Volume 4 Issue 1

Are early warning scores too early for paramedic practice?

The use of early warning scores (EWS) is now widespread in medical practice. Typically, EWS are used in inpatient settings to identify patients who require additional intervention to avoid unexpected intensive care admission or death. Prehospital care involves the rapid identification of critical illness but also undifferentiated urgent care. This large range of variation in acuity means EWS systems must be particularly accommodating. This article explores the use of scoring systems in paramedic practice and argues the need for more research, especially in non-trauma based tools.

Support for self-care in Scotland: how can paramedics advocate the self-care agenda?

Paramedics work very much on an episodic basis and this is entirely expected as they see patients when there has been a traumatic incident, acute onset of symptoms or acute exacerbation of an existing condition. This means that their work, although involving assessment and treatment planning, tends to be focused on the current complaint. In the UK, paramedics work to guidelines drawn up by the Joint Royal Collages Ambulance Liaison Committee (JRCALC). These focus on managing the specific condition or complaint. As a result, it may seem that supporting self-care is not congruous with the work of paramedics, but self-care support is becoming increasingly supported within the wider NHS and there is significant research around this subject. The purpose of this article is to describe what self-care is, its origins, and underpinning theories. It will also describe the drivers promoting it in the current health care context in Scotland, what is missing from current research, what implications exist for healthcare practitioners and provides an example of how paramedics can deliver effective support for self-care.

Potential applications of capnography in the prehospital setting

End-tidal carbon dioxide (ETCO2) monitoring is well established in hospital theatre and critical care settings (Lah and Grmec, 2010), employed for observation and monitoring in anaesthesia. Its application has now extended to the prehospital environment, primarily for the verification of endotracheal tube (ETT) placement, endeavouring to reduce the occurrence of oesophageal intubations (Grmec and Malley, 2004). In recent times, technological advances, coupled with an increased appreciation of the importance of prehospital interventions, has resulted in the production of additional equipment capable of monitoring ETCO2 in non-intubated, self-ventilating patients via a non-invasive nasal cannula. Despite having an extensive range of potential uses, the apparatus is widely underused (Langhan and Chen, 2008). In this article, potential applications in the prehospital setting will be discussed via a review of contemporary literature.

PaRAMeDIC: a randomized controlled trial of a mechanical compression device

Survival from out-of-hospital cardiac arrest (OHCA) is influenced by the quality of cardiopulmonary resuscitation (CPR). However, research shows that in the out-of-hospital environment, and particularly during ambulance transport, CPR quality is frequently sub-optimal. Mechanical compression devices can deliver high quality CPR, yet there is an absence of high quality evidence to demonstrate improved clinical or cost effectiveness outcomes. The PaRAMeDIC trial will compare manual CPR with mechanical CPR in adult patients with non-traumatic OHCA. Objectives: the primary objective is to evaluate the effectiveness of mechanical chest compressions using the LUCAS (Lund University Cardiopulmonary Assistance System)-2 on mortality at 30 days post-OHCA. Secondary objectives include survived event (return of spontaneous circulation at hospital admission), quality of life and cognitive function at 3 and 12 months, survival at 12 months and cost effectiveness. Method: the trial is a pragmatic, cluster randomized controlled trial. Ambulance vehicles are randomized to control or LUCAS arms. Patient allocation is determined by the first ambulance vehicle which arrives first on scene (manual CPR vehicle or LUCAS CPR vehicle). The trial will assess the clinical and cost effectiveness of the LUCAS-2 device. Trial Registration: The trial is registered on the International Standard Randomised Controlled Trial Number Registry (ISRCTN08233942).

Continuing Professional Development: Emergency ultrasound in the prehospital setting

OverviewThis module will explore the breadth and depth of ultrasound use in the prehospital setting. Emergency ultrasound is increasingly being seen as an extension to clinical examination. Emergency ultrasound skills can potentially positively impact upon patient outcome both in terms of out of hospital treatment and also in terms of non-nearest hospital transfer of patients for specialist care. The wide array of potential practice modification promised by prehospital emergency ultrasound need to be introduced carefully and in the context of mentoring and accreditation of potential practitioners. By using reflective questions and establishing learning outcomes, the paramedic will achieve a foundation in the prehospital use of emergency ultrasound.Learning OutcomesAfter completing this module you will be able to:• Recall the indications for FAST, DVT, pneumothorax, AAA and basic echo scans in the prehospital setting.• Recall what constitutes a positive FAST, DVT, pneumothorax, AAA and basic echo scan.• Be aware of the potential benefit of ultrasound to confirm limb artery occlusion when applying tourniquets for limb trauma.• Realise the potential prehospital triage and non-nearest hospital transfer value in using portable ultrasound examination.

Scabies: a problem that can really get under your skin

This article explores the assessment, diagnosis and current recommended treatment for scabies in the UK. There are many myths surrounding scabies which could lead to misdiagnosis. Using a case from clinical practice, some of the common features of a history suggestive of infestation are explored and the social and psychological effects of such a diagnosis are considered. As a result of reading this article, prehospital practitioners should be more aware of scabies and more able to identify it in the community setting.

