Volume 5 Issue 10

Is paramedic practice ready to adopt the NICE Transient Loss of Consciousness Guideline?

In 2010 the National Institute for Health and Care Excellence (NICE) published a guideline to assist clinicians, across various healthcare settings, to diagnose and subsequently manage patients experiencing a transient loss of consciousness (TLoC). The guideline emphasises that patients who are diagnosed as having had an ‘uncomplicated faint’ or ‘situational syncope’, from the initial assessment process, may not require conveyance to the nearest emergency department. JRCALC have included these recommendations within the latest published guidelines. Evidently, this may reduce inappropriate admissions and reduce unnecessary NHS expenditure. In addition it enables clinicians to provide care to patients within their home environment thus improving their experience and outcome as a service user. Furthermore, non-conveyance may reduce ambulance turn-around times enabling clinicians to become available to respond to life-threatening emergencies sooner. However, to utilise the guideline, clinicians are expected to be proficient in aspects of history taking, physical examination and 12-lead ECG interpretation. The current paucity of pre-hospital evidence base provides no support for use of the guideline by paramedics. It is questionable as to whether further education and training are required, before paramedics can utilise the guideline, to diagnose and discharge patients at scene without causing any detriment to patient outcome.

Severe burn injury—pre-hospital paramedic response—if it goes wrong

Internationally burn injury is one of the major causes of death and disability. Serious burn injuries are devastating events that leave patients with longterm physical and psychological challenges that are recognised by paramedics worldwide as one of the most horrific and challenging injuries known to the emergency medical and rescue services. Burn injuries may be extremely complex in their presentation, and any resulting complications may extend the need for expensive long-term management from months to years.This paper provides an overview of the complication of pre-hospital response to severe burn injury, if it goes wrong.

Hands off: can paramedics be educated at a distance?

This article looks at the challenges and opportunities presented by the use of distance methods to teach student paramedics. It examines distance learning from the perspective of the employer, the student and the higher education provider, and shows that there are considerable benefits for student paramedics and their employers in adopting a distance teaching approach to paramedic education. There are no short cuts to a successful outcome, and it is important to adopt the highest quality distance education.

Single patient use versus reusable laryngeal mask airways: a comparison

The laryngeal mask airway was first developed in the 1980s by Dr Archie Brain. The market for supraglottic airways has rapidly expanded since the 1980s, incorporating both reusable and single patient use devices, varying in design, application, cost and durability. Here, the author considers theoretical and anecdotal evidence when comparing single patient use and reusable supraglottic airways. Particular attention has been drawn to the I-Gel, pro-seal laryngeal mask airway and conventional laryngeal mask airway.

Community paramedicine: a global phenomenon?

This systematic review was undertaken by a team of researchers based in Canada who were interested in exploring the expanding scope of practice for paramedics working in the areas of unscheduled, urgent, low-acuity illness and injury. They termed this work as ‘community paramedicine’.

