Volume 4 Issue 6

Reducing the risk of postpartum haemorrhage in paramedic practice

Primary postpartum haemorrhage is the most common form of obstetric haemorrhage. Poor recognition and treatment of this condition has been linked to cases of mortality in recent years. Greater choice over birth settings for mothers and a national shortage of midwives are likely to result in more frequent exposure to maternity cases for paramedics in future years. Active management of the third stage of labour reduces the risks of primary postpartum haemorrhage and shortens the length of the third stage of labour. UK ambulance service guidelines are currently based upon physiological management of the third stage of labour, so in the absence of a midwife, paramedics cannot actively manage the third stage. Paramedic training has moved to higher education university programmes in recent years and undergraduate paramedic students receive additional training about the management of obstetric emergencies. This article discusses current clinical practice and recommends that paramedics adopt active management of the third stage of labour, in order to reduce the risk of primary postpartum haemorrhage. In addition, the author asks whether current paramedic practice is effective in treating primary postpartum haemorrhage within the pre-hospital setting, when a midwife is not present at the scene.

Lactate measurement in pre-hospital care: a review of the literature

Background:Lactate has been identified as a useful marker of shock. Lactate can be measured in the pre-hospital environment rapidly and accurately.Method:A comprehensive literature search was conducted using a targeted search strategy. Additional literature was located through reference list searching and prior awareness by the authors. This identified a number of papers which were appraised for relevance. This appraisal identified 29 papers which were included in the review.Conclusion:Lactate has been shown to be measurable in the pre-hospital environment and to be prognostic of mortality. Lactate measurement needs to be linked to specific treatment algorithms with improved outcomes for patients in order to justify inclusion in pre-hospital practice.

Occupational stress, paramedic informal coping strategies: a review of the literature

Frontline ambulance staff have high rates of sickness absence; far greater than any other National Health Service worker. Reports suggest that many of these instances are attributable to stress, anxiety and depression. Indeed, studies have observed that occupational stress is significant within the Ambulance Service. While academics frequently associate the causative factor as being related to traumatic incident exposure, there is a small, growing trend of researchers who have found that daily hassles are equally, if not a greater source of stress. Many of the studies investigating the psychological aftermath of a stressful occupational experience focus on formal coping strategies such as critical incident debriefing and trauma risk incident management. However, it has been found that paramedics often prefer to manage stressful feelings informally within their own occupational culture. This literature review explored these informal coping strategies, and found that cognitive mechanisms and peer support were the most used methods. Research in this domain is currently very limited; therefore, this review identifies several areas for further study.

Life Connections 2012

Paramedic prescribingAndy Collen, Paramedic Prescribing Lead of the College of Paramedics, spoke with general optimism about the attainment of future powers for paramedics to prescribe drugs to patients in the pre-hospital setting, though he advocated the employment of a more honed and specific strategy in order to attain it in practical terms.‘We must have a voice,’ he said, calling on the paramedic profession to ‘generate the clarity’ of their message when lobbying for powers to prescribe.Collen indicated that the transition to prescribing powers would be far more attainable and immediate if paramedics could set out a clear proposal in which the specifics of paramedic prescribing could be seen, such as the list of drugs to be included in paramedic prescribing, proposed qualification process to be enforced, and a time frame in which the proposals could be introduced into normative practice.Advocating a grass-roots approach on the matter, Collen stated that paramedics needed to ‘create a case for ourselves locally’ if paramedic prescribing was to become a reality in the near future.He urged paramedics to take a local approach to lobbying for prescribing powers, as well as targeting central government and the Department of Health to instigate the change.‘It's something that we have been fighting for some time’ he said, adding: ‘we are confident that we are moving to the next level’ namely, public consultation.Indeed, the profession will require the support of the general public as well as strong allies in the DH, parliament and Whitehall if any changes are to be made. Andy Newton, chair of the College of Paramedics, referenced the difficulties that paramedics could have in getting their message heard by politicians and voters, as well as the bureaucracy and political agenda to negotiate within what he referred to as the ‘many headed hydra called the Department of Health’.However, the College remained confident in the support from the general public, signifying that, although the paramedic profession can often be under-appreciated and misrepresented to them (in no small part because of a somewhat sensationalist media agenda on the subject), that, despite such hindrances, the profession has a prominent and immovable public respect that paramedics should not ignore when trying to influence change, ‘We already have such good public confidence,’ joked Collen ‘they call us all the time.’Sir Keith Porter, honorary professor of clinical traumatology at the University of Birmingham.Picture: Arun MarshParamedic leaders should bear in mind when finding their voice flexing their political muscles.