The myth and mending of ketamine

The origins of ketamineKetamine, a chemical derivative of phencyclidine (PCP), was first synthesized by Calvin Lee Stevens, Professor of organic chemistry at Wayne State University. Initially evaluated under the clinical number CI-581, the pharmacological actions were tested on volunteers from the population of Jackson Prison, Michigan in 1964. It was shown to be an effective analgesic and anaesthetic agent that gave patients a feeling of being ‘disconnected’ from the environment. The term ‘dissociative anaesthetic’ was coined by Toni Domino, the wife of one of the lead researchers, to describe the clinical effects of the drug (Domino, 2010).For many years, the mechanism of action of ketamine has been thought to be mainly due to the non-competitive antagonism of N-methyl-d-aspartate glutamate (NMDA) receptors. Glutamate is a major excitatory transmitter in the central nervous system—antagonizing the receptor leads to a decrease in neuronal activity and therefore anaesthesia.However, this is not the whole story. Ketamine appears to have several different sites of action and has been reported to interact with many systems such as opioid, monoamine, cholinergic, purinergic and adenosine receptors, as well as having local anaesthetic effects(White et al, 1982; Persson, 2010).‘Although ketamine is currently successfully used for analgesia in emergency medicine and the developing world, it is still unfairly demonized in some circles’The racemic mixture of ketamine, containing equal amounts of two ketamine enantiomers, S (+) and R (−), was approved for general clinical use in 1970 (White et al, 1982). During the past 41 years, the appropriate use of ketamine has divided opinion, and some controversial beliefs still muddy the waters of debate.

The College of Paramedics: 10 years on since its formation

Our historyParamedics were registered in 2001 under the Council for Professions Supplementary to Medicine (CPSM) and then later under the Health Professions Council (HPC). The professional body was formed as the British Paramedic Association (BPA) in 2001, became the College of Paramedics in 2007 and reached its tenth anniversary during 2011. The founders of the BPA, and more recently the elected office-holders of the College of Paramedics, have worked tirelessly to ensure that paramedics have a formal body that can represent them on issues that would not be within the remit of other bodies. Due to the rapidly evolving nature and relative infancy of our profession it is understandable that many paramedics raise questions about the individual roles of the regulator and professional body. In this context, before describing the role of the College of Paramedics, a short overview of the roles of the other bodies follows:

Applied paramedic science at the University of Hertfordshire: clinically focused development

BackgroundThe University of Hertfordshire (UH) was one of the first higher education institutions to offer higher education degrees for paramedics, with the first undergraduate students graduating in 2001. Since then, a range of innovative and successful paramedic science programmes have been developed including: undergraduate foundation and BSc (Hons) degrees; postgraduate specialist courses for emergency care practitioners (paramedic practitioner) and critical care paramedics.The university runs a successful MSc degree programme which is proving popular with paramedics from a variety of trusts. Since 1996, the UH has provided a part-time post-registration degree for paramedics continuing professional development (CPD)—this has been attended by students from South Central, East of England and London Ambulance Service NHS Trusts. The BSc (Hons) applied paramedic science is an innovative, clinically focused replacement designed to address paramedics’ continuing professional development requirements.

Rethinking the hand-over process

The hand-over process is often described as the clinical hand-over of patient information and transfer of responsibility from one healthcare provider to another. One important hindrance in this hand-over lies in insufficient interprofessional communication where clinical information about the patient's situation may be missed during the process (Bost et al, 2010).

Ultrasound in a moving ambulance vs a (simulated) emergency department

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).

Clinical handover in trauma settings: can it be improved?

This qualitative study, undertaken in Australia, had four aims: 1) to produce a minimum dataset to assist paramedics in clinical handover; 2) to outline attributes of effective and ineffective handover; 3) to determine feasibility of advanced data transmission; 4) to identify how best to display data in trauma bays.

Australian first responder programmes: a review of the literature

Early access to defibrillation for cardiac arrest patients is highlighted in the seminal paper describing the ‘chain of survival’ concept. The objective of the study was to identify Australian first responder programmes and report their effect on survival rate from out-of-hospital cardiac arrest (OHCA). Methods: a literature search was conducted using medical electronic databases Medline and EMBASE, with the databases searched from their beginning until the end of May 2011. References from retrieved articles were reviewed. Articles were included if they reported on Australian first responder programmes and their outcomes, including survival to discharge from hospital. Articles were excluded if they were not written in English or were hospital-based. Results: there were 674 articles located by the search with seven articles meeting the inclusion criteria. Two articles were subsequently excluded, as they did not report survival outcomes. The survival rates from cardiac arrest ranged from 4% with the Metropolitan Fire and Emergency Services Board first responder programme to 71% with St John Ambulance Australia at large public events. Conclusion: the results of this study suggest the survival from OHCA attended by first responders in Australia is, in some studies, comparable with international studies.

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