Spotlight on Research

Supporting bystanders involved in out-of-hospital cardiac arrestOver the years it has been evidenced that early recognition and appropriate treatment of cardiac arrest can impact on survival rates, and this work emphasises the important role that bystanders can play in the management of out-of-hospital cardiac arrest (OHCA).This qualitative study was undertaken in Denmark between March and July 2013. It focuses on the concept of systematic debriefing of bystanders involved in OHCA, as well as exploring the effects that debriefing can have on these people.Data collection involved audio-recorded, semi-structured telephone interviews with a sample of 15 individuals who had participated in resuscitation attempts in OHCA, and who had also received telephone debriefing (audio-recorded) after the event.The debriefing was delivered by Emergency Medical Dispatchers (EMDs) who, in Denmark, are specifically trained paramedics or nurses. The debriefing guidelines were based on concepts of adult learning and adapted from the field of medical simulation encouraging participants to reflect on their performance.Twelve EMDs were trained in the debriefing process (although only nine participated in the study), and they were also taught how to recognise possible warning signs of people who were not coping. The project manager monitored the EMDs' approaches to debriefing throughout the study, and the debriefing guide was adjusted accordingly—although there is no specific information offered in the paper as to the extent of these changes.EMDs contacted the bystanders between two and four days after the cardiac arrest event to debrief them, and this interaction was opened by asking the bystander to describe their experiences. Subsequently, the EMD explored the bystander's coping strategies and, if the EMD felt it was necessary, they advised the bystander to contact their GP for additional support, which applied to two of the 15 participants in this study. All bystanders were given a dedicated phone number to call the dispatch centre if they had further questions after the debriefing.The follow-up interviews were carried out between one and two months after the debriefing and explored areas including the bystanders' reactions when receiving the debriefing, their perceptions of the effects of the debriefing and their views as to its value, and their recommendations for development of a systematic approach to debriefing.It is a strength of the paper that the interview schedule and the debriefing guide are included in the paper to inform the readers' understanding of these events.Using a phenomenological approach to analysis, six main themes were identified from the first set of data obtained during the debriefing itself. These related to: challenges when identifying OHCA; bystanders' emotions and perceptions of OHCA; working with health professionals; what happens to the patient in terms of outcome; how bystanders cope with the experience; and reflection on the event, which covered a wide range of topics including what more, if anything, could have been done and what to do to prepare for future events.From these interviews, it emerged that in relation to short-term effects, participants generally valued the debriefing, seeing it as a useful safety net in case any of the bystanders were not coping, plus it gave an opportunity to discuss and reflect on the event with a health professional rather than just friends and family.Some participants indicated that there were positive debriefing effects even at two months after the session, notably in terms of increased confidence in their own skills having had that opportunity to clarify any areas of uncertainty with a qualified health professional.Overall, participants were in support of this type of debriefing event after involvement in OHCA resuscitation attempts. They reported it was important that a health professional routinely initiated the interaction so that it was not seen as the bystander asking for help; they were in favour of the dedicated phone line to the EMDs viewing this as a positive mechanism of support; and they stressed the importance of qualities such as strong communication skills (including active listening) in the EMD facilitating the debriefing session.As with many research studies, this study has some limitations and questions around methodological decisions including the decision not to involve bystanders who were related to the person in cardiac arrest. The authors recommend that future research could address these deficits but emphasise that this is a preliminary, exploratory study which has begun to explore the role that debriefing could play on a bystander's experience of being involved in OHCA.Additionally, there needs to be consideration of the differences in organisational structure of emergency health care provision between Denmark and the UK before looking at transferability of the findings between the two countries.Nonetheless, this study raises important considerations which would be useful to explore within a UK context in order to see whether implementation of a similar process of support and reflection could impact on our bystanders' level of skills and motivation to engage in resuscitation attempts of people in out-of-hospital cardiac arrest.

Self-extrication in road traffic collisions: do we really need to cut the roof off?

Road traffic collisions are commonly encountered in the pre-hospital environment, and extrication of vehicle occupants can be challenging. Allowing a person to self-extricate from the vehicle, rather than using the process of prolonged mechanical extrication (the process of removing a vehicle from around a person), can be beneficial to the patient in a number of ways. The chance of catastrophic spinal injury (in this case taken to mean ‘any spinal injury that results in permanent disability, long-term medical problems or shortened life expectancy’) is low, and self-immobilisation during the extrication process will mean the patient is capable of protecting any injury they may have, without making it worse in any way. This is supported when the physiology of the spine, and the kinetics involved in road traffic collisions are considered. In addition, the self-extrication method is likely to reduce the time to definitive care, potentially improving the outcomes for many patients. It will also reduce anxiety, mental trauma and an unnecessary use of resources. Inviting a patient to remove themselves from a car is not a declaration of an uninjured cervical spine, and so immobilisation must still be used, in line with local policy, once the patient is out of the vehicle.The author presents an algorithm to assist the pre-hospital clinician in deciding if self-extrication is appropriate. It is based on the alert, systemically well patient agreeing to the plan and being aware that they may change their mind at any time. The need for focused research on the mechanics of extrication, rather than methods of immobilisation, is encouraged with a view to a validated algorithm in the future.

