Spotlight on Research

Mail order weight loss agent-buyer beware!The paper describes a surveillance study conducted by poisons specialists working at the four National Poisons Information Service (NPIS) centres covering the UK. The service since 2005 has standardised its operating procedures, providing 24-hour toxicological support to healthcare providers via telephone or online TOXBASE® enquiry; moreover, standardising its procedures has allowed information to be stored on a national database which forms the axis for this study.The study describes data collected from telephone enquiry records and TOXBASE® user sessions concerning the substance 2, 4-Dinitrophenol (DNP) between the periods 1 January 2007 to 31 December 2013. The paper reports age, sex, reported dose, duration of exposure, clinical features and outcome, the latter using a validated poisons severity score (Persson et al, 1998).The weight-reducing properties of 2, 4-DNP have been well documented. It does, however, have a considerable toxicological profile and was banned by the FDA in 1938; although its effects on French munitions workers were documented much earlier during WWI (Tewari et al, 2009). 2, 4-DNP uncouples oxidative phosphorylation, increasing metabolic rate, heat production and lipolysis, but has a narrow therapeutic index and displays considerable inter-individual variation in dose response. Despite this 2, 4-DNP is readily available via the unregulated mail order sector (Siegmueller and Narasimhaiah, 2010).In this regard the paper demonstrates the value of a well organised surveillance study, acting as a signal amplifier for toxicological trends; a point made apparent by Figure 2 showing a sharp rise in both telephone and TOXBASE® enquiries from 2012.Throughout the paper the results are well presented; for example, demonstrating that as enquiries regarding 2, 4-DNP have risen, so has mortality from one fatality in 2012 to three in 2013. Furthermore, a clinical features table allows the reader to establish the main presenting features of 2, 4-DNP toxicity in conjunction with key epidemiological data presented in Table 3 indicating that of the five fatalities from 2, 4-DNP exposure during the study period, four were male and occurred as a result of acute, not chronic toxicity.‘The paper offers a balanced mix of biochemical, clinical and epidemiological data in a well presented format that is certainly relevant to the out-of-hospital clinician’A key strength of this paper lies in its methodology insofar as the search criteria are sharply delineated, with only clinical enquiries included in the study while data from educational establishments were excluded. This robustness is further strengthened by virtue of 2, 4-DNP being a substance of interest to NPIS, as such follow-up calls are made to clinical teams involved in the case to gather follow up data; this has certainly enhanced the results section of the paper, in particular Tables 2 (relating to clinical features) and 3 (detailing the reported fatalities).Although the paper alludes to the incomplete dose information in some of the cases and makes no secret of the reliance on clinical interpretation of symptoms by the healthcare professional making the enquiry, it is consistent with previous reports of 2, 4-DNP toxicity. The paper further indicates that non-educational establishments may use TOXBASE® for purely educational purposes and as such may have contributed to a spike in enquiries; indeed a further contributing factor to this increase may have been the Food Standards Agency's 2, 4-DNP warning issued in 2012, which corresponds with the spike in NPIS enquiries.This notwithstanding, the paper offers some valuable insight into the role of the NPIS, while alerting the clinician to the potential for toxicity from hitherto unsuspected agents freely available via mail order. The paper offers a balanced mix of biochemical, clinical and epidemiological data in a well presented format that is certainly relevant to the out-of-hospital clinician.

Intranasal and buccal midazolam in the pre-hospital management of epileptic tonic-clonic seizures

Epilepsy is a common neurological condition causing seizures or convulsions. This article looks to analyse the treatment and management of a patient suffering from a prolonged epileptic tonic-clonic seizure by the administration of two common benzodiazepines: midazolam and diazepam. Epileptic seizures carry high risks of secondary injury and the potential for long-term neurological damage; therefore, it is imperative that paramedics can provide swift and effective treatment for these patients. With current advances in pre-hospital care, paramedics should be aware of the latest advances in techniques, management and the associated legal issues. This article will look specifically at the administration of benzodiazepines and in particular the comparison between midazolam and diazepam and the routes of administration available.

