Volume 5 Issue 3

Ischaemic strokes and treatment with thrombolysis: The key lies with paramedics

The treatment availableIn the case of an embolic cause, which creates an ischaemic stroke, alteplase (Actilyse® manufactured by Boehringen Ingelheim) can be used—this is a drug developed to break down clots. Although anticoagulants such as heparin decrease the growth in size of a clot in an artery, thrombolytic agents such as alteplase actively reduce the size of the clot. This works by activating the production of plasmin from its precursor plasminogen. Plasmin degrades fibrin, which is a substance activated in the coagulation cascade; the system the body uses to produce blood clots in order to stem bleeding. This is known as fibrinolysis.There is a time limit for the administration of such a treatment, because the affected brain cells die after approximately three hours, and the damage is irreversible—leading to a situation in which the risks of undertaking thrombolysis provide no net benefit to the patient.The main risk is of a symptomatic intracerebral haemorrhage. Of note to all healthcare professionals is that this commencement of treatment threshold has recently been revised up by NICE (National Institute for Health and Clinical Excellence). ECASS III was a Europe-wide trial from 19 countries with 821 patients.It involved the randomised, placebo-controlled administration of altepase between 3–4.5 hours from stroke onset. Published in 2008, it has been accepted into the September 2012 NICE guidelines (NICE technology appraisal guidance 264) as it is now clinically justifiable to treat patients up to 4.5 hours from the onset of their stroke—in line with a more favourable outcome overall for the treated group.Figure 1.A demonstration of the mechanism which can lead to an artheroscerotic plaque in a cranial vessel causing thrombosis and occlusion of the artery. High blood lipids are clinically a good indicator of increased risk of ischaemic stroke.

Recognising children with surgical problems in the pre-hospital setting

Identifying surgical condition in children can be challengingIt is of paramount importance that surgical teams are involved early in cases where the situation can progress and rapidly deteriorate (e.g. intussusception or appendicitis) (UK Ambulance Service Clinical Practice Guidelines, 2006). The variation in presentation caused by age-related, idiosyncratic or non-specific presentations in children, however, increases the diagnostic challenge.Therefore, whenever a suspicion about a surgical problem arises, the child should be transferred to specialist services. Some of the reasons why recognising and diagnosing surgical conditions in children can be challenging are highlighted below:The history is usually obtained from another individual (parent or carer)Vomiting is a common presentation in surgical problems; however in children it is a very common feature even in the absence of a surgical pathology (e.g. gastro-oesophageal reflux, anxiety, gastroenteritis)Younger infants are more likely to present with congenital anomalies (e.g. malrotation, gut atresia, pyloric stenosis)There is a general lack of understanding amongst the public (and healthcare professionals) (Walker et al. 2006) about what constitutes ‘bilious’ vomiting. (Bile has a distinctive dark green colour; however, yellow vomiting is often reported as ‘bilious’. The child that truly vomits bile has a bowel obstruction until proven otherwise)The physical assessment and diagnostic procedures can be difficult from technical, physical and emotional aspects.

SQIFED: A new reflective model for action learning

Action learning is a much under-used aid to professional development within the NHS. As a reflective tool its strength lies in the contribution of a group to an individual's interpretation of real-life problems. With the increasing demand on clinicians to maintain records of their professional development a structured reflective model for action learning would provide the vehicle by which the action learning experience may be recorded and presented. The SQIFED model is presented and described here. SQIFED facilitates not only reflection on the immediate key issue but also the opportunity to revisit the scenario with a fresh focus.

Sticking the knife in: Time to review management of tension pneumothorax

Outcomes from traumatic cardiac arrest are poor (Lockey et al. 2006; Soar et al, 2010). Those who do survive tend to have had a quickly reversible cuase for their arrest (Vanden Hoek et al, 2010).One such mechanism is tension pneumothorax; and in a retrospective database review of London HEMS traumatic arrests six patients regained cardiac output immediately following decompression of a tension pneumothorax (Lockey et al. 2006).Had their tension pneumothoraces not been rapidly decompressed successfully prior to transport to hospital, the continuation of positive pressure ventilation during CPR would likely have further increased intrathoracic pressure. This would render chest compressions ineffective and almost certainly lead to death.There is currently much doubt surrounding the effectiveness of needle decompression for tension pneumothoraces, and needle decompression without release of air certainly does not rule out this important reversible cause of cardiac arrest (Rojas et al. 1983). In order to improve the outcomes for patients in traumatic cardiac arrest in the UK there is an argument for introducing finger thoracostomy to a paramedics skill set as a safe and effective method of both draining and ruling out tension pneumothorax in the limited setting of traumatic cardiac arrest.

