Volume 6 Issue 10

Evaluation of pre-hospital point-of-care testing for lactate in sepsis and trauma patients

Objective: Lactate is a significant marker of critical illness and mortality in sepsis and trauma patients. The purpose of this study is to evaluate point-of-care lactate testing by paramedics in a UK ambulance service.Methods: Selected enhanced care paramedics were trained to use the lactate meter in patients with suspected sepsis and patients who trigger the major trauma bypass protocol. Feedback was collected on the practicalities of using the meter and the potential impact on the diagnosis of sepsis.Results: Data were collected on 114 patients, 96% had suspected sepsis (n=109) and 4% (n=5) were patients who had sustained trauma. The participants found that the ability to take lactate readings was useful and increased their confidence in their clinical decision making.Conclusions: Point-of-care lactate measurement is feasible in pre-hospital care and appears to support paramedics in their decision making.

Palliative emergencies in the pre-hospital setting

Objective: To provide a narrative on the most common palliative emergency situations that requires the attendance of a paramedic. This narrative looks specifically at pain, seizures and breathlessness, and critiques the underpinning evidence supporting their treatment and protocols.Discussion: Pain—the presence of pain in palliative care is highly prevalent with up to 70% of patients living in a permanent painful state. Clinician-led pain assessment has been shown to underestimate the patient's pain by as much as 60–68% and none of the assessment tools used are fully inclusive. Further research is needed to formulate an assessment tool that recognises palliative pain as a progressive disorder requiring constant assessment.Seizures—Seizures occur as either a result of disease progression or as a side effect of medications. Studies have shown that intramuscular midazolam is more effective than intravenous lorazepam, which is itself more effective than intravenous diazepam. The ease of administration of intramuscular and buccal midazolam for out-of-hospital use should make midazolam the first-line treatment for palliative care patients that suffer from seizures. The implication for future paramedic practice highlighted from these studies is the need for more research in the treatment of palliative patients with seizures.Breathlessness—Cold facial stimulation has been shown to be very effective as a non-pharmacological treatment for breathlessness. Opioids help to relax the patient which aid in regulating breathing patterns although a consensus on the route of administration which provides the best possible effect is yet to be reached. The evidence base for the use of anxiolytics is weak and some studies have shown no beneficial effect to their use. Although anxiolytics are effective in reducing anxiety their effectiveness in helping breathlessness in palliative patients is questionable. Home oxygen should be adopted as a first line treatment according to experts working in end-of-life care, and treatment of oxygen should not be delayed by waiting for results of other trials for other treatments.

Essex and Herts Air Ambulance: a focused case series for pre-hospital practice Case 3: a femoral shaft fracture

The femur is the longest bone in the human body and is surrounded by a dense and vascular cylindrical sheath of soft tissue. Femoral fractures are often the result of high-energy traumatic injuries and result in pain, blood loss and immobility of the affected leg. General principles of acute management include analgesia, assessment of the patient for associated injuries and restoration of anatomical alignment of the leg. Assessment and documentation of the neurovascular function in the foot distal to the fracture is essential. Haemorrhage from a femoral fracture can be extensive, even more so if the fracture is open. Control of further blood loss and attention to the patient's cardiovascular status is mandatory.We report the case of a 23-year-old woman who was involved in a pedestrian-versus-car incident and sustained an isolated right femoral fracture. Scene and patient assessment are discussed along with early management principles including analgesia and traction. We also discuss where an extended care service such as a Helicopter Emergency Medical Service (HEMS) may be of assistance

Experiences of two paramedics deployed to the Phillipines in response to Typhoon Haiyan

This article describes the experiences of two paramedics from the UK International Emergency Trauma Register (UKIETR) who deployed as part of the UK-Med response to Typhoon Haiyan in 2013. Each had a key role in the deployed teams, both targeting distinct but differing health needs following the Typhoon. Tim Byrom was a member of the first team activated on 13 November 2013. He formed part of a surgical, anaesthetic and rehabilitation team that assisted the Australian Medical Assistance Team (AUSMAT) at their field hospital in Tacloban. Peta Watts was in the second team, deployed two weeks after the Typhoon following invitation to continue assessments and health provision on outlying islands. Her experience involved being part of a unique and effective collaboration between the Department for International Development (DfID), UK-Med, and the British Military in the delivery of an integrated humanitarian aid package.

Pre-hospital paediatric seizures: midazolam versus diazepam

This literature review aims to scope the current evidence for use of diazepam and midazolam for managing seizures in children, with particular focus on pre-hospital management. Many emergency departments now use buccal midazolam as first-line treatment for managing paediatric seizures, while ambulance services continue to use diazepam via the rectal (PR) or intravenous (IV) route.This review concludes that the evidence for the continued use of diazepam by ambulance services should be reconsidered if we are to provide the best standard of care for our paediatric patients—and move our treatment in line with best practice, and what is considered the norm in a hospital setting.

National Air Ambulance Week

Last month, air ambulance charities across the country appealed to the public to celebrate the work of local air ambulances and promote awareness of the services they provide. Running from 22–28 September, National Air Ambulance Week is a national campaign introduced by the Association of Air Ambulances, which gives the air ambulance community a national voice and an opportunity to promote the work that they do at a local level (Association of Air Ambulances, 2014).