The research paramedic: a new role

Fitting the role into the changing face of paramedic practiceThe paramedic profession has changed dramatically over recent years and continues to change. We have moved away from protocol-led treatment and more towards independent clinical decision making supported by higher education (Emms and Armitage, 2010). This change in paradigm has moved us towards the realms of autonomous practice and helped us to develop as a profession. Paramedic training through higher education places more of an emphasis than ever before on understanding the research that underpins our practice.The current focus on evidence-based medicine has highlighted some of the opportunities for research in paramedic practice, which is a natural role for a research paramedic. Some areas of paramedic practice have historically been based on ‘scanty science’ (Callaham, 1997) and recent research-led changes, such as the changing attitude to the use of oxygen, show how much of an effect on day-to-day practice research can eventually lead to. A number of papers have been published which discuss the pressing topics that need to be researched in pre-hospital care (Brace and Cooke, 2010). Paramedics with skills, knowledge and experience in research will prove valuable in future trials. The inclusion of a paramedic, at all stages of a research trial, is thought to be both beneficial and key to overcoming some of the barriers to pre-hospital research (Schmidt et al, 2009; Hargreaves et al, 2013).A personal viewI joined the ambulance service in 2003 as a trainee advanced technician following the Institute of Health Care Development (IHCD) training route. I qualified as an advanced technician after a year or so then worked across the region until I sat my paramedic course in 2007. When I joined the ambulance service I had no inkling of where my career would lead and focused on the goal of learning to be a competent clinician, which to me meant becoming a paramedic. At that time, and until recently, I think the goal that a lot of people aimed for was qualifying as a paramedic. Becoming a paramedic was the end of a long and arduous process for me and at that point I wasn't looking where I would go next.Nowadays being a paramedic is a starting point for many people. Many entrants into the profession start with the expectation of being a qualified and operational paramedic at the end of a university-led course. Opportunities to progress beyond the role of paramedic are appearing in a variety of guises. Some paramedics may work on helicopters, specialise in primary care, some people may lean towards critical care, Hazardous Area Response Team (HART) offers a chance to develop your practice along different lines and most trusts have some form of team leader/station officer role. A different route that is also emerging is to develop a career in research.Once qualified as a paramedic I worked in a busy station until 2009 when I started the training to join the newly created HART. I worked in HART from 2010 until late 2011 when I moved across to take up a secondment in Research and Development (R&D) as a trial coordinator. This initial position was a temporary post which served as a good opportunity to see how a different area of the profession worked and see whether I was interested in pursuing this direction.Since 2011 I have been involved in a number of projects including large trials such as the Head Injury Transportation Straight to Neurosurgery trial (HITS-NS) and the Pre-hospital Randomised Assessment of a Mechanical Compression Device in Cardiac Arrest (PARAMEDIC) as well as other smaller, more localised pieces of research.The research paramedic role is a hybrid role combining clinical and academic elements. One of the ways that I see the research paramedic role developing is by building links between theory and practice, closing the gap between academics and clinicians. Clinical practice and experience informs the development of the next generation of research and allows a researcher to identify the gaps in the knowledge and see the issues that may benefit from research. Academic training and partnerships are necessary to develop the research and conduct robust and efficient trials that generate usable knowledge that is transferrable into real world clinical practice. Partnerships with hospitals and other NHS organisations are important to establishing the impact of most, if not all, pre-hospital interventions. Interventions performed in the pre-hospital environment may require data encompassing the complete patient journey, or their long-term usage of other healthcare services, to show an impact.The regulatory and professional representative bodies for paramedics both acknowledge the role of research in the paramedic profession. The Health and Care Professions Council (HCPC) standards of proficiency for paramedics make explicit mention of the possibility of working in a research setting and various references are made to the research related knowledge expected of all registered paramedics (HCPC, 2007).The new College of Paramedics (CoP) career framework which is due out in late 2013 includes a prominent research strand. This shows how the CoP believes that research is integral to the development of the profession in all the various directions being explored. The CoP career framework shows the scope for paramedics to operate at advanced, specialist and consultant levels and how these roles map against suggested levels of higher education qualifications (College of Paramedics, 2013). The CoP has a dedicated research and development advisory committee (RDAC) that can help and support paramedics pursuing research interests.The nursing profession, which we as paramedics work with on a daily basis and have learnt a great deal from, have the established role of the research nurse (Pick et al, 2011). This role has much to teach the evolving research paramedic and the two roles may work and develop closely in the future. The research nurse role is arguably further along in their evolution than the research paramedic role so there are lessons that can be taken in terms of integrating the dedicated research role into wider practice.

The forensic paramedic: an outline of the role and essential criteria for the job

