Volume 6 Issue 6

Essex and Herts Air Ambulance: a focused case series for pre-hospital practice Case 2: tension pneumothorax

A tension pneumothorax is an important reversible cause of deterioration in the multiply-injured patient, but it is not always easy to make the diagnosis. Features that indicate the development of a tension pneumothorax can be subtle in the spontaneously breathing patient. The ‘classical’ features may not all be present and in addition, the clinical signs of tension may develop over time with increasing patient compromise. This is a life-threatening situation, which requires relief in order to save the patient's life. A tension pneumothorax can be managed in one of three ways: needle decompression, insertion of an intercostal chest drain or by open thoracostomy. Needle decompression can be performed quickly and safely by paramedic crews using well-established techniques in both the conscious and unconscious patient.We describe a case of a 55-year-old male who was ejected from his motorcycle at high speed. He was conscious with a Glasgow Coma Score (GCS) of 15 and complaining of difficulty breathing. In contrast to the often quoted classical features of a tension pneumothorax, we review the more common clinical findings in tension pneumothoraces as illustrated in this case study. We aim to show that the diagnosis can be reached by careful history taking, examination, and attention to patient physiology. The case study also shows that a tension pneumothorax can be a dynamic developing situation in which patient compromise develops over time. We highlight that much can be done in the pre-hospital phase to treat such a patient while expediting transfer to hospital. We review the pre-hospital management of a tension pneumothorax and also describe our procedure for pre-hospital chest drain insertion in the context of effective teamwork between a paramedic road crew and an attending helicopter emergency medical service (HEMS).

Paramedic perceptions and attitudes to working with patients with alcohol-related injury or illness

AimsTo ascertain views, perceptions and attitudes of paramedics when working with patients presenting with alcohol-related injury or illness, and to explore perceived barriers and facilitators for the introduction of alcohol interventions to the NHS ambulance services.MethodsA total of 142 (24%) from 589 paramedics from the North East Ambulance Service NHS Foundation Trust returned completed surveys between January 2013 to April 2013, which included measures of current perceptions and attitudes of working with patients with alcohol-related injury or illness, and the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ).ResultsParamedics reported little to no formal training on working with patients with alcohol-related injury or illness (77%). Paramedics scored low across all domains of the SAAPPQ for working with both problem and dependent drinkers. Not having suitable counseling materials (77%), not enough training (72%) and no facilities or time to deal with prevention (69%) were key barriers.ConclusionsAt this present time, levels of commitment, motivation, satisfaction, legitimacy and adequacy are low in front-line paramedics when working with patients with alcohol-related injury and illness. However, they are open to finding ways to provide interventions if they are adequately trained and have appropriate referral pathways open to them.

Pulse oximetry in the pre-hospital setting

In order to sustain life respiratory gases are essential. The ability of the paramedic to monitor these gases is key to high-quality, effective, prehospital care. Pulse oximetry provides the pre-hospital care provider with a resource that enables them to monitor patients when they are in the field. The standard method for monitoring peripheral arterial oxygen saturation is pulse oximetry. It is common that supplemental oxygen is given to target levels of oxygen saturation, assisted by the use of pulse oximeters. Other methodologies are available that allow the monitoring of carbon dioxide through capnography and carbon monoxide through CO-oximetry. A pulse oximeter is a non-invasive product that assists the paramedic in assessing the haemoglobin content in a patient's blood.

