Volume 7 Issue 4

Spotlight on Research

Ultrasound in cardiac arrest: a feasibility studyOver the years there has been growing interest in the use of ultrasound as a diagnostic tool to enhance paramedic practice when managing patients with a variety of clinical presentations.This study aimed to evaluate whether paramedics can be educated to carry out focused echocardiography in life support (ELS) involving the use of ultrasound scanning to assess cardiac function, as well as recognise reversible causes of cardiac arrest.The study was undertaken in the Scottish Ambulance Service using paramedics from the Resuscitation Rapid Response Unit (3RU) who are regularly exposed to out-of-hospital cardiac arrest. Eleven of the 3RU staff attended a one-day training course focused on ELS.They were taught to acquire both parasternal and subxiphoid views, and to assess the images for presence of movement, quality of function, recognition of rhythm, presence of fluid (i.e. pericardial effusion), and size of the chambers of the heart.In total, nine paramedics participated in the data collection. Participants' knowledge was assessed through the use of pre- and post-course questionnaires to assess whether there was any difference in theoretical knowledge level (including interpretation) linked to participation in the educational intervention.Additionally, after completion of the course, each paramedic was assessed on their ELS performance on three healthy volunteers. Participants had to a) perform one subxiphoid and one parasternal scan—they were assessed on time taken and quality of image; b) perform both scans in a 10-second window simulating the rhythm checks during a cardiac arrest (only if they managed this was the quality of the image assessed). Image quality was evaluated using a five-point scale with 1 being poor quality, and 5 being high quality.Results demonstrated a significant improvement in knowledge from a mean pre-course score of 54% to a post-course score of 89% (p<0.001).During the moulages, in relation to practical skills, all nine participants managed to produce images from both parasternal and subxiphoid views on every attempt. For the parasternal view the mean time taken to acquire an image was 13.1 seconds and the mean image quality was 4.1. For the subxiphoid view, mean time was 13.2 seconds with a mean image quality of 3.8.During simulated resuscitation, in both views the success rate was 88% of images attained within the 10-second time frame, with a mean image quality of 3.8 in the subxiphoid view, and 4.0 in the parasternal view.Ten weeks after the course, four participants were re-assessed involving a repeat questionnaire and another practical assessment. Three participants acquired a subxiphoid image (mean quality 3) and one achieved a parasternal view (image quality 4). Theoretical knowledge was reduced (82%; p=0.13), and this was deemed as non-significant; however, it is not possible to draw any firm conclusions from such a small sub-group.The authors recognise that their study has limitations—for example, the small sample size and the use of a specific cohort of paramedics who are exposed to a high number of cardiac arrests (which prohibits generalisation of the results). Additionally, the participants were scanning healthy volunteers in a controlled environment, which does not accurately reflect the nature of the out-of-hospital environment.In conclusion, although this is a small-scale feasibility study, the results demonstrate that paramedics can be trained to perform ELS. However, before implementing this practice across all Trusts, there is a need for larger studies to be undertaken involving non-specialist paramedics to establish whether these findings can be repeated. In addition, the authors recommend that future research should focus on establishing whether ELS actually contributes in a meaningful way to paramedics' clinical decision-making about management of patients in cardiac arrest in the pre-hospital setting.

Adrenal insufficiency: improving paramedic practice

Acute adrenal insufficiency, which includes Addisonian crisis, can lead to severe morbidity and even death if ineffectively managed. Unfortunately in the pre-hospital setting patients with acute adrenal insufficiency often receive sub-optimal care. The early administration of hydrocortisone in these cases is critical and significantly improves outcomes to the extent it can be life saving. Such therapy is part of current paramedic practice; however, there is evidence that hydrocortisone is rarely used in the pre-hospital setting. Ultimately, patients with acute adrenal insufficiency may currently be sub-optimally managed by paramedics. To combat this, this article will define the current optimal practice in this area and explain how an e-learning package will be used within North West Ambulance Service NHS Trust to educate paramedics in best practice in this area.

A pre-hospital search and rescue training exercise for students

In June 2013, Warwick Wilderness Medicine society (WWM) at the University of Warwick, UK, ran a pre-hospital care training weekend culminating in an ambitious search and rescue (SAR) training exercise in the Lake District, England. Seventeen participants were provided with refresher training in wilderness medicine. They were then directed to undertake an area search and subsequent pre-hospital management of three simulated patients. The training was run by WWM without outside involvement. Details of the training day are discussed along with the feedback received from participants and the faculty. Areas for improvement are summarised for the benefit of other organisations planning similar activities.

