Volume 7 Issue 10

Spotlight on Research

Spinal immobilisation: still uncertain?In this paper, the authors argue that spinal immobilisation during extrication of patients in road traffic collisions (RTC) is still routinely practised, despite the lack of evidence. The current research builds upon a previous ‘Proof of Concept’ study undertaken by this team (Dixon et al, 2014), which identified up to four times more cervical spine movement when using traditional rescue equipment, as opposed to allowing haemodynamically stable patients to self-extricate under paramedic instruction.Using biomechanical analysis, the most recent study sets out to identify which technique used during extrication from a vehicle causes the least cervical spinal deviation from the neutral in-line position.Sixteen participants were recruited: seven males and nine females, aged between 18–40 years (mean age 24 years), height between 157–198 cm (mean=174 cm); five participants weighed under 65 kg, six people were in the 65–80 kg category, and five weighed over 80 kg. Participants were excluded if they were under 18 years, already had knowledge of extrication procedures and/or they had medical conditions that may be aggravated by extrication such as spinal injuries, arthritis etc.Crews comprised four members of the fire service and two members of the ambulance service, which reflected standard deployment to RTCs in that geographical region. They were fully trained in manual handling procedures and the equipment used in the study.Reflective markers were placed on participants, enabling measurement of flexion, extension and rotation of the cervical spine, and movements were captured using three-dimensional motional cameras.Each participant was exposed to six techniques for extrication, and the starting point for all scenarios involved the participant sitting face forward in the driver seat of the test vehicle. Techniques included: participant self-extrication under paramedic instruction, participant exits car under own volition having been fitted with cervical collar and receives manual c-spine stabilisation, participant has cervical collar applied and is extricated on a long spinal board (LSB) through rear window, participant has cervical collar applied and is rotated 90° to driver door side and extricated on the LSB head first through passenger door, participant has cervical collar applied and is rotated 90° to passenger side and extricated on the LSB through the driver's door, participant is fitted with a cervical collar, immobilised with a short extrication jacket (SEJ) and lifted through the driver's door without any rotation.Results confirmed that self-extrication with no collar produced a mean cervical movement of 13.33°±2.67° (range 8.25°–18.79°). The next smallest mean cervical spine movement during other techniques of extrication was found when using the LSB in-line extrication (through rear window) with a mean of 13.56°±2.34° (range 9.40°–17.25°). The largest mean cervical spine movement occurred when using the LSB and extrication of the patient through the driver's door—mean of 18.84°±3.46° (range 13.25°–26.89°).Two techniques (LSB and extrication through driver's door, and SEJ) produced significantly higher movement than other techniques (p<0.05).Both height (p=0.003) and mass/weight (p=0.02) were found to be significant independent predictors of movement.Limitations of the study include the small number of participants, the narrow age range of participants, and the use of healthy volunteers. It is not possible to assess whether the findings from these simulations are transferable to the clinical setting but, nonetheless, this study provides a strong foundation on which to develop future larger scale research.In conclusion, in simulation, haemodynamically stable participants experienced less movement of the cervical spine through controlled, instruction-led self-extrication, rather than being exposed to extrication using traditional EMS equipment. The authors argue that these findings add to increasing evidence that current practices of extrication may not provide optimal care for patients involved in road traffic collisions.Spotlight on Research is edited by Julia Williams, principal lecturer, paramedic science, University of Hertfordshire, Hatfield, Hertfordshire, UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk

Equal value of physical and mental health: transforming outcomes by 2021

In March 2015, NHS England launched a Taskforce to develop a five-year strategy to improve mental health outcomes across the NHS. Aysha Mendes looks at a report produced by the Taskforce in September, considering its key priorities and themes, as well as the role of ambulance services in this equation.

Exploring trends in demand for urgent care

Last year, Rod Jones, statistical advisor, Healthcare Analysis and Forecasting, published an article considering factors affecting bed occupancy and capacity at A&E departments. In this article, he provides further justification for why trends in demand for urgent care may be as a result of a persistent infectious agent, as opposed to the more usual ‘spike’ infectious events observed for influenza and other non-persistent infections.

The NHS Constitution lacks clout

The NHS Constitution for England brings together the principles, values, rights and responsibilities underpinning the NHS. However, Ian Peate argues that for it to be valued, supported and used by patients and staff, carers and the public, and for it to have more significant impact, then awareness must be raised.

Improving mental health outcomes

Within our society there has been a long-standing lack of parity between mental and physical health, with those suffering from mental health issues often experiencing stigma and discrimination. Luckily this is beginning to change. In 2013, the Minister for Care Services, Norman Lamb, campaigned for parity of esteem between mental and physical health, following a report produced by the Royal College of Psychiatrists (Department of Health and The Rt Hon Norman Lamb, 2013). The report set out the rationale for a parity approach to mental and physical health, and made recommendations for how parity can be achieved, predominately in health and social care (Royal College of Psychiatrists, 2013). More recently, newly elected leader of the Labour party, Jeremy Corbyn, has created a dedicated Minister for Mental Health in his shadow cabinet. Liverpool Wavertree Labour MP, Luciana Berger, is the first to be appointed to this role. However, there is currently no equivalent position in the Conservative party.

Australian paramedic graduates transitioning into UK NHS ambulance services: what are the potential challenges?

With United Kingdom (UK) Ambulance National Health Service (NHS) Trusts and Foundation Trusts actively recruiting Australian paramedic graduates, this article seeks to stimulate discussion by identifying differences existing between the two ambulance systems, as well as highlighting potential challenges that Australian graduates may face when transitioning to the UK ambulance service. It also identifies similarities between Australian and UK ambulance systems, which may assist new graduates to overcome the transition shock. This article suggests that transition shock is not solely related to Australian graduates moving to the UK, and may well be present for graduates moving to comparable international ambulance services in Canada, the Middle East, Ireland and South Africa.