A simulated wilderness exercise: the development of relational competence in paramedic students

The aim of this study was to assess the impact of a cognitively and physically challenging simulated wilderness exercise (SWE) on the development of relational competence in senior paramedic students. New paramedic graduates reportedly bring limited relational competence to their work role. The SWE, conducted in a wilderness landscape in Central Victoria, Australia was developed to address this limitation. Our study, an interpretative qualitative design, used a convenience sample of paramedic students who attended the three-day event (n=29). Qualitative data were collected through participant field diary and focus groups. Thematic analysis of study data identified four themes associated with relational competence, with each giving voice to participants’ new understandings of themselves in the work environment, namely: ‘interpersonal relating’, ‘maturity, respect and tolerance’, ‘self-awareness in the team environment’ and ‘belonging and professional identity’. It is clear that the challenge of working in teams in an unfamiliar and physically taxing environment prompted and/or extended relational competence in study participants. The practice implication of this finding is that these graduates will perform the relational aspects of their work role with greater ease, thus strengthening transition to normal work pressures in their first professional work role.

Increasing objectivity in the assessment of interpersonal skills and attitude

The concept of failure to fail has become more widely discussed in paramedic practice over recent years; however, it has been observed that on occasion mentors and managers experience challenges around the non-practical components of paramedic practice. Consideration has been given to identifying those elements of practice which can be more challenging to encapsulate, with the aim of providing objective feedback and where necessary set pass/fail standards. A non-practical skills matrix has been developed for consideration by those responsible for the development of ambulance staff and students.The proposal encourages qualities of the burgeoning concept of distributive leadership, incorporates elements of the document Towards a New Model of Leadership for the NHS (Department of Health (DH), 2013a), and having been mindful of the NHS response to the failings of Mid-Staffordshire and the findings of both Lord Francis’ and the Health Ombudsman (Parliamentary and Health Service Ombudsman, 2011; DH, 2013b), it responsibly aims to aid in the implementation of aspects of the recommendations capturing the current drive towards improved demonstrable compassion in UK care delivery.

Why evaluation is important to you, me and everybody

The Health and Care Professionals Council (HCPC) suggest that the use of operational evaluation and monitoring contributes to the creation of correct and current assessment standards (HCPC, 2009).This short article is aimed at anyone who attends training courses including mandatory, induction, CPD, management and clinical skills, and explores the theory of evaluation and its benefit in adding depth and value to all training purposes.

Is it time to change? The use of intranasal fentanyl for severe pain in the pre-hospital setting

The treatment of pain is a commonplace issue for today's paramedics, where the need for new analgesics to overcome cannulation barriers is gathering momentum. Intranasal fentanyl has proven itself to be a very safe and effective form of analgesia that overcomes those barriers and can help paramedics provide a higher standard of care. Although research into its use in the pre-hospital environment is still limited, evidence of its effectiveness in the accident and emergency department has highlighted its potential for helping paramedics treat severe pain where venous access is compromised. Studies have shown that intranasal fentanyl compares with the analgesic standard set by intravenous morphine and is rapidly becoming the drug of choice in the paediatric accident and emergency department.

Book Review

Clinical Leadership for Paramedics Every time I receive books to review from the JPP editor, I tear off the brown packaging with the enthusiasm of a five-year-old child on Christmas morning. And top of the pile sits another text on clinical leadership—feelings now akin to receiving another pair of white socks on the aforementioned Christmas morn.Clearly no shortage of texts on this subject, but what makes this one stand out is how it manages to address concepts, such as the NHS Leadership Academy, leadership and competency frameworks, from the perspective of paramedic practice. It is not concerned with the narrative as much as how it translates for our profession.The primacy which I place on paramedics’ literature being informed by paramedics themselves is not borne out of some narrow professional pride but based on the premise that our practice is discernibly different to other fields of medicine.Imagine my joy when but a few pages into the text, attention is drawn to the plethora of paramedic profiles that exist in the UK, each with their own scope of practice and perspective on clinical leadership. To compound this new-found elation, and with direct relevance to clinical leadership, a designated chapter on ‘Paramedic Leadership’ is included, as well as one on ‘Decision Making’—addressed specifically from a paramedic's perspective.Not all the contributors are paramedics and nor do they need to be. Drawing on the experience and knowledge of allied health professionals generates eloquent, and well-informed, contributions on subject areas integral to clinical leadership.The case studies presented are fairly limited and lack depth, but self-evaluation exercises and reflective points to consider are summarised throughout. More importantly, the editors have managed to achieve that most difficult of literary balances, incorporating theoretical paradigms within the parameters of paramedicine. No easy task.Reflecting a trend where paramedics are not just contributing to but generating literature and research in health care, I cannot recommend this book strongly enough. Congratulations to all involved. A must buy.

Student paramedic conference helps advance cardiac care

Post script—Paul VigarThe Canterbury Christ Church Student Paramedic Society was set up to promote the role of the student paramedic and to provide continuing professional development opportunities for all health and social care students, with a focus on working out of hospital.I understand that this was only the second student paramedic society to be set up in the UK and I am extremely proud of the work they have done. A number of interesting events have been organised since the society was founded, culminating in this ambitious conference. The quality of the speakers and the number of delegates that attended the Advanced Cardiac Care Conference in September speak for themselves; this was a professional, well-evaluated event and I hope that the society will continue their hard work in providing such experiences for students and registered health care professionals alike.

SADS UK honour lifesavers at National Defibrillator Awards

On Saturday 18 October at the Royal College of Nursing, cardiac charity SADS UK commended those in the community who have used CPR and the defibrillator to save lives, at the National Lifesaver Defibrillator Awards.

Allied health professionals’ contribution to the quality of care and service delivery

A report has been produced by QualityWatch exploring the quality of care and the services that are delivered by allied health professionals (AHPs) in the UK. Ian Peate looks at the comparative data between the various professional AHP groups, before exploring the section of the report that focused on paramedics.

Patients and pay: meeting the demand

Last month thousands of health workers, including paramedics, took part in the first strike over pay in 32 years.