Pre-mature babies born in the pre-hospital setting: A challenging situation

Age of viabilityThe UK Ambulance Service Clinical Practice Guidelines (2006) recommend that paramedic teams should make every effort to transport a mother where the delivery is imminent between 20 to 37 weeks of gestation as the baby is likely to need specialist care once delivered (Fisher et al. 2006). There are no clear recommendations available from the UK parliament regarding the ‘age of viability’. After consideration of the available evidence a conclusion was reached that while survival rates at 24 weeks and over has improved, this has not been the case below that gestational point (Select Committee on Science and Technology Twelfth Report, 2007).It is also important that paramedic teams remain aware of the guidelines on giving intensive care to extremely premature babies as laid out by the Nuffield Council on Bioethics and this is highlighted in Table 2. These guidelines are also important in situations where an expectant mother in labour may ask the paramedic not to resuscitate the preterm baby (or enquire what to expect once the baby is transferred to hospital) and a quick but focussed discussion may be necessary in such situations.Table 2.Guidelines on giving intensive care to extremely premature babies (adapted from recommendations by the Nuffeld Council on BioethicsAt 25 Weeks and above.Intensive care should be initiated and the baby admitted to a neonatal intensive care unit unless he or she is known to be affected by some severe abnormality incompatible with any significant period of survival.Between 24 weeks, 0 days and 24 weeks 6 days.Normal practice should be that the baby will be offered full intensive care and support from birth and admitted to a neonatal intensive care unit, unless the parents and the clinicians are agreed in the light of the baby's condition it is not in his or her best interest to start intensive care.Between 23 weeks, 0 days and 23 week and 6 days.It is very difficult to predict the future outcome for an individual baby. Precedence should be given to the wishes of the parents. However, where the condition of the baby indicates that he or she will not survive for long, clinicians should not be obliged to proceed with the treatment wholly contrary to their clinical judgement, if they judge that treatment would be futile.Between 22 weeks, 0 days and 22 weeks 6 days.Standard practice should not be to resuscitate the baby, resuscitation should only be attempted and intensive care offered if parents request resuscitation, and reiterate this request, after thorough discussion with a paediatrician about the risks and long-term outcomes and if the clinicians agree that it is in the baby's best interests.Before 22 weeks.Any intervention at this stage is experimental. Attempts to resuscitate should only take place within a clinical research study that has been assessed and approved by a research ethics committee and with informal parental consent.

Seasonal variations effect on trauma admissions: Myth or reality?

It has been long hypothesised that the volume of trauma is related to the weather. This hypothesis has been strongly supported by various studies showing this relationship both in adult and paediatric populations. Projection of admission figures based on weather forecasting has the potential to become a significant tool in predicting the short to medium term workload and therefore improve the provision of emergency care. To achieve that, there is a need for more accurate weather forecasting and a better understanding of how weather affects workload. This would allow for evidence based changes in the allocation of resources.

Future electric vehicles for ambulances (FEVA)

The Future Electric Vehicles for Ambulances (FEVA) project is a proof of concept study to explore the feasibility of introducing electric vehicles as smaller, lighter and more compact solo responder vehicles as part of an ambulance fleet. The limited use of electric vehicles in the ambulance service is largely due to the initial cost and performance (journey duration and charging) of the battery technology. In the next 10 years it is likely that the capabilities of electric vehicles will significantly improve to the point where they will become a viable and fully operational option. The Nissan NV200 vehicle was used as a concept platform to represent the size of future electric vehicles for the delivery of solo response emergency and pre-hospital care. A full-size interior mock-up was built using the knowledge gained from previous research projects (Smart Pods and CURE). It was taken to five NHS Ambulance Trusts to firstly explore expectations for low carbon electric vehicles including range and performance and fuel economy / taxation benefits; and secondly evaluate a mobile mock-up of a FEVA interior for solo responders.

Traumatic brain injuries: Continuing dilemmas in the pre-hospital care arena

This article examines the clinical assessment, diagnosis and management of an agitated traumatic brain-injured patient in the pre-hospital setting by a UK Helicopter Emergency Medical (HEMS) Team. Using a case study from clinical practice, the signs and symptoms, aetiology and clinical management options are discussed and compared against current best evidence, with the specific aims of improving mortality and morbity in critically-ill traumatic brain-injured patients.

Continuing Professional Development: Gout: A new focus on an old disease

OverviewGout is an increasingly common condition predominantly affecting middle aged men. Although commonly related to the intake rich foods, a raised serum uric acid level also causes gout. Gout may present in the pre-hospital setting due to the intensity of the key presenting symptom – that of pain.This Continuing Professional Development (CPD) module focuses at the aetiology and incidence of gout, discusses the presenting signs and symptoms likely and suggested management plan. Although patients with gout rarely require hospital admission, a differential diagnosis of septic arthritis should be excluded and patients may require referral to the Emergency Department to confirm or exclude this diagnosis.Learning OutcomesAfter completing this module you will:• To provide an overview of the incidence and prevalence of gout in the UK• To outline and identify the presenting symptoms and underlying aetiology• To outline the therapeutic and nontherapeutic treatments• To describe some lifestyle choices impacting on the prevalence of gout

