Volume 3 Issue 2

Great North Air Ambulance Service: prehospital anaesthesia course

BackgroundThe PHA guidelines were published in 2009. Four years prior to this, GNAAS decided that the simplest way to ensure its paramedics and doctors were appropriately trained to safely undertake PHA,was to develop a course as part of the initial crew training. This was particularly important, not only for those team-members with limited anaesthetic experience, but also for those anaesthetically trained who had little or no experience of undertaking anaesthesia outside the controlled environment of a hospital.

Are paramedics and emergency physicians made differently?

This German based study set out to examine the personality characteristics of emergency physicians (EPs) and paramedics looking for any commonalities in people choosing to work in emergency situations, and to compare these identified personality traits to those of medical doctors (not practicing emergency medicine), and final year medical students.

February roundup of the EMS blogging world

The Social MedicFrom one guru of social media in EMS to another. The Social Medic, David Konig, has started a bit of a blogging masterclass on his own blog.First off is a post that walks those new to reading blogs through some of the common terminology that you may find when visiting the EMS blogosphere. If you have never heard of a ‘ping’ or a ‘permalink’, then this is the post for you. ‘Blogging terms to know’ is an essential first look for any reader who has decided to explore this alternative means of sharing information and best practice (The Social Medic, 2011a).He then follows up with ‘Choosing an identity’, that looks deeper into the decisions that need to be made if you are thinking of venturing into blogging yourself (The Social Medic, 2011b). Think you have a name in mind for your blog? Is it the right one? Go and have a read and think about the image that you want to portray to the internet and to represent your service and/or profession.

Book Review

My new year’s resolution was to be more positive about books not directly aimed at the paramedic profession or written about one specific aspect of paramedic practice.

Emergency ultrasound in the prehospital setting

Paramedic practice in the UK has seen some diverse and lengthy changes in the last ten years. The way that ambulance services are now involved in emergency care is very different, with more focus placed on the efficient and appropriate use of other primary and secondary care resources. The advent of closer and more formal working relationships between prehospital care physicians and paramedics will provide the opportunity to further develop the quality of care delivered by the doctor-paramedic team. It is now widely accepted that for the most seriously injured patients out of hospital, the application of physician-led skills such as prehospital anaesthesia contribute significantly to the process of the early management of trauma and improvement of outcome (Van der Hoeven and De Koning, 1995). Similarly, the development of the team approach has meant that more goal–led therapies can be instituted in a timely fashion. The use of ultrasound in the prehospital environment is not new. While its role is not yet fully established (Brooke et al. 2010), it is nevertheless finding its rightful place in the hands of both trained physicians and paramedics. The diversity of applications for paramedic–led ultrasound is also gaining momentum with high levels of sensitivity and specificity reported (Heiner and McArthur, 2010; Tazarourte et al, 2010). This article addresses some of the issues regarding the use of ultrasound in prehospital care and describes some of the applications which are taught in the emergency and prehospital ultrasound course at the Imperial College, London.

UK Survey of emergency physicians’ priorities for clinical decision rules

One of the first stages in the development of new clinical decision rules (CDRs) is determination of perceived need because this is the most important predictor of ultimate adoption. This study examined the current use of two common CDRs and the clinical priorities of UK emergency physicians (EPs) for the development of future CDRs. Methods: The authors administered an e-mail and postal survey to a random sample of 350 members of the British Association of Emergency Medicine (total membership n=1700). Results: The total response rate was 44.5% (155/350). The respondents were predominantly male (67.7%), with a mean age of 44.0 years (SD +/- 10), and a mean of 10.8 years experience (SD +/- 7). Regarding the two pre-existing Canadian C-spine and CT head rules, 62% of responders were aware of these rules. Regarding a proposed acute headache CDR, 94.6% of those surveyed indicated that they would consider using a highly sensitive and well-validated decision rule if it was developed. The top priorities in the four main categories were admission with anterior chest pain (42.8%), imaging for suspected transient ischaemic attack (34.5%), management of serious vertigo (29.7%) and investigation of febrile child <36 months (40.6%), respectively. Discussion: This UK survey identified the sampled emergency physicians’ priorities for the future development of CDRs. The top priority was investigation of the febrile child < 36 months. These results will be valuable to researchers for future development of CDRs in emergency medicine in the UK.