Spotlight on Research

Is less sometimes more? Airway management in cardiac arrest…In this retrospective database analysis, McMullan and colleagues reviewed the Cardiac Arrest Registry to Enhance Survival (CARES) registry for 2011 to determine the influence of airway management approach on rates of sustained return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge and survival to hospital discharge with good neurological outcome (Cerebral Performance Category 1 or 2).The CARES registry collates data relating to cardiac arrest from 400 emergency medical service (EMS) agencies across the USA. This analysis included adults (age ≥18 years) and excluded cases where age was unknown or not reported and where airway management data were not reported or the device used was listed as ‘other’. Cases were classified as receiving endotracheal intubation (ETI), supragalottic airway (SGA) insertion or no advanced airway. SGA devices used by participating agencies include King Laryngeal Tube, Combitube and Laryngeal Mask Airway (LA). Cases where ETI or SGA insertion failed were classified as no advanced airway.Outcome analyses compared ETI versus SGA, and no advanced airway management versus advanced airway management (SGA or ETI). During 2011 there were 12 875 cardiac arrests reported. Children (n=256), patients where age was unknown (n=83) and cases where the EMS agency did not provide airway management details (n=1,847) were excluded from analysis.An advanced airway was placed in over 80% of the remaining 10 691 patients, with approximately two-thirds undergoing ETI. The King airway was the most commonly used device in the third of patients managed via SGA. Patients undergoing ETI were more likely to be male and older and less likely to receive public access defibrillation. Patients receiving no advanced airway were more likely to have a cardiac arrest in a public location or healthcare facility and to have their arrest witnessed by EMS staff and present with a shockable arrest rhythm.ETI was independently associated with increased adjusted odds of sustained ROSC, survival to hospital admission, hospital survival and good neurological outcome when compared with SGA insertion. Stratification of outcomes according to presenting arrest rhythm revealed that these associations persisted for patients in shockable rhythms only. Patients with no advanced airway intervention demonstrated higher adjusted odds of survival when compared with those receiving ETI or SGA.These results must be interpreted with caution given some of the methodological limitations associated with this study. The CARES registry does not provide data relating to number of attempts at advanced airway insertion; therefore, it is not clear in how many cases a SGA was inserted as a rescue device following ETI failures that might be expected to result in worse outcomes. Patients who did not receive advanced airway management may also represent a group in whom ROSC was achieved more rapidly, negating the need for such intervention and representing a group with potentially higher survivability. Similarly, in-hospital data relating to potential confounders such as use of mild therapeutic hypothermia and percutaneous coronary intervention are lacking. Nonetheless, these findings again challenge the assumption that SGA devices are a universal alternative to ETI in out-of-hospital cardiac arrest.

An overview of the Medical Emergency Response Team (MERT) in Afghanistan: a paramedic's perspective

This article gives an overview of the Medical Emergency Response Team (MERT) while deployed in Afghanistan during Operation Herrick. The article is an information piece giving a brief history, training background and an overview on how the MERT works and is governed. It will give an insight into the clinical procedures used by a multi-disciplinary pre-hospital care team, the decision-making process and the advances made in military pre-hospital care. It is written from a paramedic's perspective and develops the understanding of how MERT and wider military developments during this conflict have impacted on civilian trauma care and what potential it has in the future.

Continuing Professional Development: Major trauma and catastrophic haemorrhage

OverviewMajor trauma is a leading worldwide cause of mortality, killing or seriously injuring thousands of people each day. Casualties have the potential to die immediately as a result of massive head injury or rupture of major vessels, or shortly afterwards as a result of progressive blood loss and hypoxia. A third group survive the initial insult, but succumb to their wounds days or weeks later as a result of secondary conditions including multiple organ failure and sepsis. This Continuing Professional Development (CPD) module will focus on the rapid assessment and timely management of casualties of major trauma, with particular emphasis placed on the catastrophically haemorrhaging patient.Learning OutcomesAfter completing this module you will be able to:• Define the concepts of major trauma and catastrophic haemorrhage• Appreciate the range of traumatic injuries sustained in the United Kingdom• Revise the pathophysiology of haemorrhage and hypovolaemic shock• Understand the management of the traumatically injured patient• Learn about a range of recent developments in trauma care

Continuing Professional Development: Venous thromboembolism

OverviewThis Continued Professional Development article will outline the epidemiology and risk factors surrounding venous thromboembolism (VTE), a disease which encompasses the pathology of both deep vein thrombosis (DVT) and pulmonary embolism (PE). This article will allow the reader to understand the subtypes of VTE and their management in an acute setting.Learning OutcomesAfter completing this module you will be able to:• Understand the risk factors of VTE• Understand the pathophysiology of VTE• Know when to suspect VTE according to clinical probabilistic scoring• Describe the important features of care in pre-hospital VTE.

Where are we going? Outlining the next year

Now that I have had some time to settle into my new role I have been able to better outline how I can contribute to what that College is aiming to achieve over the next year. This is an exciting opportunity and I am grateful to the London Ambulance Service and the College in facilitating this appointment.

