Assessment and management of chronic pain in adults: implications for paramedics

Chronic pain represents a complex health problem that affects a significant number of individuals living in the community. Paramedics will encounter patients with a complaint of pain that may be associated with injury, malignancy, and degenerative diseases such as osteoarthritis. In some cases, the patient may have a diagnosis of ‘neuropathic pain’ where there is no obvious basis for the pain. Some individuals with chronic pain may experience exacerbation of pain. This may occur in association with malignancy and disease progression, and when the pain becomes unmanageable, this becomes a health emergency. These individuals may rely on paramedics to manage this distressing symptom. However, in order to care for patients with chronic pain, paramedics need to understand the physiology of pain, use validated tools to assess pain, and appreciate the range of therapeutic approaches used to manage this debilitating symptom. As such, this article aims to provide information to support the paramedic's assessment and management of patients with chronic pain. Paramedics have practice guidelines for the management of acute pain, and these may be adapted to care for patients with acute exacerbation of chronic pain.

Ambulance service charity celebrates 25 years of caring

The Ambulance Services Benevolent Fund is the only UK ambulance service charity to offer care to all ambulance personnel. 2011 is a very significant year for the ASBF as it marks 25 years since Norman Lakin had the personal vision and consideration for his fellow members of the ambulance services to set up the ASBF.

Cardiac arrest in the young: rare but possible

It can be hard to believe that someone young and active may be at risk from heart problems, but each week in the UK at least 12 apparently fit and healthy young people die from undiagnosed heart conditions. Cardiac Risk in the Young (CRY) is a charity that works to support families affected by the sudden cardiac death of a young person, to help young people who have been diagnosed with life threatening heart conditions and to reduce the number of tragedies that occur. 2010 marked the 15th anniversary year of CRY. Here, Gareth Mallon, a community paramedic and developing tutor for the East Midlands Ambulance Service (EMAS), discusses his personal involvement with the charity in more detail.

Anaphylaxis: the difficult diagnosis

The incidence of anaphylaxis is rising. The number of hospitalizations due to anaphylaxis has increased over the last couple of decades, with a threefold increase in England between 1994 and 2004 (Department of Health (DH), 2006).

Automated external defibrillators: everywhere?

Cardiac arrest is one of the biggest causes of death in the UK. There is an abundance of evidence showing that defibrillation is the most effective treatment in cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia, providing there is a support network to ensure installation, maintenance and training for users of the automated external defibrillator (AED). This article uses the authors' personal experience to review and discuss AED use in the workplace and in public access defibrillation programmes, as well as reviewing current guidelines.

Prehospital continuous positive airway pressure ventilation in ACPO: part 2

Acute cardiogenic pulmonary oedema (ACPO) is a common medical emergency facing UK paramedics. While swift management can delay progression of ACPO, a significant portion of patients spiral into deteriorating respiratory and cardiac function, leading to respiratory failure requiring endotracheal intubation (ETI). Continuous pulmonary airway pressure (CPAP) is increasingly being adopted into treatment regimens for ACPO in hospital. This is the second part of a paper seeking to critique the literature surrounding CPAP. Part one found how CPAP can provide early improvement in respiratory distress, metabolic abnormalities and need to ETI in hospital, yet these are not transferred into improved survival (Rees, 2011). Adherence and maximisation of medical therapy within JRCALC, and future potential of intravenous nitrates should also be explored by paramedics wishing to introduce CPAP into their practice. Methods: A comprehensive literature search of MEDLINE and CINAHL from 2000 to November 2010 was conducted using ‘CPAP’ as a subject heading combined with the subheadings: ‘pulmonary oedema’, ‘pulmonary edema’ ‘ACPO’, ‘heart failure’ ‘pre hospital’ and ‘paramedic’ as key words. A second search was conducted using ‘non invasive ventilation’ as a subject heading along all subheadings above. Results: A total of 253 papers were retrieved. These were manually scanned for relevance and eligibility, leaving a total of 53 papers for review. Given the relative scarcity in prehospital care literature all articles were reviewed, with nine finally selected for inclusion. No high quality UK prehospital studies were found. Application of CPAP resulted in significant improvements in physiological variables, need to ETI and relief of breathlessness. Despite these benefits, they are not transferred into improved mortality. Conclusion: The use of CPAP patients in ACPO can provide early improvement in respiratory distress, metabolic abnormalities and need to ETI in hospital. However, these are yet to be robustly transferred into improved survival. Despite this, many UK paramedics currently have limited options in supporting ventilation for ACPO. Adoption of CPAP into UK paramedic practice may offer options of a non–invasive means of supporting ventilation prior to ETI, with the potential of improving mortality by intervening early in ACPO. However, the limited number of quality prehospital studies presents many questions over its potential. Quality UK based studies are urgently needed.

