Volume 5 Issue 4

Continuing Professional Development: Decision making for paramedic practice

OverviewMaking decisions is something we all do several times a day. For the majority of the time, such decisions are made unconsciously or certainly with little regard or much thought or insight into the decision making process itself. However, some of life's bigger decisions tend to be taken more seriously and we often consult with others, such as family, friends and colleagues, undertake some research, or look at various websites before making these choices.In your clinical and professional paramedic life, many of the decisions that you make on a daily basis can vary enormously; from saving someone's life, to deciding which health care professional to refer a patient to. All are undertaken with perhaps little thought to the decision making framework or theories that underpin your practice.As many of your decisions are fundamental to patient care, it is important to have a greater understanding as to how we reach the decision that we do, why we make them and how we could improve on them. This Continuing Professional Development (CPD) module will explore some of these supporting processes and how they specifically relate to paramedic practice.

Cognitive appraisal linked to managing psychological trauma

As a professional group, paramedics experience disproportionate levels of stress and burnout compared with other healthcare professionals and emergency workers. Evidence suggests that stressors include lack of control over decision-making and tensions with management, as well as the more traditional stressors, such as witnessing pain and distress, and being vulnerable to abuse.

Prehospital pain management: how would you score it?

Involvement in the management of patients’ pain is a daily event for many ambulance crews, but is there room for improvement? This qualitative, phenomenological study (undertaken in the East Midlands, UK) set out to explore staff and patients’ experiences and opinions of pain management in pre-hospital settings.

How diabetes affects the body: outlining acute and chronic complications

What happens if you have no insulin?Before 1922, and the work of Nobel Prize winning Canadian medics Dr Frederick Banting and Charles Best (still a medical student at the time), developing diabetes in childhood was akin to a death sentence. It was described by ancient physician Hippocrates as a short, disgusting and painful condition (Medvei, 1993) due to the rapid dehydration, starvation, pain, and coma leading to death that occurred in type 1 DM.Polyuria (massive urine production) occurs because the increasing amounts of glucose unregulated in the blood stream shifts the osmotic balance of the blood to the point that when the kidneys filter the blood, less of it is returned at the distal end of the nephron (the structure that filters blood in the kidneys). This means water, and important electrolytes, such as potassium and sodium, are being taken out of the system and no longer returned by the kidney, causing polydipsia (increased thirst), a sensation we feel at just 1% dehydration.Fortunately, glucose is also excreted along with the other products when it displays high blood levels, but not in significant enough quantities as to correct the problem. Characteristically, patients developing diabetes drink large quantities of water while urinating large quantities of sweet-smelling urine, frequently throughout the day and night. There is an inability to keep up with the vast amounts of water being excreted, which means a lack of insulin also leads to dehydration.Insulin is released when blood sugar levels rise after a meal. All excess glucose from carbohydrates that are unused by cells for energy are encouraged to be stored as glycogen by a process known as glycogenesis. This is stored as emergency reserves for the body to use in starvation, and release is stimulated by glucagon.The lack of insulin and subsequent high levels of glucagon lead to a breakdown of fat and muscle tissue glycogen, a large molecule containing hundreds of chains of fatty acids. The body believes that food is scarce and at risk of starvation. Glycogen’s fatty acids are released and converted in the liver. These fatty acids eventually yield FADH2, NADH and acetyl coenzyme A, which are used in the Krebs cycle of intra-cellular energy production. This process is used in cells to continue normal function from energy reserves or normal dietary intake. The brain exclusively uses glucose in normal life, not the products of stored energy breakdown as described above, which can lead to a faint feeling in starvation.However, unlike in normal function, ketone bodies are produced as a by-product of the fatty acid synthesis. This isn’t normally a problem because the body does not have to break down the carbohydrate glucose that is ideally available to use as energy. These ketone body by-products do have a use, as after a few days starvation they will begin to be taken up as an energy source by the brain and heart to keep a person alive. Until then they are excreted (Table 2).Table 2.Common ketones produced by the bodyKetones are acidic and can unbalance the pH of the blood.Ketones cannot be converted back into acetyl coenzyme A (acetyl-CoA) and therefore have to be metabolised or excreted within a few hours. This causes a continual process of breakdown in diabetes, even if there is minimal energy expenditure by the patient.Acetone is a by-product, along with CO2 of fatty acid breakdown. It is produced in small quantities in the liver and excreted in respiration and urination.Acetoacetic acid is released when ketones are being used in the production of energy for use in the brain in starvation.beta-Hydroxybutyric acid is used by the brain as an energy source in low-glucose states, and is a by-product of the production of the useful metabolic enzyme acetyl-CoA, which is used in cells as energy through Kreb’s Cycle.Ketone bodies are detected by using a nitroprusside dipstick, which turns from pink to purple in the presence of ketones.We can use the fact that ketone bodies are released specifically in the breakdown of fats to detect diabetes. One type of ketone body (acetone) is excreted by the kidney in this process, and is detectable in the urine as ‘ketouria’. A urinalysis positive for this will indicate a starved or diabetic state. Ketones are also excreted in respiration, so a sweet, fruity smell of acetone on a patient’s breath may also be present. Ketones may smell like nail polish remover, because that is one of the domestic uses of acetone.In the meantime, the normal blood glucose is not being taken into cells and used as energy because insulin isn’t encouraging its uptake. The cells are blind to the presence of glucose and instead use the synthesised fatty acids and ketone bodies to stay alive. The kidney will excrete glucose in detectable, high levels that can be seen in urinalysis, due to the osmotic imbalance discussed earlier. This is called glycosuria. Normally, the nephrons in the kidney reabsorb glucose as it filters blood in the proximal tubule, but at high levels it will be allowed to release through the urine, in an attempt to counter the osmotic imbalance that leads to polyuria.These previously described problems in diabetes are all unpleasant and distressing, but due to the acidic nature of ketones, the most acute problem becomes evident with a shift in the pH of blood. Blood needs to have a pH between 7.35–7.45 to be compatible in life, and this metabolic acidosis causes a series of symptoms that can quickly lead to death. This will be discussed in the next section.An undiagnosed diabetic can present acutely, more often in type 1 DM than type 2. Remembering that in type 1 diabetes insulin production may have halted completely, all the above processes are happening, which can appreciably lead to serious illness in a very short period of time. People with type 2 diabetes are not always as acutely affected by their insulin levels as they still have limited function, which is more likely to lead to less specific symptoms such as fatigue and headaches from excessively high blood glucose over a longer period of time, or may only be picked up during routine checkups without any symptoms presented at all.

