Volume 6 Issue 1

The evolving role of the Emergency Medical Retrieval Service critical care practitioner

BackgroundEMRS has two teams available 24 hours a day. Each team comprises of two, the first person being a consultant with a specialty in emergency medicine, anaesthetics or intensive care, and the second person being either a senior registrar from the same specialities or one of the CCP team.‘Retrieval can be described as the deployment of a critical care team to a seriously ill or injured patients’ location to undertake resuscitation and stabilisation prior to safe transfer to definitive care (Hearns, 2012).’Secondary retrievals are necessary due to the unique geography of Scotland, as there are many remote healthcare sites situated on the west and north coast. These retrievals take place from a variety of healthcare facilities including district nurse practices, remote GP surgeries, community hospitals and rural general hospitals. The patients who arrive at these facilities are often critically ill and with limited equipment and specialist staff available at these facilities, patients can easily exceed the local critical care capability. The service ensures these patients have equal access to the appropriate level of care (Sturgeon, 2008) by bringing the emergency department resuscitation room or intensive care department skills to the patient, regardless of location.In the pre-hospital environment, the service responds as the EMRS trauma team. This has provided a dedicated pre-hospital critical care team for the west coast of Scotland and the densely populated area of greater Glasgow, thus ensuring critical care support to the ambulance clinicians of the west of Scotland (Findlay et al, 2007). Within the Glasgow area, the service responds in one of their dedicated response vehicles, whilst further distances are reached by helicopter in a Helicopter Emergency Medical Service (HEMS) configuration with the Scottish Ambulance Service rotary aircraft Helimed5.Due to the range of locations and geography, the service utilise various transport platforms to reach secondary locations. Transport is predominantly by air in association with the Scottish Ambulance Service rotary and fixed wing aircraft, although at times due to weather the service utilises the search and rescue rotary aircraft. Even with these multiple aviation options, there have been instances of severe weather or high demand where it has not been possible to get to the patient, which has seen the team utilising transport platforms such as ferries and lifeboats.

Research developments within the Allied Health Professions Research Network (AHPRN)

The Allied Health Professions Research Network (AHPRN) is a UK-wide body designed to bring together clinicians, researchers, academic staff and other interested parties from all of the allied health professions (AHP) to explore different issues in research, including: practical challenges in research, methodological questions, grant funding, research career development, and many other areas. You can find your nearest hub by going to their website: www.csp.org.uk/professional-union/research/networking/allied-health-professions-research-network or alternatively, type AHPRN in a search engine and follow the links.

Fundamentals of blood pressure measurement

A healthy blood pressure is vital to life and both low and high blood pressure can be life-threatening. This article looks at how the body regulates blood pressure, what a healthy blood pressure is, how it should be measured and what happens when blood pressure rises or falls. Paramedics may see patients who have a previous diagnosis of hypertension or who have suffered the devastating consequences of undiagnosed and uncontrolled hypertension such as myocardial infarction and stroke (Law et al, 2003). Hypotension may be a presenting sign in conditions such as haemorrhage, both obvious as in the case of trauma and concealed as in the case of a slow gastro-intestinal bleed (Dutton et al, 2002) and may also be a sign of chronic disease such as neurological or endocrine disease (NHS Direct Wales, 2013). It is therefore important to understand how to recognise possible causes of blood pressure changes, understand how these fluctuations occur and how to measure blood pressure accurately in order to accurately assess the patient's condition.

An audit of 4679 consecutive emergencies for an emergency care practitioner

An audit using a sample of 4679 consecutive emergency patients seen by a single emergency care practitioner working for a statutory ambulance service in England between November 2007 and November 2013. The results show that the most common type of call attended are traumatic injuries followed by medical problems. The data shows that 53% of patients attended were discharged at scene, with another 8.3% referred to specialist pathways and just 29.3% sent to the majors side of the emergency department. Additionally, it is shown that referrals are made appropriately in the vast majority of cases with just 2.4% of attempted referrals being rejected as inappropriate. Whilst further work is needed to quantify how these figures compare to a more traditional paramedic role, it is suggested that the introduction of a few specific skills such as skin glue and the use of antibiotics for chest infections to general paramedic practice could dramatically reduce unnecessary hospital admissions.

The challenges of pre-hospital paediatric trauma care

The challenges paediatric trauma presents to pre-hospital and emergency clinicians have remained constant over the years. Recently, there has been a nationally increased focus to improve the quality of trauma care in the UK, leading to the development of regional trauma networks in 2012. This focus includes children. This article will discuss the challenges and issues of dealing with paediatric trauma and how some of the problems encountered might be mitigated.

