Volume 4 Issue 2

Continuing Professional Development: Glucagon treatment for symptomatic beta blocker overdose

OverviewSymptomatic 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 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 pre-hospital 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 pre-hospital intervention in cases of symptomatic beta blocker overdose?Learning OutcomesAfter completing this module you will be able to:• Have an understanding of the pharmacology of beta blocker medication and develop an understanding of the toxicity of beta blockers in overdose, and have an awareness of potential toxic doses for adults and paediatrics.• Understand how the presenting clinical features in symptomatic beta blocker overdose relate to an extension of their pharmacology and demonstrate knowledge of current pre-hospital management guidelines and treatment options following beta blocker overdose.• Have an awareness of the indications and implications of intravenous glucagon use in symptomatic beta blocker overdose, and the potential role for this intervention in pre-hospital practice.

Scenario-based electronic learning: a viable educational method

All prehospital practitioners should participate in the task of establishing a body of knowledge that relates specifically to prehospital care (Gregory, 2011). The rapid pace of change in prehospital knowledge and the release of new clinical practice guidelines would indicate that systems need to be developed to disseminate this knowledge effectively and efficiently. Electronic learning (e-learning) is one method. Prehospital personnel's reaction to electronic learning has not been widely evaluated. Aims: this article presents an overview of the lessons learnt through a structured evaluation of a pilot e-learning module which was delivered to advanced paramedics. Methods: A series of scenario-based educational modules encompassing recent changes in advanced paramedic clinical practice guidelines were developed. In February 2011, the pilot module was made available to 207 advanced paramedics in Ireland. A quantitative and qualitative assessment of this programme was performed. Results: during a four-week trial period, 51 out of 64 registered advanced paramedics who participated in the e-Learning programme, completed an extensive evaluation of the pilot module. The results indicate a strong positive response towards e-learning as a method of delivering learning to advanced paramedics. Discussion: e-learning is a medium set to gain popularity as a method of training in the future due to the ability to rapidly transfer new and updated clinical knowledge within a cohort of practitioners. The medium offers flexibility and cost efficiencies. Conclusion: e-learning has proved a successful tool for delivery of prehospital educational information. Practitioners are prepared to take responsibility for their own education and appreciate the ability to schedule their own learning time.

CPR compression depth and rate in relation to physical exertion in paramedic students

The International Liaison Committee on Resuscitation (ILCOR) guidelines suggest rescuers deliver cardiopulmonary resuscitation (CPR) in cycles of 30 chest compressions and 2 ventilations (30:2) at a rate of 100 compressions per minute with a compression depth of 4-5 cm. Given this increase from the previous CPR cycle of 15:2, there is now also greater emphasis on pushing faster and deeper with minimal interruption. This has led to speculation surrounding rescuer fatigue and compression inefficiency. The purpose of this pilot study was to assess the level of work intensity and fatigue among undergraduate students during simulated CPR, including the quality of chest compressions. Methods: this was an observational pilot study investigating second year undergraduate paramedic students’ fatigue levels and quality of chest compressions following 20 minutes of simulated CPR. Data were collected at baseline and after every 2 minutes until conclusion of twenty minutes. Measurements of work intensity and fatigue included heart rate, rating of perceived exertion (Borg), compression depth and compression frequency. Results: a total of 7 subjects participated (2 male, 5 female), with five students aged 21-25 years. Male subjects showed a significantly slower compression rate when compared to females (108.0 vs 125.6 chest compressions per minute, P=0.006). Heart rate was significantly higher than rest (prior to commencing CPR) after 14 minutes of CPR (P=0.045). Perceived exertion was significantly higher than at rest at 2, 6, 10, 14, and 18 minutes, (P<0.01). Conclusion: this pilot study suggests that high levels of fatigue and perceived exertion are present early when undertaking CPR in a controlled setting, with some fatigue attributed to the faster than recommended chest compression rates.

