Continuing Professional Development: Diagnosis and management of minor head injury in the UK

OverviewHead injury accounts for a large amount of emergency services work in the UK. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. These studies included a review of current practice in the management of minor head injured patients (GCS 13–15) by way of a survey of UK emergency departments. We also performed a systematic review of the head injury literature to identify the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Paediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. This review helped to identify the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department.Learning OutcomesAfter completing this module you will:• Have an understanding of the significant clinical characteristics following head injury• Understand potential pathological problems following head injury• Be able to assess the relevant clinical features of all patients following head injury• Be familiar with key clinical decision rules for patients with head injury• Be able to provide the appropriate pre-hospital management for all head injured patients.

Children's congenital cardiac services

The future of the UK's Children's Congenital Cardiac Services has been in question since the Bristol Royal Infrmary Inquiry (Kennedy, 2001) and the subsequent Paediatric and Congenital Cardiac Services Review (DH, 2003). In 2009, the ‘Safe and Sustainable Children's Cardiac Services’ national stakeholder engagement event, concluded that the configuration of children's heart surgery services in England were not sustainable (NHS Specialised Commissioning Group (NSCG), 2009: 5). The NSCG proposed a new model of provision for children's heart surgery in England and Wales with fewer, larger specialist surgical centres (NSCG, 2010). Ultimately, it is anticipated, that this measure will improve the outcomes for children and young people but one of the consequences of this proposal will be longer transfer distances for ambulance crews tasked with managing very sick children with congenital cardiac disease.

Pre-hospital management of smoke inhalation: are we missing something?

The recently proposed European guidelines for the management of smoke inhalation and cyanide poisoning—presented at the 6th Mediterranean Emergency Medicine Congress (MEMC) in Kos, Greece, 2011—contrast greatly with usual practice in the UK, where we tend to focus on the management of carbon monoxide (CO) and do not routinely treat or suspect cyanide poisoning. Indeed, a recent survey conducted at the College of Emergency Medicine (CEM) (Hospital Pharmacy Europe, 2011) annual conference revealed that 84% of UK emergency medicine physicians would not routinely consider treating cyanide poisoning empirically in smoke inhalation victims—a key recommendation of the new algorithms presented at the recent MEMC in Kos.

How much longer?

Irecently presented at the College of Paramedic Conference hosted in University of Western England in December 2011. I was approached afterwards by a couple of students from another UK academic institution who explained that they had not been taught the (CABCDE) Structured Approach method of patient assessment (Halliwell et al, 2011). The students themselves seemed very able and willing to understand and embrace the simple concept that unless haemorrhage is controlled there is no point in securing Airway or Breathing. This concept is not new, being proposed by Hodgetts et al in 2006, and adapted in my own Trust in 2007.

Headaches: recognizing a serious cause

Headache is one of the most frequent medical complaints with an estimated 95% of the general population experiencing it at some stage in their lifetime, and 90% of people experiencing it per year (Latinovic, 2006). Although serious causes of headache are fairly uncommon, their recognition is important as the vast majority can be treated. They usually present in the acute setting to accident and emergency and acute assessment units. A considerable proportion of acute headaches are benign and patients seek medical attention because of an underlying concern of brain tumour or haemorrhage. Symptoms that indicate a high risk of a serious underlying pathology, or ‘red flags’, may enable clinicians to differentiate those in need of urgent medical attention.

Organ donation after death in the community or emergency department

The transplantation of human organs is entirely dependent upon organ donation. With increasing numbers of patients on transplant waiting lists, there is evergrowing pressure to recruit organ donors. Modern society, however, presents many challenges to organ donation. Ethical, cultural, and legal issues strongly influence donation, while an ageing population with a falling rate of traumatic death provides fewer donors (NHS Blood and Transplant, 2011). In order to meet these demands, surgeons are developing techniques to obtain organs from donors who would have not previously been suitable for donation; one such technique seeks to obtain organs from patients who die in the pre-hospital environment. This article presents an overview of the current process of deceased organ donation and a detailed review of the potential of organ donation from patients who die outside hospital or in the emergency department. The UK NHS paramedic staff would play a key role in such a system.