Tension pneumothorax: are prehospital guidelines safe and what are the alternatives?

Tension pneumothorax is a life-threatening complication of chest injury. It can cause rapid physiological decompensation, cardiac arrest and death. The Joint Royal Colleges Ambulance Liason Committee (JRCALC) provide guidelines on the prehospital diagnosis and treatment of this condition. The aim of this article is to ask whether or not these guidelines are effective and if there are feasible alternatives to the management of tension pneumothoraces in the prehospital environment.

Aspects of military prehospital care

The military prehospital care experience has adapted civilian practice to reflect the nature of injuries sustained in recent conflicts. The main adaptations stem from differences in the mechanism of injury, clinical timelines and personnel. The large number of blast injuries and resulting extremity trauma means that an emphasis is placed on the control of catastrophic haemorrhage using a number of novel haemostatic strategies. This paradigm of <C>ABC is now universally followed and differs from civilian practice in a number of other ways— particularly in the management of C-spine, airway, chest injuries and circulatory access. This review highlights these differences in practice and outlines military techniques and protocols. It also emphasizes those areas in which civilian practice has borrowed from its military counterparts and successfully employed their techniques. This may become more relevant in the modern, post-September 11th era, in which urban mass casualty incidents are no longer a fictional fear.

Letters to the Editor

Dear Editor, I am grateful to Peter Jones for taking the trouble to respond to my paper (Woollard, 2010).

A response to ‘Fighting the fire’: fire chiefs’ proposal to run England’s ambulance service

In October 2010, JPP published a comment by Prof Malcolm Woollard, titled ‘Fighting the fire: a response to fire chiefs’ proposal to run England’s ambulance service’, expressing his view as to why the proposal by the Chief Fire Officers Association (CFOA) is not workable. JPP has received a letter regarding this, which is printed below, along with a response from Prof Woollard that also discusses the latest report published by the CFOA.

College of Paramedics’ Position Statement on the designation of paramedics: Undertaking Extended Scope of Practice