The forensic roleAssessing fitness to detainThis is one of the most commonly requested examinations performed by the forensic paramedic and may be required in connection with adults or juveniles following arrest for an alleged offence, an initial mental health assessment where custody staff have concerns over the mental welfare of a detained person (DP), those detained by immigration, and those on remand or sentenced.The forensic paramedic must consider the health, safety and wellbeing of a detainee to be of paramount importance and concerns for this may at times override forensic considerations. In simple terms, if the forensic paramedic would be concerned at leaving the person at home with no supervision or care, then the detainee may not be fit for detention.The forensic paramedic must be aware of the conditions related to detention and although medical conditions may not be life threatening, there are times when continued detention may not be desirable for the care of the detainee.Full discussion with custody staff may enable a mutually agreed acceptable management plan, e.g. bailed to attend another day for interview, or attendance at hospital etc. This may be influenced by consideration of the level of charge in terms of the serious nature of the offence. If the forensic paramedic recommends release, they should enquire whether community care is available or consider hospital referral.The purpose of the examination for fitness to be detained (FTBD) is to assess illness, injuries, problems related to substance misuse—including alcohol—and mental health disorders. Forensic paramedics give advice to custody staff to enable them to care for the detainee during detention, and to determine those detainees not FTBD and who need diversion to other healthcare services. Many detainees have complex healthcare needs and often advice regarding necessary medication and the need for review by either FME or a crisis team, as required.The forensic paramedic may be approached to assist the police with information to aid their investigation. This can create a conflict of interest and the forensic paramedic must be prepared to justify the sharing of any information at a later date if necessary.Fitness to interview and chargeThe importance of assessing a detainee's fitness for interview, lies in the well-established fact that certain vulnerable individuals may make false or misleading statements to the police that are not in their best interest. A careful and well-documented examination is necessary to recognise such individuals and ensure that appropriate safeguards are in place, and to rebut subsequent defence claims that a detainee's confession should be ruled inadmissible because they were unfit for interview at the time of the confession.Annex G of PACE Codes of Practice, Code C, contains general guidance to help police officers and healthcare professionals assess whether a detainee might be at risk in an interview. A detainee may be at risk in an interview if it is considered that conducting the interview could significantly harm the detainee's physical or mental state, or anything the detainee says in the interview about their involvement or suspected involvement in the offence about which they are being interviewed might be considered unreliable in subsequent court proceedings because of their physical or mental state.A personal viewWhen I qualified as a paramedic in 1988, I never thought I would end my NHS career involved in the field of forensic practice. After a career of 28 years with the ambulance service, which gave me opportunities ranging from being a member of an air crew to international work, I left in 2005 to pursue a career in primary care as an emergency care practitioner with a primary care trust (PCT).I quickly moved to another PCT that was providing custody cover on a trial basis in the North East on a 24-hour seven day a week operation with ECP’s employed in that area. Due to the success of this trial, from 1 May 2007 further custody suites were added, making it a countywide service covering six custody suites.The contract was further expanded and eventually went to tender for full service. I applied for and was successful in my application for the position of clinical lead for the contract management. I retired from the NHS in 2012 after the NHS won the contract to provide all medical services to the constabulary.During my time as the contract manager I was responsible for developing a training package for practitioners. This training included custody suite training, police custody evidential issues, safety awareness in custody, and forensic sampling. I also studied offender health and substance misuse. I found it very difficult to find academic training suitable for practitioners in advanced forensic practice.The United Kingdom Association of Forensic Nurses (UKAFN) is working to establish professional standards for forensic nurses in both the sexual assault examination and custody areas of forensic nursing. I joined UKAFN and became a paramedic member of the steering group with a recent appointment of treasurer. I am looking forward to starting the UKAFN approved Postgraduate Certificate in Advanced Forensic Practice, which was developed with the Faculty of Health at Stafford University. The NHS commissioning of custody healthcare will demand professional standards; UKAFN have been working with the Faculty of Forensic Legal Medicine (FFLM) to set professional standards for forensic practitioners.When healthcare professionals identify risks, they should be asked to quantify the risks. They should inform the custody officer: whether the person's condition is likely to improve, whether the condition requires or is amenable to treatment, and how long it might take any improvement to take effect.Any suspect will be unfit for interview if they have a physical or mental illness that is likely to deteriorate significantly because of the delay in obtaining treatment that the interview will engender, or as a result of the stress of the interview.As part of the holistic assessment, the forensic paramedic must be able to assess whether a detainee should be interviewed, considering how the detainee's physical or mental state might affect their ability to understand the nature and purpose of the interview. The extent to which the detainee's replies may be affected by their physical or mental condition rather than representing a rational and accurate explanation of their involvement in the offence and how the nature of the interview, which could include particularly probing questions, might affect the detainee.The forensic paramedic must consider the various vulnerability factors that render an individual more likely to provide an unreliable confession. Factors that need to be considered include the health of the individual (physical and mental, including substance misuse), the likely demand characteristics of the interview, personality traits that increase vulnerability, and the totality of the circumstance.Detainees presenting with mental health problems are common in police custody; it is not uncommon to see people in crisis. Although mental health is an important factor in determining the reliability of testimony, it should be recognised that the fact that a suspect suffers from an illness does not necessarily mean that they are unfit for interview.Detainees with learning disabilities may have difficulties in understanding their legal rights and in communicating with police officers. They are also more likely to be suggestible, acquiescent and more prone to providing false confessions; therefore, an appropriate adult will have to be considered for the interview process.Significant intoxication by alcohol or drugs will make a person temporarily unfit for interview.The decision regarding the fitness for interview of a suspect who has been drinking or misusing drugs should be based on a medical and functional assessment to give an estimated time for fitness.A person suffering from alcohol or drug withdrawal is, in some ways, especially vulnerable to giving a false confession. Such persons may believe that compliance will result in early release and that the risks entailed in providing a false confession may seem worthwhile in the presence of an overwhelming desire to re-establish access to their supply of drugs or further alcohol. Drug withdrawal states can markedly affect levels of anxiety and prevailing mood, which may increase suggestibility and compliance.Any detainee displaying signs or symptoms of alcohol or drug withdrawal is managed using Patient Group Direction (PGD) medication to manage withdrawal and to prevent the detainee being under duress. Occasionally, when a detainee dependent on alcohol starts to fit, a trip to an accident and emergency department is required.Other assessmentsOther aspects of the forensic paramedic's work can include taking intimate samples with lawful authority, and consent for suspects involved in sexual assault and violent crimes.The taking Road Traffic Act (RTA) blood samples from a driver that has failed a roadside breath test and provided a boarder line reading during the station procedure is another common call for the forensic paramedic.Many detainees, as previously stated, have very complex healthcare needs and require their own medication during attention. Verification of medication for use in custody requires a full medical and medication history, including substance use. Own medication brought into custody must be appropriately labelled, packaged, dated, and regularly used.Recording of injuries is required for either complaints or evidential reasons that have to be recorded on body maps, including a description of the type and size of the injury. Once the injury is recorded, if possible it will be dealt with in custody, if not, then the police escort the detainee to hospital.Writing statements and appearing in court as a professional witness is part of the role of the forensic paramedic. Writing the first few statements and attending court can be a daunting prospect, which thankfully has not happened that often.

