Volume 4 Issue 9

Exertional heat stroke: a rapidly progressive pre-hospital presentation

On a day when outdoor temperatures reached 30 °C, the ambulance service responded to a 19-year-old male who had collapsed in the late afternoon. His first day of employment for a local building company had been spent working outside on the roof of a residential property. He had applied sun cream and hydrated often. His work colleagues were emphatic that he’d been well all day but within 10 minutes he had become disorientated, vomited and collapsed.

Book review

The electrocardiogram (ECG) was introduced more than 100 years ago by Willem Einthoven (for which he was awarded a Nobel Prize in Medicine) and has become the ‘gold standard’ technique for diagnosing cardiac arrhythmias, myocardial infarctions and other coronary events. To this day the initial diagnosis and treatment of acute coronary syndromes represents one of the key performance indicators for paramedics in the pre-hospital environment and so this book really hits the bullseye when it comes to improving standards.

Pre-hospital recognition of Kawaski disease: a guide for paramedics

What is Kawasaki disease?Kawasaki disease is an acute systemic inflammatory illness of young children that can result in coronary artery aneurysms, myocardial infarction and sudden death in previously healthy children (Rowley et al, 2010).Dr Tomisaku Kawasaki, a paediatrician from Japan, documented visiting a four year old child with a rash, fever and an unknown presenting illness. He monitored fifty Japanese children with similar symptoms over a period of six years before finally documenting KD as a diagnosis in 1967 (Burns et al, 2004). Although positive that KD was a potentially fatal disease, other professionals disagreed. Other pathologists and paediatricians from Japan challenged Dr Kawasaki’s prognosis arguing that KD had no long–term side effects (Burns et al, 2000). This debate continued until a report was published in 1970 looking at ten autopsy reports from deceased children who had KD (Burns et al, 2000). The reports showed that patients had died as a result of coronary artery aneurysms secondary to KD demonstrating the long–term health repercussions for those with the disease. Since this initial diagnosis, KD has been seen in almost every country throughout the world (Brogan et al, 2002).KD has more cases reported in Japan than any other country (Brogan et al, 2001) although there has been no evidence suggesting that direct person–to–person contact increases the risk of spreading the disease (Tizard, 2005).Similarly, infantile polyarthritis nodosa (IPN) has been closely linked to KD since its diagnosis due to the close clinical signs of the two conditions. IPN is a rare and chronic condition affecting children, generally below the age of two. IPN affects small and medium arteries causing ischaemia and infarction (Thatayatikom et al, 2011), and, although paramedics are unlikely to be able to differentiate between IPN and KD in the pre-hospital environment, background knowledge of both is important in order to recognise and understand clinical changes in the presenting patient. It should be noted however that there are currently no protocols for the management of adult patients who have previously had KD during their childhood (Gordon, 2009).

Glasgow coma scale: being conscious of mistakes

The Glasgow coma scale (GCS) is the tool most commonly used by paramedics to assess and compare levels of consciousness; the results of this assessment often determine initial and ongoing treatment. Limitations surrounding the use of the GCS in difficult clinical environments and in patients with certain preexisting comorbidities has increased interest in potential alternatives. Despite widespread use of the GCS both in the hospital setting and in out-of-hospital environments, there is limited evidence examining paramedic accuracy when using this assessment tool.

Death notification after a motor vehicle collision: is there a ‘best’ time to tell the survivors?

Telling survivors of a motor vehicle collision (MVC) that someone else has died in that incident is a sensitive undertaking for health professionals. The paper highlights that there is no consensus in the literature as to the best timing to deliver this potentially upsetting news, or even whether it should happen at all in the early stages of the survivors’ management and treatment, especially if they do not ask for this information.

Paramedics' experiences with death notification: a qualitative study

Objective To explore paramedics’ experiences and coping strategies with death notification in the field.MethodsUrban and urban/rural paramedics participated in four focus groups across Ontario, Canada.They were asked about their experiences communicating death notifications and the support they received. Transcripts were analysed using the constant comparative method. Themes were generated inductively.ResultsTwenty-eight paramedics participated. Four themes emerged: the practical aspects of deathnotification, how paramedics acknowledge the emotional toll, how they manage the emotional toll, and the support mechanisms they used. Communicating a death notification is stressful and paramedics’ personal attitudes to death influence how they communicate a notification. Switching roles from clinician to supporter is challenging. Deaths that are unexpected, traumatic, obvious, involve children, with which the paramedic identifies, or are the paramedic’s first experience are especiallystressful. Paramedics receive support by talking to peers and using informal support networks. They prefer support from people who have had similar experiences.ConclusionParamedics’ experiences with death notification are stressful, challenging, andrewarding. More formal support for paramedics is necessary, especially when the nature of the death is distressing. Our study suggests that further training is required to increase paramedics’ comfort with this challenging communication.

