emergency care) qualification, both domestically and abroad; but the nature of in person training can place restrictions on many potential students, who may not have the time or availability to attend the in-depth schooling. Therefore, the decision was made that, as of April 2011, all lectures, along with a myriad of texts, web resources, video clips, as well as the module exams, would be placed on the BASICS Education website (BASICS, 2011).