Paramedic clinical leadership

Paramedic clinical leadership within the North West regionWhat is clinical leadership?The role of the supervisor and team leader is well documented to be integral in ensuring a team can deliver quality in whatever it does (Glenapp, 2008; Parsons, 2009). In the context of ambulance service out-of-hospital care, the importance of this supervisory/leadership role is no different. For the correct quality of care to be delivered within the unplanned and complicated environment of unscheduled care, it could be argued that the importance of strong leadership, supervision, and coordination is greater than many other more conventional healthcare environments. It is with this challenge in mind that this article has been formulated, to offer an element of understanding to a situation now prevalent within the UK's NHS ambulance services; clinical leadership, and more specifically that of front-line clinical leadership and supervision.In ‘Taking Healthcare to the Patient’ (Department of Health (DH), 2005) a number of recommendations were made, but specifically the document highlighted the need for transformational leadership within ambulance trusts. Clinical leadership is regarded as a process by which an individual infuences others to set standards, accomplish objectives and directs the organization to greater consistency. Leaders are generally identified by a number of key characteristics; knowledge, skills, and attributes. Therefore clinical leadership that covers a range of areas will encourage clinicians to inform strategy, improve and drive quality, service design, and resource utilization. This work will prove critical to boards, executives, and clinical teams to ensure their organizations are developed and shaped appropriately. Clinical leadership in the ambulance services is designed to provide a framework that will support ambulance trusts as they move forward in the 21st century. Although good clinical leadership is vital for ‘today’, ambulance trusts must also ensure they look forward to the medium–longer term with reference to succession planning and talent management.The report also identified a potentially more pressing need for changes to the workforce at this level. In recent years call volume and subsequent attendance has shown a 4–5% increase year on year (NHS Information Centre, June 2010). Conversely, the number of life threatening calls requiring an immediate response have not seen this rise and remained static at around 10% of total call volume. It is increased demand for urgent primary and social care that now makes up the bulk of the calls received by ambulance services. Traditional ambulance training has focused on the need to manage life threatening emergencies, leaving many situations where paramedical staff can offer no more than transport to the emergency department. To safely address this ever increasing demand, ambulance services also need to invest in education and not just training, a view shared by Lendrum et al (2000). The College of Paramedics (2008) suggest that a practitioner working at this level, making decisions to refer to other sources and not transport, should be educated to a minimum of HE level 6, a view shared by the Government's own ‘Skills for Health Career Framework (2010)’.What has NWAS been developing in terms of its clinical leadership?Following the merger and subsequent re-organization of the North West Ambulance Service's (NWAS) general management structures some years ago, there has been development of clinical roles and responsibilities and implementation of a robust model of clinical leadership and supervision across the organization. In ‘Taking Healthcare to the Patient,’ Peter Bradley discussed at length the need to establish a tiered system of clinical leadership throughout the ambulance services and to also create an aspirational career pathway within the paramedic profession. This is further emphasized in many other related policy documents both locally and nationally.Clinical leadership within NWAS is leading to a network of clinical leaders across the organization, educated over and above that of registrant level (academic levels 6, 7 and 8), providing a tiered system of clinical leadership to the practitioners working within the teams they clinically lead. In conjunction with this clinical leadership, all the extended role paramedics will practice at a level above that of base registrant with the ability to offer a greater degree of assessment, diagnosis, treatment and referral capabilities than that of current paramedics. These practitioners will have the following titles: ‘…competent clinicians have been forced to develop their careers away from patient care…’Senior Paramedics–educated to bachelors level (academic level 6). Responsible for the clinical leadership of a team of paramedics and emergency medical technicians;Advanced Paramedic– possessing masters level education (academic level 7). Responsible for clinically leading a team of senior/ specialist paramedics; and,Consultant Paramedic– educated to at least masters level, aspiring to PhD (academic level 8). Responsible for clinically leading a team of advanced paramedics and the most senior paramedics within the organization.The NWAS’ current development processes have also led to an increased clinical presence within the emergency control centres, with the creation of a specialist paramedic role to manage low acuity calls.

