Continuing Professional Development: Management of an isolated neck-of-femur fracture in the elderly patient

OverviewIn the UK, femoral neck fractures affect up to 75 000 elderly people per year, with up to a third of these patients dying within twelve months. While there is a paucity of research specific to the pre-hospital field, current evidence demonstrates that optimal treatments include appropriate and adequate analgesia, fluid management and correct immobilisation of the injured leg. Analgesia should be considered immediately in a stepwise approach, through the variety of options open to paramedics and should be progressive to the patients needs. Fluid management should be considered to stabilise the patient and prepare them for surgery. Transfer to the ambulance should be done in a safe manner, ensuring the patient is immobilised and remains pain free. This pre-hospital management of the patient with a femoral neck fracture ensures they receive appropriate management before initiation onto a care pathway in hospital.Learning OutcomesAfter completing this module you will be able to:• Identify there are different types of femoral neck fracture.• Recognise the importance of completing a full set of observations and taking a full history, including a pain assessment.• Demonstrate the pharmacology of analgesia appropriate for use in elderly patients in prehospital care.• Explain the importance of non-analgesic treatment in the management of femoral neck fractures, such as IV fluid therapy and immobilisation of the injured leg.

The ambulance service: the past, present and future

Education: the key enabler at both pre and post-registrationThe move from training to education for paramedics is one example of the failure to reform ambulance services to meet the changing nature of demand. Education of the workforce is a prerequisite for lasting change and the core enabler for changing clinical behaviour, though it has proved to be slower than some might have expected. This is despite further adverse media attention from BBC’s Panorama (BBC, 2000) and other programmes that have highlighted defciencies in ambulance services’ operations and academic recognition that conventional ambulance paramedic training does not match the demand actually dealt with by paramedics (Lendraum et al, 2000).Disappointingly, as Armitage notes (Armitage, 2012), the process of professionalising paramedic education and training is far from complete, despite the efforts of many paramedics themselves and the efforts of the College of Paramedics, whose ‘prime directive’ is to develop the paramedic profession and raise the profle of the work paramedics. The role of a strong professional body for paramedics is indeed a key ingredient to success. The College of Paramedics is the primary advocate for paramedics in the UK and in a real sense the guardian of the uniqueness of paramedic practice. The value of a sound professional body has not been lost on other professions and interestingly Peter Neyroud, the former chief of the National Police Improvement Agency has argued for the creation of such a body for police offcers, in a report requested by the Home Secretary. Many of his recommendations for the Police, particularly in respect of the College’s leadership role and its’ work in relation to education and developing the paramedic profession are routine activities for the College.Even the commitment to move to a universal minimum of a foundation degree for new entrants to the paramedic profession has yet to be implemented, although is now scheduled to happen in 2013, subject to Health Professions Council approval. Quite why the recommendations of the former Ambulance Service Association and Joint Royal Colleges Ambulance Liaison Committee JRCALC, 2000), chaired by Professor Chamberlain, which recommended embracing an educational approach in 2000 were not followed is, uncertain, but represents another example of an opportunity lost or at least not seized in a timely manner. Widespread differences in education funding remain around the country, with an almost unfathomable and unjustifable range of qualifcations, together with inconsistencies in respect to commissioning and access to the NHS bursary scheme.This position stands in marked contrast to the situation with all other allied health professions (AHPs) despite positive research fndings (Woollard, 2006; Mason et al, 2007) and publications (DH, 2003; 2008) both of which identifed the potential of paramedics. Despite this attention, less than 1 000 operational paramedics have received the additional education, training and skills needed to function at the specialist paramedic level, with only a fraction of these accredited via the formal examination, designed and developed by the profession with support and quality assurance from colleagues at the Royal College of General Practitioners (RCGP), the College of Paramedics and St George’s Hospital, University of London.Confusion over title, career structure, education and credentialing are now being resolved, however, most ambulance services do not yet have suffcient adequately prepared