HistoryA number of developments have occurred to address the professional needs of paramedics to have a scope of practice that matches the changing demand from both patients and the NHS requirements.Practitioners in emergency care (PEC)In 2000, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), in partnership with the Ambulance Service Association (ASA), proposed the development of practitioners in emergency care (PEC) to broaden the skills and knowledge of paramedics in order that they could meet the diverse requirements of patients, particularly those with undifferentiated but not life-threatening health care requirements.The role of the PEC was designed to ‘up-skill’ the workforce and support modernization efforts. Many ambulance professionals were keen to expand their roles and such advancement had wide support from the trade unions.Quality Assurance Agency (QAA) Benchmark StatementThe Benchmark Statement produced by the QAA at the request of the DH and with the involvement of the Health Professions Council (HPC), clearly identified that paramedics should have the competency set to meet patient demand, and specifically enhanced patient assessment and clinical decision–making. The document also embraced the EU system directives relevant to paramedics (QAA, 2004).The British Paramedic Association (BPA) Curriculum GuidanceThe BPA produced the first Curriculum Guidance for the profession in February 2006 (BPA, 2006). This document included a career framework for paramedics with the level of ‘paramedic practitioner’ reflecting an increased primary care role for paramedics, embracing the concept laid down in the QAA statement.Allied health professions with a special interestThe DH acknowledged the value of paramedics with an extended scope of practice in the form of community paramedics in the document, Implementing a scheme for allied health professionals with special interests (DH, 2007).Ten Key Roles for Allied Health Professionals (DH)In August 2003, the DH published the ten key roles of AHPs to clarify the role and what they should aim towards. It indicated that all AHPs (including paramedics) should be able to act as the first point of contact for patient care having the skills of diagnosis, ordering diagnostic tests, prescribing, discharge, referral, teaching and health promotion. (DH, 2003).Standards of Proficiency (HPC)The current Standards of Proficiency (HPC, 2007) for paramedics reflect that all paramedics should be able to undertake full patient assessment, have clinical reasoning skills and refer patients appropriately.Taking Health Care to the PatientThe DH report, Taking Healthcare to the Patient (2005), outlined the need to develop a paramedic career framework in line with the changing workload demand.The Allied Health Professional Career FrameworkThere are 15 groups of allied health professionals, with paramedics joining the ranks of AHPs in November 2000 as the twelfth professional group to be admitted to the register. The NHS AHP Career Framework applies to all AHPs and provides an opportunity to build a clinical career path within each professional group.Emergency care practitioner (ECP) developmentAlongside paramedics developing within the higher education setting as first contact practitioners (following QAA, HPC and BPA standards), the NHS Modernisation Agency adopted the PEC concept and called this an ‘emergency care practitioner’ (ECP).The British Paramedic Association (BPA) Curriculum Guidance (Second Edition)The College of Paramedics; (BPA) issued the second edition of the Curriculum Guidance in January 2008. This document, which was revised following wide stakeholder input, clearly identifies the role of the paramedic and associated competency set. It also outlines a scope of practice and a career framework for specialist, advanced and consultant paramedics.Critical care paramedicsMany of the approximately 750 paramedics who have undergone clinical development in the specialist paramedic role undertake responsibilities in the area of managing patients with undifferentiated primary health care needs.More recently, roles to support improvements to services for patients with serious injury and illness have been developed. The NHS has funded a curriculum for this role and two universities offer programmes designed to produce critical care paramedics.These staff are trained to plan a role in the delivery of trauma and resuscitation care and have a developing scope of practice geared to these needs, potentially fulfilling elements with ‘enhanced care team,’ or similar initiatives.

Specialist practice for paramedics: a bright future?

ProgressPerhaps the biggest single prize that we still need to seize is unlocking the full potential of our profession and this means making paramedics ever more relevant and effective in meeting emerging patient need through the development of scope of practice.There has been limited and rather fumbling progress here—both in terms of the move from training to education and particularly in respect of the post-registration training where paramedics are providing care to the ever-increasing number of patients with less critical undifferentiated urgent care needs. Nevertheless, much remains to be accomplished and there are both challenges and promising developments in equal measure.

So how can we frame our identity?

A weakness of the paramedic profession is the lack of reflective literature examining our role and place in society. This is in marked contrast to other health professions that have developed distinct bodies of professional knowledge and theory to help guide and support their members (Kinsella, 2009).

Continuing Professional Development: Recording 12-lead ECG's

OverviewThe British Heart Foundation estimates between 113 000—146 000 myocardial infarctions occur in the UK each year. Evidence shows that patients with ST elevation myocardial infarction (STEMI) require timely reperfusion therapy to improve survival (Keeley et al, 2007). Therefore, paramedics must be confident in their ability to record electrocardiograms (ECGs) quickly and accurately. Accurate ECGs are also crucial for identifying angina pectoris, malignant and non-malignant arrhythmias. This module aims to address some of the issues involved in recording a diagnostic quality ECG and highlights some pitfalls faced in the emergency prehospital setting.Learning OutcomesAfter completing this module you will be able to:▪ Define the term diagnostic quality ECG and understand why it is key to appropriate diagnosis and management▪ Reflect on the advantages of holding a recognized ECG qualification▪ Appreciate the importance of calibration verification and identify situations where it is necessary to change voltage or speed settings▪ Become more confident in locating electrode positions accurately▪ Understand the importance of not using operator controlled filters and reflect on the consequences of choosing an inappropriate setting▪ Identify, reduce or remove common artifacts.

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