Potential use of amiodarone to treat new-onset AF in the pre-hospital setting

Incidence of atrial fibrillation (AF) is high, it is the most prevalent arrhythmia in the UK, Europe and the USA (Naccarelli et al, 2009; Davis et al, 2012; Dagres et al, 2013) and is associated with significant morbidity, high risk of stroke and mortality (Cottrell, 2012). Clinical guidance from the National Collaborating Centre for Chronic Conditions (NCCCC) (2006) and the National Institute for Health and Care Excellence (NICE) (2006) supports clinicians working in primary and hospital-based emergency care, but not those working in pre-hospital care. Updated guidance from NICE (2014) highlights the importance of providing rapid, personalised, evidence-based care, yet does not provide any guidance for pre-hospital clinicians responding to emergency presentations of AF. Paramedics have knowledge and experience of identifying AF, possess antiarrhythmic, anticoagulant and anti-platelet medications as part of their formulary and possess the necessary skills for obtaining intravenous access.This article reviews the national guidance and available best-evidence to provide safe treatment to patients presenting with new-onset AF and considers areas that merit further research.

A brief history of analgesia in paramedic practice

Paramedics and ambulance clinicians have an important role in alleviating pain. However, clinician-initiated analgesia has a relatively short history when compared with the field of medicine. Several barriers to the introduction of pharmacological options for the management of pain appear to have delayed the introduction of options for managing severe pain. These include legislative restrictions as well as concerns about the adverse effects of analgesics.This report describes the history of analgesia in paramedic or ambulance practice in the United Kingdom (UK) and Australia in order to add to the knowledge base for this profession, and to inform the development of strategies to advance pain management practice.

A critical appraisal of the impact of Section 3 of the Mental Capacity Act (2005)

Paramedic's have verbalised uncertainty on how to proceed when treating unwell patients who refuse treatment, stating that they feel ill-equipped to interpret situations when patients refuse treatment. They expressed a need to be formally trained in how to systematically, yet quickly, assess a patient's capacity, rather than relying on intuition or opting out with the ‘take them to hospital’ approach, as they report it is better to face the accusation of assault or battery, than allegations of negligence.This article will explore the appropriate mechanisms and approach for the assessment of capacity in emergency situations. Capacity will be defined according to the Mental Capacity Act 2005 (c.9), with an explanation of consent and the particular difficulties faced by paramedics in the assessment of capacity in an emergency will be identified and analysed.

Hearing the voice of the minority

The College of Paramedics recently published its five-year strategic plan (College of Paramedics, 2014) where it set out its vision for the next two to five years. The document should be important for all members of the paramedic profession but there is little doubt that it will go unnoticed among the majority of paramedic registrants. The College states that around 19% of paramedics who were registered with the Health and Care Professions Council (HCPC) in October 2013 were members of the College, which equates to around 3 700 members. The numbers are growing slowly but when the College of Paramedics membership is compared with other healthcare professions, it is concerning. The Chartered Society of Physiotherapists (2014) boasts 59 000 members even though there are only just over 47 000 registrants, and the British Dietetic Association (2013) has more than 7 500 members from a registrant population of just 8 355 (HCPC, 2014).

Preparing for the future, protecting lives today

The National Ambulance Resilience Unit (NARU) has just completed its third full year as an operational organisation. Now is a good time to pause, take a breath and contemplate the huge progress it has made during the past three years, says Keith Prior, director, NARU.

Paramedic Pathfinder: is it really better than current practice?

Following the recent publication of an article on the Paramedic Pathfinder in the Emergency Medicine Journal, James Goulding argues that rather than highlighting a step forward for the paramedic profession, it serves as an indication that there needs to be more rigorous research before a change in current methods can be recommended.

Continuing Professional Development: Managing anaphylaxis in the out-of-hospital setting

OverviewThis Continuing Professional Development (CPD) module will explore the most severe form of allergic reactions, anaphylaxis. This will include outlining the definition, prevalence, pathophysiology and paramedic management of the disease. There are a number of self-directed activities to complete as you move through the article together with a list of further resources to expand your research. This article requires the reader to have a basic appreciation of normal physiology associated with the immune system and an appreciation of the general approach to assessing and managing patients in the out-of-hospital, emergency setting before completion.Learning OutcomesAfter completing this module you will be able to:• Outline the definition, pathophysiology and epidemiology of anaphylaxis• Identify the key diagnostic features of anaphylaxis, including the causes and physical presentation• Outline how anaphylaxis is managed by paramedics

How Your Doctor Sees You: A Guide to the Body in X Rays and Scans

When I first read the title of this book, I wondered if it would provide some cheeky tips on how to bypass the ever-vigilant GP receptionists and actually see your GP! As it turns out, the content is more cerebral than that and does not concern itself with such petty distractions.

Emergency Services Network: looking at the future of mobile communications

The Emergency Services Mobile Communications Programme is a cross-departmental programme responsible for the delivery of the new mobile communication system of the future to the emergency services. Alistair Quaile gives an outline of the key objectives, as well as some of the potential suppliers.