Kerbside consultations: advice from the advanced paramedic to the frontline

AimTo observe the issues, benefits and challenges of providing dynamic telephone clinical advice to frontline clinicians by advanced paramedics of the North West Ambulance Service NHS Trust.MethodIn order to focus on the key issues the study used a mixed method approach. A group of 11 advanced paramedics took part in two focus groups which was then followed up with a questionnaire to frontline clinicians. Using focus groups in the research not only allows for the possibility of multiple realities but also for participant validation. Using a qualitative approach allowed theory to develop and emerge which was then codified into themes and the data was then used to develop a questionnaire for frontline clinicians who had received clinical advice in the past in order to provide an element of quantitative data.FindingsFive themes emerged from the stud: function, responsibility, barriers, education and support.ConclusionThe study finds that clarity is required in relation to responsibilities and clinicians would benefit from a structured model to communicate information over the telephone—we believe the introduction of remote advice has improved patient safety and support to staff and has created opportunity for additional learning.

Pre-hospital psychosocial care: changing attitudes

Holistic care is often a term widely associated with mental health professions, self help and alternative therapies, and often wrongly deemed irrelevant by those working in the pre-hospital care arena. The paradigm of an individual being much more than just the skin and bone holding itself together has gained increasing emphasis over recent decades in medicine, nursing, and now paramedicine. This article reviews the current literature and focuses on the concept of paramedics exploring not just the traditional physical needs of their patients but also the psychological and sociological. It further explores the drive to change attitudes held by pre-hospital practitioners that holistic care as irrelevant and meaningless. By distancing ourselves as a profession from the outdated perception of paramedicine as merely an emergency transportation service, we can change attitudes and thus expand the constraints of biomedical models of emergency and unscheduled health and appreciate the importance of biopsychosocial care for both patients and practitioners.

Serotonin toxicity: pre-hospital recognition and management

Serotonin toxicity is a preventable, potentially serious condition caused by an increase in the neurotransmitter serotonin. The condition can produce a wide variety of symptoms ranging from mild to life threatening. Common signs of severe life threatening toxicity include clonus, myoclonus, hyperreflexia, muscle rigidity and hyperthermia. Serotonin toxicity is caused by taking one or more serotonergic agents which are responsible for raising intrasynaptic serotonin to an abnormally high level. Severe and fatal toxicity are usually associated with taking two different serotonergic agents with different pharmacological actions such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). There is no specific pre-hospital treatment for serotonin toxicity. It is based mainly on patients presenting signs and symptoms. The cessation of any serotonergic agents will normally resolve symptoms within 24 hours. Unfortunately it is a condition still not widely recognised by health care professionals (HCP), therefore it is important pre-hospital clinicians are aware of the clinical features of the condition and how best to manage them.

Integrating clinical research into paramedic practice:current trends and influences

This article aims to evaluate some of the major influencing factors on the integration of research into paramedic practice. It looks at national research and development policies, the paramedic role, training developments, the influence of the College of Paramedics and the HPC, research funding bodies, support of organisational structures and ambulance culture. It also looks at the collaborative research between ambulance services and academic institutions and how these influencing factors impact on the integration of research into practice in the pre-hospital setting. Strategies are proposed to overcome some of the barriers to the integration of clinical and research practice by the paramedic. These focus on changing national policy to promote greater clinician involvement in research and greater communication between UK universities and research networks to make academic research careers more accessible to university-trained paramedics. The development of roles within ambulance trusts to incorporate both clinical practice and research engagement is also discussed as well as a focus on increasing the College of Paramedics’ representation of the profession to enable more paramedics to access opportunities to become actively involved in research.

Emergency medical services take on the challenges of 2012

National Interoperability SummitNational and international events in 2012 are opening the discussion once again around the importance of interoperability within the blue light services. The National Interoperability Summit at The Emergency Services Show will be providing a platform for discussionsaround this critically important topic that is being supported by the Home Office, Cabinet Office, Department of Communities, local government and the Department of Health. Debates will cover an overview of the Joint Emergency Services Interoperability Programme (JESIP), an Olympics de-brief, perspectives from ACPO, CFOAand AACE, the Government’s aims and priorities and external challenges fromthe worlds of law, academia and the military.To register for your free visitor pass or to learn more about attending The Emergency Services Show 2012, please visit: www.emergencyuk.com

Continuing Professional Development: Epinephrine and its use in acute life-threatening asthma in adults

OverviewThis CPD module, will act as revision of existing treatments for acute asthma exacerbations, as well as discussing the indications for use of epinephrine in asthma and the potential problems you may encounter with its use.Although epinephrine has been used for many years in other medical emergencies, such as anaphylaxis, is not widely used for asthma exacerbations. This module will discuss a number of different methods for the delivery of epinephrine; however it should be appreciated that not all of these routes are suitable for use in asthma.You will also have the opportunity to reflect and consolidate your existing clinical knowledge of epinephrine, as well as providing a basis for further learning about the pre-hospital management of acute asthma exacerbations.There are a number of resources available through the ‘Journal of Paramedic Practice’, and other guidelines and information available to supplement your learning; in particular from the British Thoracic Society, Scottish Intercollegiate Guidelines Network and Joint Royal Colleges Ambulance Liaison Committee.Learning OutcomesAfter completing this module you will:• Describe and use the clinical findings with which to determine the severity of an asthma exacerbation.• Understand that asthma is a condition with a significant mortality rate, and patients can rapidly deteriorate without appropriate resuscitation.• Understand the different pharmacological treatments in acute asthma, and their uses in current guidelines and protocols.• Appreciate the emerging role of epinephrine in pre-hospital practice and the different routes by which it can be given.• Identity and reflect upon personal areas of concerns in the pre-hospital management of acute asthma exacerbations.

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