Ambulance response time in Ireland: the legal implications

In Ireland, reports indicate that response times by ambulances to 999 or 112 pre-hospital emergency healthcare calls are not meeting key performance indicators. This can have implications for the patient and the ambulance service. Delays in response times or a failure to meet key performance indicators could lead to claims for negligence against the ambulance service, as has happened in the United Kingdom (UK). In such cases, the plaintiff must prove that he or she is owed a duty of care, that there was a breach of the standard of care expected, that he or she suffered an injury or wrong, and that the injury or wrong was a direct result of the ambulance service not attending within a reasonable or set time frame. This paper will examine the legal implications of failing to respond to 999 or 112 telephone calls within a reasonable time or within agreed guidelines.

Single–dose activated charcoal—a feasibility study in an ambulance setting

Following a previous article published in the Journal of Paramedic Practice (Walker, 2013) this article summarises the findings of a study conducted by South Western Ambulance Service NHS Foundation Trust (SWASFT). As a result of the literature review detailed in the previous article, approval was given to run a 6-month study examining the feasibility of paramedic crews carrying and administering single-dose activated charcoal (SDAC) to patients of self-poisoning attended within 1 hour of ingestion of a suitable toxin. Sixty nine patients were offered SDAC, with an acceptance rate of 94%. Fears of adverse incidents such as vomiting, aspiration and increased time on scene appeared almost entirely unfounded and crews found the medication easy to use and popular with patients. Paracetamol, usually at hepatotoxic levels accounted for 57% of all overdoses encountered, most of these receiving SDAC within 1 hour, with 81.5% of all patients receiving the medication in that time frame. SWASFT has now adopted SDAC as a treatment for patients of overdose.

A clinical review of the indications for, and subsequent implementation of, a pilot pre-hospital sepsis pathway within NWAS

Aim:Review the clinical evidence for, and introduce a modified ‘Red Flag’ sepsis screening tool, treatment pathway and associated education package into a pilot site within the North West Ambulance Service NHS Trust (NWAS) and evaluate its impact.Methods:Retrospective application of a modified ‘Red Flag’ sepsis screening tool to 259 hospital confirmed cases of sepsis to evaluate the current identification and treatment of sepsis within NWAS. A subsequent prospective pilot launch of the tool within central Manchester in collaboration with Salford Royal Foundation Trust and Central Manchester Foundation Trust hospital emergency departments, collecting and analysing 100 cases of suspected sepsis in which the screening tool has been utilised.Results:The modified ‘Red Flag’ sepsis tool was found to be highly sensitive when applied retrospectively. Only 46% of confirmed severe sepsis cases were found to show hypotension (systolic BP <90 mmHg) pre-hospital. In the pilot, complete analysis of Systemic Inflammatory Response Syndrome (SIRS) criteria and a suspicion and documentation of sepsis increased from 15% to 94%. Compliance with a bundle of care in suspected severe sepsis cases increased from 10% to 90%.Conclusions:The introduction of a modified ‘Red Flag’ screening tool significantly improved pre-hospital sepsis identification and treatment within the pilot site. Paramedics were able to give fluid boluses to normotensive patients in suspected severe sepsis safely without adverse incident.

Continuing Professional Development: Recognising oral and facial conditions

OverviewThis Continuing Professional Development (CPD) article will focus on conditions which may affect the face and oral cavity. It will provide an outline of each condition and consider the possible cause or origin. Finally, it will discuss how to recognise when presentations warrant immediate medical admission, or can be referred to other healthcare practitioners in the community setting.Learning OutcomesAfter completing this module you should be able to:Understand a number of conditions surrounding the face and oral cavity.Describe the possible aetiologies associated with the development of these conditions.Recognise when presentations require immediate medical admission or can be referred to other healthcare practitioners in the community setting.

Book Review

Guidelines for Reporting Health Research: A User's ManualCompleting a trilogy of research-themed reviews, this month provides a logical conclusion to the series. Unlike previous reviews, this is not concerned with conducting research, but rather the reporting of it. Another point of distinction is that the editors are not focused on how research may be incorporated into clinical guidelines, more the practice of how the research is reported in the first instance.A historical perspective is provided, which details the evolution of robust and transparent reporting guidelines, as well as a reference to some of the less-favourable reporting practices. Central to that is the editorial and peer-review process, which inevitably accompanies any publication of research. Having been involved in both of those aspects of publishing, I took particular note.A veritable wealth of reporting guidelines are presented and discussed by the contributors, covering a broad range of research designs. What I found quite telling is the level of detail and scrutiny involved in each of the ‘check lists’ and the extent to which each reporting guideline is tailored to a specific type of research. A timely word also on the contributors. The editors have excelled in pulling together a multi-national group of authors, across an equally diverse range of medical disciplines, whose expertise is brought to bear in well-written and informed individual chapters.This text, however, amounts to far more than a simple list of guidelines. Additional information is offered on how to develop a reporting guideline and more importantly, use one to produce quality health research, as well as clarifying any ambiguities between a guideline for reporting a piece of research as opposed to designing one.The primacy now placed on evidence-based practice necessitates the inclusion of robust clinical evidence across all fields of medicine, not simply that concerned with paramedic practice. What this book offers is an insight into how that evidence should be presented and what can be construed as best practice for detailing the research which produced the evidence in question. An invaluable read.

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