Pre-hospital femoral neck fracture management: A review of the literature

Introduction:Falls are a common incident in the pre-hospital setting with a significant number resulting in fractures to the femoral neck.There is some disagreement as to the best way to manage this injury, especially the immobilisation of the affected leg. The objective of the study was to review the literature evaluating the best practice management of patients who present with a femoral neck fracture in the Australian pre-hospital setting.Methods:A literature search was conducted using medical electronic databases, Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from the beginning of each database until the end of September 2012.Articles were included if they reported the pre-hospital management of a patient with a femoral neck fracture. Non-English and hospital-based articles were excluded. References from articles retrieved were reviewed.Results:There were 49 articles located with five articles meeting the inclusion criteria. All five articles described the evaluation of pain management techniques for patients presenting with injuries to the femoral neck. There were no studies that investigated the immobilisation of a femoral neck fracture.Conclusions:This study found a lack of evidence for the management of pre-hospital femoral neck fractures in Australia.Further pre-hospital studies are required to determine the most effective pain management technique as well as the best method to immobilise a femoral neck fracture.

The ‘grotesque truth’ of Richard and Judy

British paramedics' blood is boiling at an article written by Richard and Judy (Richard Madeley and Judy Finnegan) in the Daily Express. And members of the College of Paramedics are reporting a backlash from members of the public. They are calling for Richard Madeley to apologise unequivocally and to donate his Daily Express fee to the Ambulance Services Benevolent Fund.

A pressing issue: Finding a voice for the paramedic profession

Along with a majority of other paramedics working as part of one of the many UK ambulance trusts, this author spent a significant part of January feeling excessively grumpy and irate at the press—namely, certain pieces of unfair journalism that failed to account for both sides of an argument. But then, being a paramedic, the author is biased and it comes as no surprise that they would call it unfair.

Britain's changing demographic

The changing demographic of almost every MEDC in Europe and, indeed the world, will herald significant change in their social, political and financial infrastructure. This has been the case in certain counties such as Japan and Germany (who have seen their population pyramid tip to top-heavy since the early 90's) but has yet to be experienced in full force by the UK.

Reflection of the London Obstetrics CPD Master Class

The London MASTER.Class programme is a series of CPD events provided by the College of Paramedics held across London. These events aim to provide CPD of the highest quality and are open to all learning styles by facilitating a blended learning format. We seek to find the leading authorities in their field to ensure the content of our MASTER.Class events are current, comprehensive and applicable to the pre-hospital clinician. At our MASTER.Class events we try to offer a relaxed atmosphere and typically run for the full day with a complementary buffet lunch. Depending to the subject we try provided as much ‘hands on’ learning as possible making the content as relevant to the modern Paramedic as possible.

If time is brain, why do people wait before seeking help?

The English National Stroke Strategy clearly emphasises that stroke must be treated as a medical emergency as rapid access to appropriate treatment for people with acute stroke is vital for improving patient outcomes.

What gets in the way of effective pre-hospital pain management?

This qualitative study, informed by grounded theory methodology, explores emergency medical services (EMS) staff's attitudes towards pain management. The researchers wanted to establish whether attitudes can act as deterrents when making decisions to administer analgesic agents to patients.

Emergency Medicine Conference 2013

Olympian challengeJason Killens, Deputy Director of Operations at the London Ambulance Service provided a summary of the trusts achievements, failures and most importantly, lessons learned in handling the significant and media-sensitive 2012 London Olympic Games. In particular he spoke about the ‘nervousness over industrial action’ at the time of the games, as well as the stress of dealing with ‘admissions from Olympic athletes and their families who attended the games’ a worry no doubt exacerabted with the looming hoards of reporters and journalists ready to pounce on any failure from the LAS, avoidable or not.Killens also accounted the intersting ‘8 % rise in the number of incidents throughout the games [Paralympic games not inclusive]’ but suggested that that was likely due to the increase in activity and number of people in the capital at the time rather than increased call-outs within the native population. Though accepting some shortcomings found as a result of the games (‘we would have had a larger response team in hindsight…we were caught out to be honest’) the way the LAS delt with the affair sounded, on the whole, admirable—and, as a further bonus, the games also managed to educate thousands of people across the capital in quality CPR practice.Fiona Lecky, Clinical Professor at the University of Sheffield and Reserch Director for the Trauma Audit and Research Network gave a talk titled: Imporing Pre-hospital Trauma Services in the UK. Having worked as a crowd doctor at anchester United's Old Trafford and also as a practitioner at the Olympic games Lecky, clearly no stranger to pre-hopsital trauma both ‘at the desk’ as well as ‘in the field’, noted the most difficult aspect of trauma care facing paramedics, the decision of whether to ‘stay and treat or scoop and run?’Lecky noted how this question becomes even more difficult to to answer in cases of blunt trauma, in particular to the head of the patient, as paramedics have to decide on very little information in a very short period of time, and often without communication (if the patient is either unconscious or has a high Glasgow Coma Score). Lecky drew attention here to those incidents where specialist knowledge on-scene can prove invaluable, and that without it, the issue of patient concent concernign treatment can become particularly contentious.