staff who can effect the necessary change to meet the diverse needs of patients. Nor does a coherent doctrine to drive the necessary philosophical and organisational change in thinking, without which meaning service redesign cannot take place. It seems that the old unconscious dogma continues to hold sway and acts as an invisible, hindering factor.Table 1.The changing concepts of operations for ambulance serices in the UK since 19481948-1960 Dominant Concept of Operation/ Priorities1970-1980 Dominant Concept of Operation/ Priorities1990-2000 Dominant Concept of Operation/ Priorities2000-2010 Dominant Concept of Operation/Priorities2010-2020? Dominant Concept of Operation/ PrioritiesLocal Authority provided transport.Transport (ambulance service).Transport/emergency Ambulance/EMS modelTransport/EMS model, ambulance aid at technician and paramedic-level responsibilities.Some schemes extending the paramedic role (e.g. ‘community paramedics’).Clinical decision making and triage. Needs-led transport to various facilities. Expansion of mobile healthcare. Progressive integration to wider health economy. Broader range of treatment options.Treatment at the first-aid levelTreatment including gradual development of Advanced Life Support, ALSTreatment including development of Advanced Life Support, ALS, with some expansion in the scope of paramedic practiceTreatment including paramedic advanced life support with development of paramedic practice. Extension of role with patient assessment/minor illness/injury management. Few schemes prosper.Regulated paramedics operating at higher education level. Specialist practice in primary care. Critical care paramedic introduced, providing ‘enhanced care teams’ for seriously ill/injured. Paramedic control practitioners. Models of care include ‘hear and treat’/‘see and treat’.Civil defence roleAssessment and triage (usually mass casualty incidents)Assessment and triage [normally limited to mass casualty incidents]Recognition that expansion of scope of practice desirable beyond critical care; variable experimental schemesIncorporation of 111 serviceRenewed emphasis upon major incident, anti-terrorist and rescue/‘civil defence’ role [emergence of HART capabilityNeeds-led transport. Full implementation of cardiac, stroke/TIA trauma, vascular and other networks. Increased reliance on care during transportParamedics become registered Allied Health Professionals, leading to higher educational standards and an opportunity to extend practice to meet patient needs.Emphasis on AS ‘rescue’ role. Paramedic rescue specialist. Promotion of medical sub-speciality in pre-hospital care focused on ‘hyper’ acute patient population, (0.15%-0.5% of 999 calls).The ambulance services and the paramedic profession can make a signifcant contribution in providing a more appropriate service to meet the population’s demand. But they can only achieve this through the development of the workforce, which will increasingly become based on the development of paramedics.Paramedics have been subject to regulation since 2000 and are an example of a ‘disruptive technology (Cheristensen, 2009). Essentially, this means that paramedics, like other AHPs, and in common with some well known technological developments, such as the digital camera or mobile phone, become more effective, more able and yet relatively cheaper than available alternatives over time.Well-trained fexible paramedics are, therefore, both a ‘game changer’ and a bargain for any health economy and a key ingredient of any efforts to produce high quality mobile health care.Somewhat paradoxically, the establishment of a new medical sub-speciality in pre-hospital care to address the relatively small number of patients presenting with major injuries seems surprising and options appraisals detailing what advantage such services may bring are awaited. It may yet be possible to determine an economic arrangement that fuses the roles of paramedics and medical staff from this new sub-specialty and the effect on those physicians who give of their own time to provide this role, many of whom will be holding the purse strings in the new Clinical Commissioning Groups, is equally uncertain. Perhaps charitably funded Helicopter Emergency Medical Services, being a potential model, but as Rawlins notes ‘innovation [if] cost ineffective cannot—so far as the NHS is concerned—be innovation.’ (Rawlins, 2012)This lack of consensus has been noted by Mackenzie (2009) asking how to serve the small number of critically ill patients through the most effective combination of paramedics and doctors. Discussions continue as to how a relevant, cost effective and harmonious set of arrangement might best be achieved. Equally, the opportunities associated with the wider use of paramedics, who are already in funded positions operating as a ‘disruptive’ technology have undoubtedly yet to be fully exploited and it will be essential to complete the professionalising process, matching the educational standards of other AHPs, implementing the AHP career structure and fully embracing specialist practice in order to deploy the full benefts.