Planning and writing an evidence-based critical reflection

The shift of training and education of technicians and paramedics towards an academic pathway in higher education Institutes has placed greater emphasis on the need for students to demonstrate clinical effectiveness through evidence– based practice (EBP) and critical reflection in and on practice. However, the health care literature highlights that students often find it difficult to grasp the elements involved in asking questions about their practice, searching the literature and applying their findings to their critical reflections on practice. Evaluation of the learning needs of a group of nursing students reflected these findings. As a result, a guide was formulated to support student nurses in the development and application of these skills when using the Gibbs' model of reflection and this has been adapted for student paramedics. This article presents a set of guidelines which incorporate the Lenburg competency, outcomes and performance assessment (COPA) model (2002); a patient intended outcome, paramedic intervention (PIP) model, and an adapted Gibbs' reflective cycle model (Figure 1) which paramedic students can use to develop the skills required to systematically plan and write evidence based critical reflections on practice.

The Liverpool Care Pathway: a tool for paramedics?

This short review examines the implementation of the Liverpool Care Pathway in health care settings and asks whether it would be suitable for paramedics to use in the bid to improve end of life care in the UK. Improvement of end of life care is now a government agenda and subsequently greater attention is being given to it. Currently, very few people achieve a death they would have wished for. Many would prefer to die at home, however, only 18% of deaths do occur at home. The knowledge and implementation of the Liverpool Care Pathway into paramedic practice could help improve end of life care and reduce unnecessary transfers of patients to emergency departments.

Continuing Professional Development: Cocaine toxicity: assessment and cardiac risk

OverviewThe UK has the highest prevalence of drug use within Europe, with a 13% increase in cocaine and ecstasy related deaths between 2004–2005. This is significant to emergency medical personnel as cocaine toxicity may present clinically as acute coronary syndrome (ACS) minus typical associated risk factors. Cocaine use has an immediate effect on the body within seconds to minutes of administration. The resultant effect is manifold and can be divided into the two broad categories of central nervous system (CNS) and cardiovascular. Cocaine has a strong association as a trigger of ACS, acute myocardial infarction (MI) and sudden death in a population of patients largely free of classic cardiovascular risk factors. This module will assist in understanding the effects of acute cocaine toxicity, recognizing electrocardiogram (ECG) changes and implementing an appropriate treatment plan.Learning OutcomesAfter completing this module you will be able to:▪ Refresh your understanding of the anatomy and physiology of cardio-vasculature and the central nervous system (CNS)▪ Have an understanding of the effect of cocaine on the body, and how this may present in the clinical setting▪ Further develop ECG recognition in the symptomatic patient, and understand the consequences of significant cardiac changes.▪ Explore the concept of critical thinking within clinical decision-making▪ Be able to better anticipate and implement a treatment plan in accordance to JRCALC guidelines.

Paramedic courses at the University of Central Lancashire

Pre-registration diplomaIn 2008, the local strategic health authority released a tender document for local higher education institutes (HEIs) to bid for commissioned pre-registration paramedic education in the form of a two-year, full-time diploma of higher education. This new course accepts direct entry students via the UCAS application system, as well as existing emergency medical technicians, who enter the course in year two and complete a one year conversion programme to become registered paramedics.The pre-registration diploma is also conjointly validated by the HPC, which means that successful students will be automatically entitled to apply for registration as paramedics. This move of pre-registration paramedic education into universities has also ignited the higher education spark amongst many existing paramedics within the North West Ambulance Service, to the extent that many of them are well on the way to completing a post-registration diploma in higher education focused on prehospital care.

When keeping cool is not the best option

This prospective observational study was designed to establish the incidence of accidental hypothermia in major trauma patients (MTP) and to identify factors that influence the prehospital temperatures of these patients.

Intraosseous infusion: a ‘humerus’ subject?

The intraosseous (IO) route is frequently used to gain vascular access in adults who are in out-of-hospital cardiac arrest (OHCA). As yet, no optimal location for first attempt insertion has been established.

Don't blame it on the bougie

This prospective, randomized, crossover, single-blind study compared bougie-assisted intubation (BAI) with standard endotracheal intubation (ETI) in a simulated difficult airway.

Book Review

This pocket-sized package certainly packs a mighty punch. Relating to one of the primary areas of paramedic practice, paramedics would do well to devote some time to reading this one. Such an important subject area deserves comprehensive and precise consideration and as you would expect given the expertise of the authors, this little beauty has it all.