Helicopter Crew Course – a paramedic's perspective

BackgroundAir ambulance operations are becoming increasingly common in the UK, often using the doctor-paramedic model.Paramedics and doctors working as fight crew often look after seriously unwell or injured patients and may have to perform complex interventions, including emergency anaesthesia, in the pre-hospital environment.Scene assessment and safety, crew resource management, clinical interventions and on-scene decision making are key skills required by air ambulance crew members, and training is needed in these areas. This is often undertaken locally but there have been calls for specialist, regional training.

Emergency Care Practitioners' clinical decision-making: how accurate is it?

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).

Frequent Emergency Medical System users: a regular problem…

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).

Implantable cardioverterdefibrillators: a case report

Implantable cardioverter-defibrillators (ICDs) are devices placed into patients with a variety of cardiac conditions to prevent sudden death from dysrhythmias. On occasion, these devices can malfunction, presenting a challenge to both prehospital and emergency department providers. In this article, we present a case in which pre-hospital providers encountered a patient whose ICD was firing continuously in a patient with sustained ventricular tachycardia. We then discuss the prehospital management of patients whose ICDs have fired. Scenarios discussed include management of the single appropriate ICD shock, management of multiple appropriate ICD shocks, and management of inappropriate ICD shocks.

Cultural challenges in getting it right for every child: a reflective account

Paramedics working within health care services are faced with difficult decisions almost every day. They are required to work within organizational and professional boundaries and in the best interests of their patients at all times. In cases involving children it is especially important to ensure the child is properly empowered and included in the decision-making process. Sometimes these requirements are difficult to assess and paramedics will draw on professional and personal experience to assist them in deciding how best to ensure appropriate empowerment and that patient care has taken place. When dealing with patients from cultural backgrounds they are unfamiliar with, language barriers and cultural differences may make it difficult for paramedics to assess whether their patient has been properly empowered and included.

Paramedic administration of glycoprotein inhibitors for ST elevation myocardial infarction

Until recently, paramedics were routinely delivering out-of-hospital thrombolysis for ST segment elevation myocardial infarction (STEMI). Now that primary percutaneous coronary intervention (PPCI) is the favoured reperfusion strategy, STEMI patients are by-passing the local emergency department and taken directly to the catheterisation laboratory via ambulance. STEMI patients within a rural setting are facing the prospect of extended transfer times for reperfusion of an already ischaemic myocardium, a potentially perilous strategy. Empirical research conducted outside the UK has identified that the pre-hospital administration of a glycoprotein inhibitor improves clinical outcome for STEMI patients. Glycoprotein naturally helps to build the fibrin mesh essential within the clotting process. Inhibition of this process by glycoprotein inhibitors IIb/IIIa (GPI IIb/IIIa) prevents aggregation at receptor sites on platelets. Original research supports the notion that GPI IIb/IIIa involvement improves patient clinical outcome for STEMI in the out-of-hospital phase. Paramedics are typically the first contact for the STEMI patient and it is tangible that paramedics have the appropriate skill and knowledge to diagnose the out-of-hospital STEMI. With this in mind, it is the purpose of this article to discuss the use of pre-hospital GPI IIb/IIIa administration and to argue that this intervention should be administered by paramedic personnel.

Transient asystole: aetiology and treatment by paramedics

Transient asystole is seen relatively rarely by paramedics. It is often mistaken for syncope or seizures, which means that paramedics may miss an opportunity to help with a swift diagnosis and therefore help reduce morbidity and mortality (Deakin et al, 2010). This article explores the aetiology of transient asystole along with its pathophysiology and analyses how some prescription drugs may contribute to the onset of transient asystole. It will look at treatment options that are available to paramedics including atropine, and establish if this is the optimal treatment for the condition.