Spotlight on Research

What was it like for you?This qualitative study was undertaken in Sweden and explores patients' experiences of their encounters with pre-hospital staff, with a particular focus on the meanings they attribute to their relationships with ambulance clinicians.In total, 20 people (13 males; 7 females) aged between 25 and 88 years were interviewed. They met the following criteria: aged over 18 years, conscious during their time with ambulance staff, and able to give informed consent.Interviews were conducted either at home (n=18) or at work (n=2) according to the participants' preferences. They were audio recorded and transcribed verbatim in preparation for analysis. Three main areas were addressed, including the actual incident/experience itself, the early stages of the therapeutic relationship, and how the relationship developed during the clinical encounter.The authors outline that the process of analysis involved three steps: naïve reading, structural analysis, and comprehensive understanding. The paper gives useful examples illustrating this approach to analysis which was informed by a phenomenological hermeneutic method, enabling the researchers to move back and forth between understanding and explanation of the content.It was in the structural analysis that the main theme ‘To surrender in dependence of another’ emerged. Overall this incorporated both negative and positive experiences, sometimes including relief at being able to relinquish responsibility to the expert healthcare professional and being able to trust their judgement and competence as clinicians but, sometimes, it was an altogether less positive experience, where participants felt powerless and disregarded in decisions relating to their own treatment and management.This overall theme was divided into four sub-themes. First, they outline ‘being in the hands of another’—this was viewed as positive, with participants describing having trust and confidence in the ambulance staff and their clinical decision-making. The patients felt safe but still engaged in the decisions relating to their care.The second sub-theme—‘being in a caring temporary presence’—reflected the relief that patients expressed that they were no longer on their own, that help had arrived. This relief started even before the physical presence of staff e.g. from the point that the patient could hear the ambulance's siren in the distance. Patients talked about the development of an empathetic, relaxed and intimate relationship that was terminated once they arrived at ED. The one-to-one relationship no longer existed in ED with frequent reports of patients feeling ‘lonely’ even though they were under hospital care.The third sub-theme—‘being important while involved’—again reflects positive experiences, where participants reported that they felt the ambulance staff involved them in care decisions and listened to what they were saying. The patients believed the clinicians respected their requests and kept them informed as to the next steps.This was in stark contrast to the fourth sub-theme: ‘being powerless while insignificant’. Here participants identified that the clinicians did not listen to them and, on occasion, they were not allowed to do things they felt capable of doing for themselves. They reported feeling disrespected, insignificant and, sometimes, humiliated.The discussion section in the paper effectively pulls all of these themes together and contextualises the findings against other existing literature. Overall, the authors recognise that there are both strengths and limitations within the study and caution against trying to generalise these findings as, clearly, the paper reflects the experiences of these 20 individuals.Nonetheless, this paper highlights areas of complexity within the patient/clinician relationship that may contribute to our understanding of this phenomenon from a patient's point of view. The authors conclude that future research should involve ambulance staff and family/friends' perspectives in order to give a well-rounded view of this phenomenon.

College of Paramedics evidence into mental health care and policing

Comments on surveyThe survey represents only a snapshot of views from a relatively small number of the UK's 20 000 paramedics. However, it is felt that this is a fair representation of the general view of paramedics, though there would need to be structured research to ensure academic rigour and scientific validity. It is suggested that the survey provides the following insights:• There is a higher level of awareness of sections 135 and 136 of the Mental Health Act 1983 than there is of understanding amongst paramedics responding to the survey• The paramedics respondents believe the level of understanding of sections 135 and 136 of the Mental Health Act 1983 among the police is fairly low• There is a resounding call among the respondents for further education and training in mental health for paramedics• There was a small majority of paramedics who felt there was a need for additional powers through legislation for paramedics, but there was clear evidence to have further treatments available for paramedics to provide this group of patients (however, more research would be need to specify what those treatments could be)• There is both perceived and actual risk to paramedics when dealing with some patients with mental health illnesses• Mental health cases are increasing as a proportion of the workload for paramedics.

Book Review

Essentially, this title covers two topics: evidence–based medicine (EBM) and how to read a clinical paper. They are not mutually exclusive, given the presence of a number of closely linked themes, but a distinction exists nonetheless.

Continuing Professional Development: Managing premature babies in the pre-hospital environment

OverviewBabies born at ≥37 weeks of gestation are considered to be born at term; therefore, any baby born earlier than 37 completed weeks of gestation are termed as premature babies. A consistent rise in preterm birth rate has been noted around the world (Norman et al, 2009). Available statistics from the United States shows that preterm births constituted 12.8% of live births in 2006; this is an increase by 20% since 1990 (Muglia and Katz, 2010). The challenges that result from preterm delivery will vary depending largely on the gestational age and birth weight. The general rule is that adaptation of the newborn to extra-uterine environment becomes more problematic with smaller and less mature babies. It is therefore important to understand some definitions related to the gestational age and weight.Learning OutcomesAfter completing this module you will be able to:• Be able to recognise some of the definitions related to gestational age and weight.• Understand why babies are delivered prematurely.• Know which vital issues to address to ensure the successful transfer and stabilisation of a premature baby.• Gain an insight into the survival rates of prematurely born babies in hospital and out of hospital.

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