Urgent treatment of acute stroke: work in progress

Developing new treatments for stroke is an NHS research priority, and despite improvements made in specialist care provision following the publication of the National Stroke Strategy (DH, 2007), it remains both a disabling condition and a high health and social care burden. To facilitate rapid growth in knowledge, the UK Stroke Research Network is funded by the National Institute for Health Research (NIHR) and includes eight Hyperacute Stroke Research Centres and the infrastructure needed to support trials of emergency treatments such as those described below.

Paramedic decision-making–how is it done?

In 2005, The Bradley Report called for a move to higher education and the ambulance services saw the advent of the degree and diploma paramedic. Historically, ambulance services have used the Institute of Healthcare Development (IHCD) vocational educational programmes to develop and educate their own staff, using a skills escalator approach to paramedic status, rather than supporting their development in the Higher Education (HE) environment. More recently the services have started to use graduate paramedics educated and developed to the requirements of the HPC Standards of Proficiency (2007) in universities across the UK. This article considers the decision-making process of the graduate paramedics against that of the IHCD paramedic, and involves the hyperthetico-dedutive and intiuitive approaches used by paramedics to inform their decisions, and the treatment that they provide. In addition, it involves the initial work of two research ethics approved empirical studies, currently in progress, that form part of the the authors doctoral studies involving sample groups of graduates from an IHCD programme, and a foundation degree and BSc Honours degree at two UK universities.

CURE (Community Urgent Response Environment): portable work stations

The Community Urgent Response Environment (CURE) concept is a new technology system developed to support the work of Emergency Care Practitioners with portable pods and packs and mobile treatment units. This paper describes a project to transfer research outputs from an academic setting into practice through collaboration between two universities, two manufacturers and the United Kingdom (UK) National Health Service. An iterative prototyping process was used with 12 Emergency Care Practitioners evaluating prototypes in two user trials by carrying out four clinical scenarios in three simulated environments (confined domestic, less confined public space, and vehicle). Data were collected with video recording, field notes and post-trial debriefing interviews and analysed thematically. The final prototypes (pod/pack 1.3 and vehicle 1.6) have potential to support a new way of working in the provision of non-critical, pre-hospital care. The user trials also identified possible efficiencies through the use of CURE by providing support for a wider range of assessment, diagnosis and treatment.

Music and CPR: has Vinnie got it right?

WoollardM, PoposkiJ, McWhinnieB (2012) Achy breaky makey wakey heart? A randomised crossover trial of musical prompts. Emerg Med J29(4): 290–4. doi:10.1136/emermed-2011-200187

Continuing Professional Development: Thermal injuries (burns) in the pre-hospital setting

OverviewThis Continuing Professional Development (CPD) module will focus on the aetiology, identification and pre-hospital recognition and management of both adult and paediatric patients presenting with burn injuries. Burns can range from simple, self-limiting injuries that may be managed at home to a life-threatening injury that can lead to life-long disability and pain. Thermal injuries, or burns, probably have the greatest potential to cause the most systemic damage of all damage to skin. This tissue damage and cell death can result from intense heat, electricity, ultra violet (UV) radiation (such as sunburn) or chemical (such as caused by acids). In addition, burns may present in association with other injuries, so may not be assessed initially as the main injury. The severity of the damage caused by burns is often determined by the underlying organ damage.Learning OutcomesAfter completing this module you will:• Provide a brief review of the anatomy, physiology and functions of the skin• Describe the epidemiology, aetiology and approaches to the assessment of thermal injuries• Outline the first line management of thermal injuries• Suggest a easy-to use guideline for the management of burns in the pre-hospital setting