Death notification education for paramedics: Past, present and future directions

Objective:To explore paramedics' experiences with death notification education.Methods:Four focus group sessions attended by paramedics were mediated by a professional facilitator mn urban and urban/rural areas of Ontario, Canada. Paramedics were asked about their experiences with death notification education and what format and content of education they would like. Transcripts were analysed using the constant comparative method. Themes were generated inductively.Results:Twenty primary care paramedics and eight advanced care paramedics with mean experiences of 8.5 and 21.5 years respectively, participated. They reported minimal death notification education in their initial and professional education. They support education in college programmes, new paramedic orientation, and through mentoring. Paramedics learn to communicate death notifications by observing others and by trial and error. They want to learn about this topic through evidence-based continuing education (CE) sessions delivered by a trained facilitator or through online independent study. Experiential methods incorporating role-play and feedback are supported. A trained peer or health care professional with similar experiences would be best to teach paramedics about death notification. Paramedics want to learn about the practical aspects of communicating death notifications, managing the reactions of the bereaved, the cultural and religious aspects of death, as well as their personal reactions to death. Paramedics’ attitudes to death notification education are influenced by their work environment.Conclusions:There is a lack of formal death notification education for paramedics. Formal education should be implemented to reduce the stress of communicating death notifications for the paramedic and for the bereaved.

Pre-hospital management of cystic fibrosis patients presenting with haemoptysis

This paper discusses the pre-hospital clinical management of cystic fibrosis (CF) patients suffering with haemoptysis. While clear guidelines and procedures exist within hospitals in regard to the management of such patients, the same cannot be said for the pre-hospital setting, with very limited clinical practice guidance. Massive haemoptysis is a serious threat to life, though for some patients such as the CF population, even a minor bleed can have devastating effect on quality of life. This paper proposes a pre-hospital clinical guideline based on a retrospective case series from a large Australian tertiary hospital. It is hoped this paper will provide important clinical information regarding CF patients suffering with haemoptysis as it is imperative the management of these patients is undertaken promptly and is well-informed.

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 UKTo outline and identify the presenting symptoms and underlying aetiologyTo outline the therapeutic and nontherapeutic treatmentsTo describe some lifestyle choices impacting on the prevalence of gout

A tribute to Roland Furber

It was with great sadness that we learnt of the death of Roland Furber on 4 February 2013. Roland, who was the President of the College of Paramedics, an Honorary Fellow of the College and had been the College's inaugural Chief Executive, had courageously fought ill-health over recent years but despite that, had still managed to drive round the coastline of England, Wales, and Scotland in the spring of 2012. That journey alone personified Roland. It had required months of planning and needed the bottomless reserves of determination, that we all knew he had, to undertake such a challenge on his own. Roland kept his followers up to date with daily blogs which can still be viewed at rolandsramble. wordpress.com, a record which has been converted into a book.

Advance care planning: What are the issues?

Advance care planning (ACP) should include discussion with the patient (while they still have capacity) as to their wishes for future healthcare provision. Originating from the United States and sometimes previously referred to as a ‘living will’, advanced care planning has been in evidence in the United Kingdom (UK) since the mid–1980s.

Mortality face to face: Death anxiety in paramedics

Death, to die, to have died: the irreversible cessation of cerebral, brain stem, circulatory and respiratory function (World Health Organisation (WHO), 2009), welcomed by some, unexpected by others, but inescapable by all. Death has in recent years in part to palliative care and patient empowerment movements become less of a taboo subject in healthcare, and one that is being discussed more openly within paramedic practice, literature and education (Brady, 2012). A subject that cannot solely be described quite as clinically as the definition above, death permeates all aspects of societal, religious, spiritual, academic, public, family, individual and even work life. For example, Nolan et al (2010) estimate that there are around 30000 cardiac arrests outside hospital in the UK every year, with paramedics having to pronounce death in around 53–61 % of all cases (Douglas et al, 2012). During such situations it regularly falls to paramedics to care for, guide and look after families, relatives and friends in often stressful, distressing, upsetting and confusing situations (Smith-Cumberland and Feldman, 2006). If this is indeed the case, the author questions to whom it falls, to care for, guide and look after the paramedics themselves; putting forward that practitioners' regular interaction with death and the inherent nature of their job increases their potential susceptibility to a concept known as ‘death anxiety’.

The matter of fact

This month a great swathe of the paramedic community will be mourning the loss of one of it paragons, Roland Furber. By all accounts and testimony seen by this author, Roland was instrumental in the founding and forging of the paramedic profession, an extremely altruistic man and a stalwart believer in principled hard work. For the JPP this last month has seen the loss of perhaps its most eminent board member and for the College of Paramedics, it's President and one of its ‘founding fathers’ and for paramedics, a veritable patron of their profession.

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