Carbon monoxide poisoning: a comprehensive review for prehospital specialists

As one of the leading causes of poisonings worldwide, it is imperative that prehospital specialists are aware of carbon monoxide (CO) poisoning and its management. Awareness of the epidemiology, and the common presentations of CO poisoning may lead to prompt evaluation and early initiation of life-saving therapy. Children under 5 years of age have the highest incidence of CO-related ER visits and are at greatest risk of CO toxicity. The clinical features are nonspecific and misdiagnoses are common. Therefore, prehospital providers should have a high index of suspicion for CO intoxication in patients that experience headache, vomiting, or altered level of consciousness following exposure to hydrocarbon combustion within an enclosed space. A carboxyhaemoglobin level is a quick and reliable way to diagnose CO exposure. To prevent complications such as altered cerebellar function, seizures, rhabdomyolysis and dysrhythmias, early recognition and treatment is imperative. Removal from the source of exposure and the provision of 100% oxygen form the cornerstone of management. Preventive strategies should also be explored in susceptible populations.

Preventing prehospital hyperoxygenation during acute exacerbation of COPD

Chronic obstructive pulmonary disease (COPD) is a long-term, incurable lung condition. Acute exacerbations are frequently encountered by ambulance clinicians and are routinely treated with oxygen therapy and nebulised drugs. Yet, delivering the appropriate amount of oxygen to these patients is challenging, and the effects of getting it wrong are significant. Hyperoxygenation of patients with acute exacerbation of COPD leads to a significantly increased rate of mortality and morbidity. This article outlines the pathology of COPD and relevant clinical guidelines. It proposes a multi-modal intervention as a solution to the challenge of ensuring the appropriate delivery of oxygen therapy to patients who are experiencing an acute exacerbation of their COPD.

Acute multiligament injured or dislocated knee: field assessment and management

Knee dislocation is a serious but uncommon injury that can result in significant trauma to the ligaments, nerves, and blood vessels of the leg. With a high rate of spontaneous reduction and signs of injury that are often subtle in the acute stage, knee dislocation can be missed if not specifically sought through meticulous and thorough history-taking and physical examination. Targeted visual inspection, neurologic and vascular examination, and palpation of the limb are all instrumental in the identification of a potential multiligament knee injury or dislocated knee. The association of significant vascular injury with knee dislocation puts the injury victim at risk of limb loss if the injury is not identified and treated in a timely fashion. By identifying the injury, reducing and splinting as appropriate, and communicating awareness of the injury to hospital-based caregivers, the paramedic has a unique opportunity to direct the course of treatment that the patient receives.

Lights, camera, disciplinary action?

The presentation of careOnly recently I watched, with interest, a programme that showed a paramedic crew attending a ‘critical’ patient (cue dramatic music) to see the paramedic driving the vehicle away using blue lights and sirens and the ambulance technician providing the clinical care. Surely this is as an abdication of clinical responsibility by the paramedic concerned with a potential breach of the Standards of Conduct, Performance and Ethics (Health Professions Council (HPC) 2008)?Worryingly, this example is not isolated as there are a number of cases where the standard of care presented suggests potential deficiencies from accepted standards. However, this is not to say that the care actually fails to meet expectations, the editing of such programmes undoubtedly plays a vital role in the presentation of care delivered and may not always paint an accurate picture (from a healthcare perspective) for the purposes of the creative process. Certainly, we must consider each case with caution and consideration of the programme makers’ limitations in terms of material presentation; ultimately these programmes thrive on the ethos of drama, alongside a limited time space in which to showcase material. The provision of pure facts would, I am sure, often make less dramatic viewing. This poses the question, what action should be taken in the event of care that appears to fall below the expected standard?‘The growth of such shows and inherent public interest in the emergency services brings to light the question of whether such media coverage is of benefit or risk to our profession’Our registrant duty includes the precept that we must inform the HPC of any suspicion of wrongdoing (HPC 2008); however, can this be confidently undertaken based upon an edited snapshot? This is a decision that cannot be made lightly and requires careful thought.