The ambulance service: the past, present and future

Time to get serious about ‘transforming ambulance services’ and really taking health care to patientsThe second challenge has been recognised for some time and was the subject of a detailed study Life in the Fast Lane, published by the Audit Commission in 1998 (Audit Commission, 1998) and considered again in 2011 in the National Audit Offce's report Transforming Ambulance Services I (NAO, 2011). Both reports skirted the issues of what real transformation in terms of the concept of operation might look like, but they did make useful observations and suggestions. In some respects these findings paralleled an earlier American Ambulance Report authored by the legendary Jack Stout who set out the primary goals that all emergency ambulance services should strive for; response time reliability, clinical sophistication, customer satisfaction and economic efficiency (Stout, 1983; 2004).These principles would fall into what are often termed ‘lean’ management methods and derived from quality management theory (Ryan, 2002). Stout also provided a useful metric, ‘termed unit hour utilisation’, to determine the productivity of an ambulance service by simply dividing the number of patients transported, or patient contacts, by the availability of ambulance time expressed in hours (Stout, 1983). For example, an ambulance service producing four unit hours of ambulance time and moving one patient would be operating at a 0.25 level of utilisation/productivity. This simple system has yet to be widely adopted in the UK, although discussion regarding a standardised approach is now underway. However, a continuing quest for higher productivity and stronger response time performance will no longer be sufficient as the following points will illustrate.The diagram below (Figure 1) brings together the external forces and some counter-measures with the red line showing rising demand and the lower blue line refecting falling income. Bringing down the unit cost is therefore imperative through enhanced utilisation, (or improved productivity), shown in green. To address the current pressures caused by increasing low-acuity demand, the key strategic priority should be to recoup and reinvest a proportion of the funds derived from enhanced utilisation to develop new clinical capabilities, (income), while ensuring that conventional indicators of quality (activity), such as response time performance, patient safety, clinical governance and patient experience continually improve as well.Figure 1.‘Spinning plates,’ 5 priorities for Ambulance Service Leaders, dealing with reduced income and increased activity at a lower unit cost while maintaining clinical quality and introducing new clinical capabilities.In this context improved capabilities revolve around developing specialist paramedic practice to address patient needs in both primary and critical care as the primary means of making the system generate the productivity gains. Delivery of primary care would include the assessment and treatment of a wide range of clinical presentations such as wound management, near patient testing and a wide range of referral options. Critical Care would include patient assessment, the provision of a broader range of therapeutics, advanced airway management, cardiovascular support, and the introduction of new technologies such as ultrasound, to help guide treatment in the field, ideally with the provision of on-line support from more senior paramedics and medical staff where necessary.The conundrum for the ambulance services and the paramedic profession is how to continue to add value and improve quality in a financially constrained environment. Some might be tempted to reduce (or at least not to improve) clinical quality, or to settle for more traditional transport oriented concepts of operation. This approach fails to grasp the opportunities associated with the use of more highly qualified paramedics and specialist paramedic practice, which would unlock the prospect of delivering mobile health care and adopting a gate-keeping function. Such approaches are predicated on the basis that unnecessary transportation to hospital can have adverse financial consequences for the rest of the health economy and only works if the issue is considered at the ‘whole healthcare system’ level, rather than considering the ambulance service to be one of many silos.If the choice is to continue with the predominant transport model, it is likely that private ambulance providers will be able to accomplish this more cheaply than many existing NHS ambulance services, but at the expense of transmitting larger numbers of patients into overburdened emergency departments. An opportunity to develop an integrated, system-wide approach could be lost resulting in increased cost and clinical risk as large numbers of patients are unnecessarily taken to hospital, ramping up downstream costs.Clinical care came under the microscope in 2000, with an Ambulance Service Association sponsored paper outlining (Nicholl et al, 2000). This may have helped influence the 2001 Department of Health's glimmering of interest in widening the ambulance service's role in reforming emergency care (DH, 2001), spawning a veritable industry of regrettably seemingly alltoo-forgettable ‘reforming’ publications. These went largely unchallenged from the ambulance sector, but for the occasional cautionary note from commentators, including Judge, who questioned the scale and wisdom of the proposed changes in respect of the ambulance service (Judge, 2004). By 2005, Peter Bradley's Taking Health Care to the Patient (THCTTP) condensed these policy ideas and other initiatives into a document focused specifically on the ambulance service role. The report made the correct diagnosis but the implementation of the necessary changes was arguably poorly executed. The second report, (THCTTP2), was the closest the NHS ambulance services have had to current policy, but while some of the recommendations have seen some action, the failure to build them into the NHS operating framework and the lack of clear doctrine has attenuated the report's effect.

Anaesthesia trauma and critical care course

RTACC course variationsRTACC–A: Paramedics working in pre-hospital careRTACC–B: Those involved with bombs, blasts and ballisticsRTACC–C: Construction workersRTACC–E: Those involved with equestrian or contact sportRTACC–F: FirefightersRTACC–P: Police officersRTACC–CP: Close-protection officersRTACC–SSS: Intelligence and security servicesRTACC–USAR: Urban search and rescue personnel

Keep up to date with Journal of Paramedic Practice!

Sign up to Journal of Paramedic Practice’s regular newsletters and keep up-to-date with the very latest clinical research and CPD we publish each month.