Clinical Guidelines—one year on

DevelopmentThe Joint Royal Colleges Ambulance Liaison Committee (JRCALC) published the first guidance for ambulance staff in 2000 and then again in 2004 and 2006. To help their Guidelines Development Group (GDG), led by Dr Simon Brown, a team at University of Warwick was engaged to help in the challenging task of ensuring that best evidence was being used and ‘consensus’ was achieved amongst experts—no easy task. The Ambulance Service Association (ASA) commissioned this work from JRCALC on behalf of the UK's ambulance services. Now that the ASA no longer exists (it ceased to represent ambulance services soon after the main mergers in 2006), AACE has the task, on behalf of its members, of seeing that a suitable set of guidelines is developed and kept current.Part of the reason for the long delay in updating the 2006 edition lay with the complexity of the task being undertaken by a range of people and often on a voluntary basis. A huge debt of thanks is due from all in the ambulance service to those experts that have so generously given their time.Going forward, NASMeD will lead for AACE on the development of new guidelines. It is important that our guidelines stay the ‘gold standard’ for use in pre-hospital care. AACE are the owners of the intellectual property rights (IPR) and are mindful to maintain their currency. All NHS ambulance Trusts invested in their development and we need to ensure this investment is well managed.It is anticipated that the Ambulance Lead Paramedics Group (ALPG) will play a key role in researching and drafting new guideline texts, and this means that your clinical guidelines will be developed by your colleagues for use in your service. JRCALC will continue to be the key reference point for the expert opinion required of guidelines that are internationally recognised as best practice. It is important that the ambulance sector ensures guidelines are developed to the highest standards and we are aware of the advice given by Harbour and Miller (2001), for example, and that from renown bodies such as the National Istitute for Health and Care Excellence (NICE).

Paramedic treatment—wherever that may be?

James Price is Chair of the HART National Operations Group and HART Manager for West Midlands Ambulance Service NHS Foundation Trust, explains areas of operation and types of PPE used by the programme, and the challenges in delivering clinical care within the Inner Cordon.

2013: the year in review

As paramedics across the country are recovering from the busiest shift of the year, the Journal of Paramedic Practice thought it would look back over 2013 and consider some of the notable events that occurred, both good and bad.

Happy 2014 to all!

It is that time of year again! I am reminded of the lyrics from one of my favourite Christmas songs by John Lennon and Yoko Ono: ‘So this is Christmas, and what have you done, another year over and a new one just begun.’ I am sure many people will be asking themselves where the past 12 months have gone and wondering whether time is going faster or if they are just simply getting slower…

Book Review

In keeping with seasonal tradition, what better way to start the New Year than with a spot of reflection? Add a little professional development and decision-making to the mix and unwanted Christmas book tokens may just have become useful! Not that there are a shortage of texts on the subjects. Far from it. But those which manage to integrate these themes into a coherent read are somewhat thinner on the ground. This may well achieve just that.

London Trauma Conference 2013

London Cardiac Arrest SymposiumThe conference kicked off with a discussion from Dr Richard Lyon on the TOPCAT study. Looking at the rationale behind the trial and some of the problems that arose, the interim results presented by Dr Lyon suggested a number of indicators for potential improvements in the management of pre-hospital cardiac arrest.Prof Simon Redwood spoke on post-cardiac arrest syndrome, outlining its cause, how it should be treated and how it can be prevented. Prof Redwood emphasised the need to develop and adopt a systems approach to all events of pathophysiological processes.Prof Tim Harris then gave a talk on the use of ultrasound (USS) in cardiac arrest. Considering whether USS can aid resuscitation, Prof Harris illustrated training requirements for its use and its potential application in the pre-hospital setting.After the first coffee break, Prof Charles Deakin delivered a presentation on cardiogenic shock after return of spontaneous circulation (ROSC). The key elements of his talk looked at how cardiogenic shock should be treated pharmacologically, how it should be treated mechanically, and what treatments are on the horizon—suggestions he alluded to included synchronised pacing, therapeutic hypothermia, extrathoracic ventilation and gene therapy.Prof Bryan McNally spoke on the Cardiac Arrest Registry to Enhance Survival (CARES), considering evidence for whether cardiac arrest registries improve survival and whether they should be implemented regionally, nationally or locally. He outlined how registries allow for communities to determine OHCA outcomes and identify risk groups and neighbourhoods, as well as enabling clinical benchmarking to identify opportunities and track the diffusion of new therapy.The Douglas Chamberlain Lecture was given by Dr David Zideman on the challenges of providing field of play (FOP) medical care at the London Olympics. Dr Zideman was the lead clinician for the emergency medical services at the London Organising Committee of the Olympic and Paralympic games. He outlined how FOP care is different depending on the sport and so knowledge, preparation and training was essential in providing the best care at London 2012.LEEPARKERFollowing lunch, Prof Karim Brohi discussed open chest cardiac massage. After alluding to the fact that external chest compressions have been around since the 1960s, Prof Brohi went on to question whether they are the best way to generate a cardiac output. In canine models, coronary perfusion pressure has been seen to be five times better with internal cardiac massage, although there are few studies showing the outcome in humans. Prof Brohi therefore questioned whether it is time to do a trial of open cardiac massage.Dr David Menzies then spoke on community first responder schemes, considering challenges they face and their potential solutions. One of the predominant issues concerns the maintenance of skills and interest, especially as training is not always standardised. Given the high level of cardiac arrests that occur at home, the continued need for CFR schemes is evident.After the afternoon coffee break, Dr Matt Thomas spoke on neuroprotective strategies for post-cardiac arrest syndrome. Dr Thomas highlighted the importance of controlled re-oxygenation as well as considering therapeutic hypothermia, a treatment that has received much debate recently. The main take home message from the talk was to not prognosticate too early, as improvements patients following OHCA can be seen as late as 72 hours.Dr Eldar Soreide spoke on recent advances in improving OHCA in the Stavanger region of Norway. Dr Soreide mentioned how we are obsessed with medical breakthroughs rather than follow-throughs, and how focusing on bystanders can improve outcomes of OHCA.Prof Daniel Davis gave the final talk of the day on what makes up a high-performing hospital team. Highlighting the work of the UC San Diego Center for Resuscitation Science, he emphasised the importance of advanced resuscitation training, inpatient/technology-specific algorithms and the need for an organised approach to data analysis.

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