Right care, right place, right time?

Ten years ago, ambulance clinicians often perceived their role as responding to patients who had experienced an accident or acute medical emergency. Ambulance services concentrated almost entirely on the need to respond rapidly. While 80% of paramedic training was focused on this group of patients, the experience on the clinical frontline was somewhat different. Where were the endless time critical patients requiring multiple invasive interventions and medicines? The reality was that this group of patients represented less than 10% of the average ambulance workload. The remaining 90% were often labeled as inappropriate as their conditions were perceived as not increasing staff knowledge, testing their competencies or enabling the use of technical skills (Lewis and Bradbury, 1982). The last ten years has brought significant change in the way that ambulance services respond to these patients. Taking Healthcare to the Patient (Department of Health, 2005) recommended that ambulance clinicians should be equipped with a greater range of competencies to enable them to assess, treat, refer, or discharge an increasing number of patients in the community.

Curriculum guidance and CPD: a busy year ahead

Curriculum Guidance and Competencies FrameworkThe development of a suitable curriculum by the College has formed a major component of the College's work prior to 2012. Over the next 12 months the approval process will be complemented by curriculum development work by the College, allowing an appraisal of quality of its implementation, identifying and promoting best practice to enhance student learning experiences.The College believes that curriculum guidance should be central to the planning, implementation and delivery of educational curricula for paramedics. It needs to reflect contemporary directions in paramedic practice by consulting with several parties who hold an interest, not only College members but employer's representatives, educators and service users. Currently work is in progress by College members to develop a third edition of its curriculum guidance for publication in mid-2012. It published a first edition in February 2006 with the second edition following in January 2008.The Curriculum Guidance and Competencies Framework form an extremely important document for the paramedic profession; it represents expert opinion and direction from paramedic professionals. The input from frontline clinicians provides expertise, experience, perspective and context on behalf of the paramedic profession to institutions providing development courses. The foreword to the second edition of the College of Paramedics’ Curriculum Guidance and Competencies Framework (College of Paramedics, 2008) explains the synergy between curriculum guidance and other important drivers:‘This curriculum guidance does not stand alone in achieving a curriculum that delivers a paramedic suitably and fully prepared for the role expected of them. Closely linked to this work and to the process of approvals for FE/HEIs are three other important documents that strongly influence the standards and quality of paramedic services that aim to be delivered: Health Professions Council (HPC) Standards of ProficiencyHPC Standards of Education and TrainingQuality Assurance Agency (QAA) Benchmark statements.The 2008 Guidance also provided explanation regarding the scope of practice for the paramedic profession (College of Paramedics, 2008: 4):‘The section on scope of practice found in this guidance defines what is expected from paramedics at each level of their career development and acknowledges that while the depth of clinical knowledge and skills remain central to good practice these aspects must be complemented by appropriate knowledge and attitudes.’Clearly identifying any professional's scope of practice is important. The paramedic role has evolved from provision of immediate life-saving treatment and routine transportation to that of a fully rounded and complex healthcare professional who is required to assess, diagnose and treat a broad range of conditions. The recent National Audit Office report (National Audit Office, 2011) and Taking Healthcare to the Patient I & II (Department of Health (DH), 2005; Association of Chief Ambulance Officers, 2011) illustrate the changing clinical workload encountered by paramedics. This has included a rapid growth in undifferentiated urgent and emergency patients encountered by paramedics in their clinical practice. Also recognised is the increasing role that paramedics have in directing patient flow through NHS urgent and emergency care networks, both in current pathways and in emerging strategies of care delivery.In response to these drivers, the College has developed a revised career framework. This aims to provide a framework illustrating potential career pathways for paramedics. The framework maps development routes for paramedics in specialisms to manage the broad range of patients encountered in their practice. The career framework is underpinned by current curriculum development by the College; integrating a potential developmental pathway from paramedic to consultant that is mapped to the Allied Health Professions career framework. It should be noted that NHS pay bands are determined by employing trusts independently of the College; references to bands within the curriculum/career framework refer to qualification/level of practice by paramedics only.As an organization acting on behalf of its members, we welcome comment on our proposed career framework and curriculum development. Please send these to: jim.petter@collegeofparamedics.co.uk.