Clinical handover of the trauma and medical patient: a structured approach

Handovers are vital to the continuity of patient care and can influence patient outcome. Several structures exist to facilitate handover delivery but further work is needed to prospectively evaluate them.This article advocates the implementation of a suitable pre-hospital handover template and the introduction of handover training. We believe the introduction of trauma networks into the UK provides the ideal opportunity to prompt hospitals and ambulance services to co-operate to standardise the approach to handover, improve training and carry out further prospective research into the most effective methods of patient handover.

The use of simulation mannequins in education

Effective and realistic simulation training is an important part of preparing paramedics for the pre-hospital environment. Alan Rice considers the various benefits and negatives of mannequin-based simulation training for paramedics.

The future of training and education

Since the advent of the paramedic profession, its means of educating and training its members has constantly evolved. The transition from predominantly first aid and transport-focused ambulance operations to more specialised services involving increased clinical decision-making has meant the way in which paramedics are trained has had to adapt to meet these accumulating demands. This increase in clinical capability has also led to the realisation that paramedics can, and do, make a fundamental contribution to unscheduled and urgent care.

Spotlight on research funding

Every now and again we have something different in Spotlight on Research and in this edition I want to talk to you about an exciting developmental opportunity being offered by the College of Paramedics (CoP).

Continuing Professional Development: Recognition and treatment of hypothermia

OverviewAccidental hypothermia is a condition which affects not only outdoor enthusiasts caught in storms, but also a significant proportion of the elderly population of countries such as the UK during winter months. Interestingly, hypothermia is both a symptom of illness and a distinct pathology in itself. With this in mind, it is an important condition for paramedics and pre-hospital medical staff to understand.This Continuing Professional Development (CPD) module will briefly revise some of the principles of heat transfer and thermoregulation discussed previously, before discussing the pathophysiology and management of hypothermic states.Learning OutcomesAfter completing this module you will be able to:• Define hypothermia, and appreciate the relevance of severity grading.• Revise the principles underpinning heat transfer, as covered in the earlier CPD module on heat illness.• Appreciate the range of patients affected by hypothermia, and typical presentations.• Gain an understanding of the pathological sequelae of hypothermic states.• Learn about general approaches to management and prevention of hypothermia.

Book Review

This text initially captures your attention given the all-encompassing title, but how much of the content is actually devoted to paramedic practice? That in itself is difficult to define given the ever-increasing scope of practice of those working within our profession. The editor is a nurse by profession and only two of the contributors are HCPC-registered paramedics. Not so much a criticism but a curious balance, as ‘paramedic’ is the only clinical role given specific mention in the title.

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