Marfan syndrome

Case studyIt is early afternoon and you have just arrived at a private residence for a 19 year-old male complaining of back pain. Your partner begins taking vital signs as you commence your assessment of the patient. The tall, slender man tells you that he called in sick to work today because he woke up with bad back pain that he had not experienced before, stating that it had become steadily worse throughout the day and that he would have taken to drive himself to the doctor but his car broke down last week.As your partner relays vital signs to you of blood pressure 148/102, heart rate 112, respiratory rate of 24, room air oxygen saturation of 99%, the patient says he has never had this pain before and can’t recall or identify any traumatic cause for the event. The patient hasn’t seen a doctor in a while, but has no history of medical problems, takes no medications and has no allergies.Your exam reveals an anxious, alert and oriented patient, with slightly pale, warm skin. His pupils are PERRL (pupils equal, round, reactive to light) but you do notice a strange appearance of his eyes, they appear disproportionately large and the pupils are asymmetrical, yet reactive. The trachea is midline, no jugular venous distention is present, and lung sounds are clear and equal. The abdomen is soft and non-tender, and you notice nothing abnormal on examination of the back (no tenderness, discolouration or signs of trauma).The patient requests transport to an emergency department for evaluation, and as you are loading him into the ambulance, you endeavour to form a differential diagnosis. Although you are comfortable with the stability of the patient, you continue to ascertain what is causing his symptoms as questioning related to urogenitary causes lead nowhere, nor does a gastrointestinal etiology seem to ft the history of his present illness.You complete a short transport to the ED, and provide supportive care only. No change occurs en route, although the patient does maintain a slight level of anxiety throughout transport and you are struck by the genuine sense of concern the patient is eliciting.On returning to the same ED later in the day and after noticing that the patient is no longer in the room you dropped him off in, you follow up with the attending physician to see what the discharging diagnosis was. You are shocked when the attending physician informs you that he was rushed into surgery an hour ago after an ascending aortic dissection was diagnosed. It turns out he has classic signs of a disease known as Marfan syndrome and therefore was a high risk candidate for aortic catastrophe.

Empathy: have we got it and do we need it?

Increasingly research is exploring attributes other than clinical competence that paramedics may need in order to effectively manage the healthcare of their patients. One such quality is that of empathy. Empathy is defined in different ways, but in healthcare it is frequently associated with the ability of an individual practitioner to appreciate and contextualise the patient’s experience, feelings and circumstances while retaining a professional objectivity. There is little previous work on paramedic empathy so the aim of this cross-sectional study was to assess the extent of empathy in paramedic students from seven different universities in Australia.

Chest compressions: they really are important.

In 2005 and again in 2010, the International Liaison Committee on Resuscitation (ILCOR) and the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were changed.

Paramedics' ‘end-of-life’ decision making in palliative emergencies

Background:Paramedics in Germany routinely treat palliative care patients at the end-of-life (EoL). For this, they play a legally significant role in EoL decision making in the outpatient emergency setting. This study was undertaken to determine paramedics’ understanding of their role in withholding or withdrawing resuscitation/EoL-treatment of palliative care patients when an advance directive is present.Methods:Using a self-administered survey, participants/paramedics were asked about (1) ‘their occupational experience’ (less/more than 10 years, (2) ‘emergency responses’ (less/more than 100/month), (3) ‘their experiences in palliative emergencies’ (less/more than 10 palliative emergencies/year), (4) ‘palliative emergency sheets concerning end-of-life decisions’, and (5) ‘their treatment options during resuscitation’. Participants were paramedics from two cities in Germany.Results:Overall, 728 questionnaires were returned (response rate: 81%). Seventy-three percent of respondents were older than 20 years, 98.5% were male. Most paramedics dealt with palliative emergencies and terminally ill patients during their work (71%). Work experience and training in palliative care shows statistically significant differences concerning our dependent variables.Conclusions:Our results underline the necessity for more training in EoL. Paramedics stated that improved guidelines regarding EoL decisions/advance directives and the possibility to withdrawing resuscitation for appropriative cases are necessary. The treatment of terminally ill patients by paramedics may present an ethical problem: if paramedics honour patients' wishes, they will violate juridical regulations. In future, a change concerning current regulations seems to be necessary as well.

Management of an isolated neck-of-femur fracture in an elderly patient

Femoral neck fractures affect up to 75 000 elderly people per year, with up to a third of these patients dying within twelve months. While there is a paucity of research specific to the pre-hospital field, current evidence demonstrates that optimal treatments include appropriate and adequate analgesia, fluid management and correct immobilisation of the injured leg. Analgesia should be considered in a step-wise approach and should be progressive to the patients' needs.Pain relief should be sought through the variety of options open to paramedics and should be initiated immediately. Transfer to the ambulance should be done in a safe manner, ensuring the patient is immobilised and remains pain free. This pre-hospital management of the patient with a femoral neck fracture ensures they receive adequate analgesia and fluid replacement before any definitive treatment at hospital.