Emergency management of severe burns

EpidemiologyIn the UK, approximately 250 000 people are burnt each year. Of these, 175 000 attend accident and emergency departments, and 13 000 of these are admitted to hospital. Some 1000 patients have severe enough burns to warrant formal fluid resuscitation; half of these are children under 12 years. In an average year, 300 burn deaths occur. These UK figures are representative of most of the developed countries, although some, such as the US, have a higher incidence.Burns are also a major problem in the developing world. Over two million burn injuries are thought to occur each year in India (population 500 million), but this may be a substantial underestimate. Mortality in the developing world is much higher than in the developed world. For example, Nepal has approximately 1700 burn deaths a year for a population of 20 million, giving a death rate 17 times that of the UK. Most burns are due to flame injuries. Burns due to scalds are the second most common.The most infrequent burns are those caused by electrocution and chemical injuries. The type of burns suffered is related to the type of patient injured. It is therefore useful to break down burn aetiology by patient groups as this reveals the varying causes of injury. In most groups, there is a male predominance. The only exception is in elderly people, among whom more women are injured because of the preponderance of women in that population.Children aged up to 4 years comprise 20% of all patients with burn injuries. Most injuries (70%) are scalds due to children spilling hot liquids or being exposed to hot bathing water. These mechanisms can lead to large area burns. Because of changes in the design and material of night clothing, flame burns are less common than they were. Boys are more likely to be injured, a reflection of the behavioural differences between boys and girls. Ten percent of burns happen to children between the ages of 5 and 14. Teenagers are often injured from illicit activities involving accelerants, such as petrol, or electrocution.Most burns (> 60%) occur in patients’ aged 15-64. These are mainly due to flame burns, and up to a third are due to work related incidents. Some 10% of burns occur in people aged over 65. Various effects of ageing (such as immobility, slowed reactions, and decreased dexterity) mean elderly people are at risk from scalds, contact burns, and flame burns. Burn victims’ health is often compromised by some other factor, such as alcoholism, epilepsy, or long-term psychiatric or medical illness. All such problems need to be addressed when managing patients in order to speed recovery and prevent repetition of injury.

Shift work: what cost?

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).

Observations from a student exchange programme: UK and Sweden prehospital care

As part of the prehospital unscheduled and emergency care course at the University of Worcester, the authors were selected to take part in an exchange programme arranged between the University of Worcester, England and Halmstad University in Sweden. The exchange took place in January 2011 and lasted two weeks, during which time the authors were based with the Halland Regional Ambulance Service. Halland is a county on the west coast of Sweden, directly south of Gothenburg. It has an area of approximately 2100 square miles or around the same size as Devon. The total population, however, is just over 299 000 (Statistics Sweden, 2010), making the total population density slightly less than half that of Devon. The county is divided into six regions, each centred on a town of the same name (Statistics Sweden, 2010) and in which the ambulance stations are located. During the programme, the authors were based in the town of Varberg and attended incidents as supernumerary crew members. They were also permitted to treat patients, provided this did not exceed levels of competency, complied with local protocols, and was agreed by the responsible clinician. During the visit, observations were made regarding all aspects of ambulance operations. The majority of practice was found to be very similar to the UK, however, a number of important differences were found and these are analysed and contrasted with UK practice. The authors would like to thank the staff and management of the Halland ambulance service for their hospitality, warm welcome and for their generosity in passing on their knowledge. They would also like to thank the staff of the universities of Worcester and Halmstad, without whom the exchange would not have taken place.

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