Knowing the difference between faints, fits, convulsions and collapses

Classification of common heart conditionsCommon heart conditions can be separated into two main categories: structural, which are detectable both in life and post-mortem, and chemical, which are detectable only in life. Examples of heart conditions within these categories are as follows:

Information and advice for prospective paramedics

Mike Dunkley was recently asked to provide an article from the student perspective aimed at potential paramedic recruits, which describes what they should expect in the application process, the education programme, and the demands of training in the pre-hospital environment.

Evaluating the incidence of unrecognised oesophageal intubation by paramedics

Objective: To determine the incidence of unrecognised oesophageal intubation by paramedics in a metropolitan setting.Methods: A retrospective observational analysis was conducted. Patient health care records from the Ambulance Service of New South Wales were used to identify patients who had been intubated by paramedics between 1 January 2007 and 31 December 2010, and transported to St George Hospital, Sydney. Medical records from St George Hospital were reviewed to determine the position of the endotracheal tube (ETT) on arrival in the Emergency Department.Results: During the study period, 196 patients were identified as having an ETT in-situ on arrival to the emergency department. There was inadequate documentation for 67 patients to determine ETT placement. Of the 129 patients included in the final analysis, 4 (3.1%, 95% confidence interval (CI) 0.9–7.8%) had an unrecognised oesophageal intubation. The final ETT positions of the remaining 125 patients were 85.3% (95% CI 78–90.9%) located in the trachea, 10.1% (95% CI 5.5–16.6%) located in a primary bronchus, 0.8% (95% CI 0–4.2%) in the larynx and 0.8% (95% CI 0–4.2%) in the pharynx.Conclusion: The incidence of unrecognised oesophageal intubations in this study was consistent with other reports in the literature, although higher than expected given the training and equipment used in this setting. An incidence of unrecognised oesophageal intubations of zero should be the goal of emergency medical services. The incidence of unrecognised oesophageal intubations may be reduced through recursive training programs and the use of quantitative waveform capnography.

Examining current trends and research in pre-hospital hypotensive resuscitation

The main purpose of trauma care is to reverse shock or reduce its deleterious effects, and in so doing, saving life. The use of aggressive fluid resuscitation may be harmful, as the resulting increased blood pressure and circulating volume could lead to clot disruption, dilution of clotting factors as well as an alteration in the body’s natural response to haemorrhage. The concept of hypotensive resuscitation and how it has evolved is discussed in this article.This article looks at the current trends in hypotensive resuscitation, examining research into the use of such strategies and whether evidence exists to support the implementaion of these strategies into UK paramedic practice.A number of sources were used to assess and access the literature. Primary and secondary sources were located that incorporated seminal and classical studies, permitting a broad overview of the subject.The paramedic has a duty and a responsibiility to provide care that is safe and effective, and this includes the use of fluids to aid resuscitation.