Patient comfort in prehospital emergency care: a challenge to clinicians

Aim:The aim of this paper is to report on a study that compared ambulance clinicians’ views of two different types of patient coverings, focusing on core caring concepts such as comfort, dignity, and safety.Design:Ambulance clinicians’ views were gathered in respect of two types of patient coverings, and 128 ambulance patients were randomly distributed into a control or experimental group receiving respectively either the traditional cotton blanket or a multi-layered TelesPro rescue covering. Views were gathered using a short questionnaire developed by the authors.Findings:Ambulance clinicians, in their own view, maintained the core caring concepts no matter which type of covering was used. Findings suggest strongly that the rescue covering provided for a superior patient experience in respect of all core concepts and one functional aspect.Conclusions:Ambulance clinicians undertake caring that encompasses the core caring concepts of comfort, safety, and dignity, while remaining vigilant to threats to these constituents of caring.

Does understanding words used by the breathless COPD patient enhance therapeutic care?

Shortness of breath, dyspnea and breathlessness are collective terms to describe the awareness of inadequate gas exchange within the respiratory system.Varying mechanisms, behavioural and physiological changes are caused by this ventilation-perfusion mismatch. This complex sensation encompasses manydiverse concepts.The spectrum of language and words used as a consequence of this sensation varies from quality and intensity to emotions and feelings. Matching the phrases to the cause supports understanding.Current studies reviewed produced clusters of verbal descriptors which reflect the multi-dimensional input as a consequence of being out of breath. Using these clusters has produced a comprehensive list of twelve words known as ‘The Dyspnea 12’ which when used, quantifies the severity of this debilitating and extremely distressing symptom.Could these verbal descriptors be used to aid the assessment and treatment of their cause in service users and provide a more holistic view to a widespread problem?

From trade to profession-the professionalisation of the paramedic workforce

How do we achieve professionalisation of the paramedic? The Trait theory identifies profession as having 1. An exclusive body of knowledge 2. Self regulation and 3. Registration. Becoming a profession leads to improved remuneration and greater respect and knowledge, but this does not lead to a change in personal conduct. Professionalism however, is connected to behaviour, attitudes, accountability and responsibility. The behavioural changes and attitudes required of a ‘professional’ are brought about through the combination of higher education and clinical leadership. Academic input integrates clinical leadership with the career structure and all staff at all levels. Clinical leaders are at the coal face, accessible during and after the event, for training and clinical supervision and are therefore transforming practice at every level.However, clinical leadership is ineffective with an uneducated workforce and an uneducated workforce is ineffective without clinical leadership, thetwo go hand in hand So...What is the way forward for the ambulance service?What are paramedics doing to develop and maintain the profession and professional

Time for paramedic licenses?

The introduction of Continuing Professional Development (CPD) audits by the Health Professions Council (HPC) (2008) provided another step towards a truly ‘professional profession’. The reliance on in-house recertifcation courses provided by ambulance services raises concerns of the effcacy of ‘sheep-dip’ style education where the best, average and poorest clinicians underwent the same courses, irrespective of their learning need. Clearly an evolution which enabled professionals to continually develop their knowledge and skills, thus becoming more effective practitioners, was a determining moment. But has the paradigmatic shift in how we educate and check our registrants created a bias towards developing skills at the expense of good-quality current ones?

Reflex anoxic seizure: an important diagnosis to remember

Children may present with a sudden collapsing episode, and the paramedic team is often requested to attend such emergencies. It is important that these episodes are correctly categorised as being either epileptic or non-epileptic events. A reflex anoxic seizure (RAS) is one such presentation. RAS is a paroxysmal, spontaneously-reversing, brief episode of asystole triggered by pain, fear or anxiety.RAS occur due to a brief stoppage of the heart caused by overactivity of the vagus nerve. This is usually triggered by an unpleasant stimulus, following which the child may appear pale and lifeless. The diagnosis is usually made by a paediatrician but it is important that the paramedic team are aware of this condition. A child with a diagnosis of RAS may be managed by reassurance from paramedic practitioners if the child is judged to be well after an episode.