On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace

On Combat: The Psychology and Physiology of Deadly Conflict in War and in PeaceWritten by a retired US army colonel with a PhD in psychology, On Combat describes the psychological and physiological effects combat has on the human condition. Although aimed at those facing physical violence and conflict—namely soldiers and law enforcement officers—there are uncanny comparisons to be made with pre-hospital critical care. By replacing ‘combat’ with ‘resuscitation’, certain sections speak clearly to the paramedic profession.One of the most relevant sections was on fear, physiological arousal and performance. Four conditions are used to describe the various changes in performance factors under increasing levels of stress: white (stress free) to yellow (vigilant), red (optimal survival) and finally black (overload). At a heart rate of around 115 bpm, fine motor skills begin to deteriorate. Conditions red and black bring about a reduction in complex motor skills, cognitive functioning, and auditory and visual senses. This is also applicable to the states we find patients involved in stressful events such as traffic collisions or violence. The associated increases in vital signs are well documented, but their inability to recall events is not so widely known.The text would also benefit those with an interest in pre-hospital training and education. Simulation, stress inoculation and learning motor-skills in high-pressured situations are discussed in some depth. Certain myths are dispelled, for instance in moments of crisis we don't rise to the occasion, we sink to our level of training. Grossman also discusses in some depth the science and psychology behind debriefs, mitigating PTSD, and techniques to control that rising panic.The text is very well structured and wonderfully lucid. The points are well illustrated with liberal use of real-life examples. Though the style is a touch inconsistent, wavering between an Americanised ode to ‘warriors’ and a serious academic work, this is quickly forgotten given its strength lies in the quality of substance.What On Combat offers is a highly salient text that sheds light on the neglected human factors of pre-hospital care. Mandatory reading for anyone seeking to improve or understand their practice.

Managing Minor Musculoskeletal Injuries and Conditions

Managing Minor Musculoskeletal Injuries and ConditionsAccepting that a significant proportion of paramedic practice is now dedicated to low-acuity medical conditions, this text immediately assumes relevance for a paramedic readership as it concerns the management of minor injuries. In truth, it appeals to a much wider audience ranging from medical students of any discipline to clinicians who already have some exposure to practice.While the documented injuries and conditions may be classified as ‘minor’, the management of them is more complex and detailed than might originally be thought. The author deals with this effectively with a coherent structure to the book throughout. Common musculoskeletal conditions are well-documented along with the relevant anatomy and physiology. The customary inclusion of references has been enhanced by additional suggested reading and the use of multiple choice question tests at the end of each section provide the reader with an opportunity to reflect on their learning.None of the above provides a unique selling point for this book, but what does distinguish this from the crowd is that the reader has been given access to a ‘companion website’. A hugely informative tool, it can be used as a supplement to the book itself or as a stand-alone resource. Easy to navigate and jam-packed with invaluable resources such as X-rays, PowerPoint presentations and case studies, as an online resource in itself it represents a veritable goldmine of material in this subject area. Clever use of e-learning, allowing for a far greater variety of learning resources to address the subject area than would be available in a conventional text.Using both the book and website in tandem provides an engaging and informative experience for the reader. More importantly, the content is precisely the level at which paramedic practice should be shaped on. Achieving the balance between presenting complex clinical material in such an easily-digestible and creative manner, it is difficult to come to any other conclusion—recommended.

Ambulance Service Institute Annual Awards 2014

On 8 May at the Cholmondeley Room and Terrace, House of Lords, the Ambulance Service Institute held their annual awards, recognising those in the pre-hospital sector who have performed above and beyond the call of duty.

Getting more AEDs in public places

Sudden cardiac arrest (SCA) is a leading cause of premature death. In the UK alone, approximately 30 000 people sustain cardiac arrest outside hospital and are treated by emergency medical services (EMS) each year (Pell et al, 2003). However, many SCA victims can be saved by bystanders who recognise what has happened, summon the ambulance service as soon as possible, perform basic CPR and use an AED to provide a high-energy electric shock to restore the heart's normal rhythm (Resuscitation Council (UK) and British Heart Foundation, 2013).

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