Sources of wellbeing: sharpening a sociological tool for diverse populations

Undergraduate paramedics studying health sociology routinely reported that they could not see the relevance of a topic judiciously added to the curriculum by Australian universities ten years ago: spirituality. The topic aimed to help students better serve their patients through an understanding of attitudes, reactions and subtle influences on health. However, when discussions shifted to the more concrete concept of religion, students became more engaged and wrote essays which revealed a deeper understanding of ethnicity, culture, and its effect on paramedic practice. Religion had been regarded as a blunt instrument in other disciplines such as nursing and social work, which utilised spirituality as a more inclusive concept. Yet for paramedics it was religion that was the key to seeing the difference in the way some patients made decisions, grieved, expressed modesty or faced death, and how religious beliefs shaped responses to treatment and transport. Shared common knowledge of religions emanating from classroom discussions helped students find strategies for their future career. Students found no difficulty in seeing religion as a definitive element in contemporary society.

Understanding the correct assessment and management of lightning injuries

While relatively rare in the United Kingdom, lightning injuries are potentially fatal and certainly serious occurrences. They are also an area of pre-hospital care with which practitioners may be less familiar. Possibly due to their rare nature, lightning strikes have also generated a number of myths and misconceptions, which may adversely affect the care given to patients and the safety of rescuers. This article discusses some of the aspects of keraunomedicine, the study of lightning injuries, and how best to manage victims of lightning strikes. This article provides an overview of the assessment and management of such patients during the immediate pre-hospital and in-hospital phases.

Paramedics and the Francis report

The report of the Mid Staffordshire NHS Foundation Trust Enquiry (2013) chaired by Robert Francis QC has been presented to Parliament. This follows the publication of an initial report in 2010 (The Mid Staffordshire NHS Foundation Trust Enquiry, 2010) concerning issues associated with mortality and standards of care at the Trust. However, it would appear that no lessons have been learned since the first Inquiry published its findings. There has been a plethora of reports emanating from various inquiries (Shipman, Winterbourne, Bristol Royal Infirmary, Victoria Climbié), which have all indicated the need for better training of staff, improved management and a focus on outcomes as opposed to targets. However, the public remains unconvinced that this has been achieved.

Fear and loathing in the NHS: exploring quality of care

Old newsPoor hospital care is not new. In 1863, Florence Nightingale declared that ‘…the first requirement in a hospital is that it should do the sick no harm’ (Nightingale, 1863). Moving ahead 150 years, the depressing recent Francis report outlined the results of the public inquiry into the Mid Staffordshire NHS Foundation Trust’s serious mishandling of patient care. This second report into the care at Mid Staffordshire (Mid Staffordshire NHS Foundation Trust Enquiry, 2013) highlighted appalling standards of care, such as patients left for long periods in soiled bedding, patients left without help for eating, patients not assisted in toileting, despite several requests, and patients treated callously and indifferently.In a century and a half, perhaps the most disheartening aspect of this Report to the majority of health professionals is that patients were denied the most basic aspects of care.Sadly, this Inquiry is not the first of its kind. In 2001, the Bristol Royal Infirmary (BRI) Inquiry was undertaken following the abnormally high death rate of several children requiring complex paediatric surgery at the BRI. This Inquiry revealed ‘flawed behaviour’ among staff, and that, while the report concluded that the surgical teams were advancing the boundaries of paediatric cardiac care, there were long periods of financial constraints (Bristol Royal Infirmary Enquiry, 2001). This resulted in a shortage of paediatric cardiologists and nurses, and a lack of capital funding for buildings and equipment in the Trust. Two cardiac surgeons were subsequently dismissed and conditions applied to a third by the General Medical Council (GMC).‘These recent Inquiries and reports of appalling health care are difficult for the vast majority of caring and hard working health care staff to understand’The National Institute for Clinical Excellence (NICE) (now the National Institute for Health and Clinical Excellence) was established as a direct result of the BRI Inquiry, which made almost 200 recommendations. The recommendations focused on the competence of the clinicians, and the importance of hospital consultants in maintaining an up-to-date skill set and training, in addition to undergoing regular appraisals, CPD and revalidation for the roles.

The paramedic’s role in reducing avoidable deaths

The Secretary of State for Health, Jeremy Hunt, has put out a call to action on reducing avoidable deaths. The aim is to reduce avoidable deaths through improvements in the fight against the five major causes of deaths. If successful, this fight against premature mortality could result in a reduction of 30 000 deaths by 2020. This is a tall order and the size of the challenge is considerable. There will need to be recourses (financial and material) made available, and this will have to be done against a backdrop of the swinging austerity measures that are in place. The government will be expected to play its part, but so too will other members of the NHS, including paramedics.

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