Can pre-hospital recognition and intervention improve outcome for patients with severe sepsis?

Pre-hospital provision of care for patients with severe sepsis and septic shock varies significantly throughout the UK. Timely recognition of this complex and highly morbid syndrome is known to be challenging, and significant evidence exists to support the clear association between advancing pre-hospital care and improving patient outcomes. The aim of this literature review is to analyse the opportunities for pre-hospital clinicians to transform the increasing burden of sepsis care. There is evidently a lack of research in this area, reflected in the relative scarcity of relevant research papers. Following a comprehensive literature search, 10 quantitative studies were selected for critical appraisal. Results would suggest that pre-hospital clinicians could effectively contribute to improving outcomes for this patient group. The clinical importance of immediate identification of sepsis is highlighted, recognising the need for sepsis screening aids, standardised pre-hospital evidence-based guidelines and diagnostic tools. Improved communication between pre-hospital clinicians and receiving hospitals was advocated. Further research was proposed to evaluate the effect of pre-hospital therapeutic interventions.

Understanding the do's and dont's of social media

Social media offers paramedics a great tool for continuing professional development; however, consideration should be given if it is to be used effectively and responsibly. Imogen Carter, College of Paramedics Yorkshire Regional Group liaison, outlines recommendations for getting the most out of the technology.

Pre-hospital technology research: reflecting on a collaborative project between ambulance service and academia

The University of Aberdeen MIME project (Managing Information in Medical Emergencies) aimed to develop technology to support volunteer rural community first responders when managing patients. This can be a particularly stressful activity with many challenges to overcome while waiting for ambulance clinicians to arrive. The MIME system employed lightweight medical sensors streaming data (heart and respiratory rate, and blood oxygen saturation) wirelessly to a tablet computer. Novel software was developed to present these data on-screen in a simple way and facilitate the quick digital capture of first responder actions and observations. MIME also applied the technique of Natural Language Generation, which interrogated sensor data, user-inputted actions and observations to automatically generate a handover report in English. This paper describes the MIME system, and then focuses on our collaboration journey between academia and the Scottish Ambulance Service. We illustrate the challenges encountered during our research and development, and describe the academia-ambulance service collaboration model that was developed to deliver success. We also discuss the Knowledge Exchange sub-context to our research activities, which coincided with the early development of research capacity within the ambulance service.

Tackling the shortage of paramedics

February marked the first time that paramedics were recommended for addition to the shortage occupation list (SOL), with vacancy rates running at approximately 10% of the total 12 500 paramedic workforce in England (Migratory Advisory Committee, 2015).

Book Review

ABC of Anxiety and DepressionKeeping with the mental health theme addressed in last month's review, the ubiquitous ‘ABC’ series takes up the mantle with a narrower look at one of the most prevalent aspects of mental illness.Sporting its trademark slenderness, an initial perusal of the content reveals that the presentation of the material has undergone somewhat of a face lift. Perhaps a literary risk on the part of the publisher given the enduring popularity of the ‘ABC’ format, but I would argue otherwise as the cosmetic upgrade has done nothing but accentuate the content.Relevant to any health professional working in the public and private sector, and those who do such sterling work in the voluntary (‘third’) sector, the contributors have been drawn from the higher education and healthcare sectors as well as social enterprises, ensuring the now customary informed and evidence-based ‘ABC’ approach is maintained here.The impact of anxiety and depression is considered across all age ranges and the relationship with specific medical conditions, such as maternity, is also highlighted. Psychological and pharmaceutical interventions are reviewed and the impact on those delivering care in this field offers an alternative perspective. The appendices deliver a strong closing to the book through a detailed presentation of a number of cognitive tests, depression scales and health questionnaires, all of which supplement the preceding text.My previous reviews bear testimony to the efficacy of the ‘ABC’ format, but a consistent observation is that while clarity and substance of material is present, depth is not. This is no different.Given the complex area of health care which this volume covers, it would be unrealistic to expect the subject matter to be fully analysed in a mere 76 pages of text. What it does do, as always, is provide an overview which would be of benefit to anyone working with those affected by anxiety and depressive disorders. Recommended.

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