Volume 7 Issue 6

Spotlight on Research

Overcoming challenges to research in pre-hospital careAlthough over recent years there has been an increased volume of research relating to out-of-hospital emergency and unscheduled care, Lerner et al (2015) suggest the evidence base remains limited, partly because of the relative newness of the speciality, and also because there are unique challenges to successfully undertaking research in the pre-hospital setting.This study set out to determine how researchers carry out pre-hospital clinical trials and to examine how emergency medical systems (EMS) can develop capacity to continue to undertake successful clinical research.Using ClinicalTrials.gov, prospective studies were identified based on the following inclusion criteria: study initiated after 2000; has at least one study site based in the USA; and involves data collection activities in the pre-hospital setting. ClinicalTrials.gov is an open access registry and results database that provides information on publicly and privately supported clinical studies round the world.A total of 39 study sites were selected and the principal investigator (PI) for each site was invited to participate. In addition, the PIs were asked for permission to contact the study coordinators and/or the EMS liaison in order to get different perspectives on barriers and enablers to pre- hospital research.In total, 25 PIs, 9 study coordinators and 7 EMS liaisons participated in the study, representing a total of 27 EMS systems from 22 different states in the USA.The interviews were conducted by one researcher and explored potential and actual barriers and enablers to pre- hospital research, as well as discussing how researchers overcame the challenges they encountered during their research. Interestingly, these interviews were not recorded and the interviewer took notes during each event—there is no discussion offered within this paper as to how the process of note-taking impacted on the dynamics of the interviews or why the researchers decided not to record the interviews.These notes were analysed, resulting in identification of emergent common themes which were reviewed by the research team and sent to all participants for further comment.‘ A key message is that pre-hospital research can be unpredictable, but that there are ways to overcome barriers to successful research in these settings ’The following issues were identified within the emergent themes as being a challenge to pre- hospital research: gaining ethics approval; acquiring funding; recruiting EMS agencies to participate in the research; collecting data and maintaining protocol compliance; training EMS providers to enrol patients; collecting outcome data from hospitals; and adequately staffing research studies.The authors identify that these findings are similar to previous studies but suggest that the differences found in this research study are that these barriers were not necessarily seen as insurmountable. The supplementary information (which can be accessed online) to this paper provides more in-depth information about the emergent themes and is certainly worth reading in conjunction with the paper itself to provide context to the issues included within the paper's discussion.Despite the study's findings pertaining to American research and EMS systems, there are some similarities to the UK experience, and this paper provides useful information in relation to paramedic research.Overall, a key message is that pre-hospital research can be unpredictable, but that there are ways to overcome barriers to successful research in these settings. The authors emphasise that we should learn from each other's experiences and avoid making the same mistakes. By developing a research culture which embraces open discourse about research processes and activities, it is possible to build on the work of researchers who have overcome challenges in their pre-hospital research, hence avoiding unnecessary pitfalls. In turn, this could help to develop both capability and capacity in relation to increasing both the quality and quantity of research relevant to the paramedic profession.

Airway management in UK ambulance services: results of the National Ambulance Service Airway Management Audit

Aim:To establish the range of airway devices provided to ambulance staff employed by the UK NHS ambulance services, which level of practitioner is allowed to use which device or intervention, and what the main factors were in the purchasing decisions taken.Methods:Medical directors from all 14 UK NHS ambulance services were invited to participate in an anonymous, web-based survey of emergency airway management equipment provided within their service and which grades of practitioner were authorised to use the equipment they provided. Additionally, they were asked for the main reasons for the purchase of the selected equipment.Results:All 14 ambulance services completed the survey questionnaire. A range of clinical grades is now employed by UK ambulance services although there is inconsistency in both title and skill set. All services provide a range of airway equipment, but there is no common inventory across UK ambulance Trusts. Nearly all staff were authorised to use some of the basic equipment, but wider variations appear with more complex or sophisticated techniques. In particular there appears to be significant gaps in advanced equipment and those authorised to use it in respect of children.Conclusions:The range of airway equipment and those authorised by ambulance services to undertake airway management interventions appears to be evolving. It is of concern that there remains an apparent lack of standardisation of the range of airway equipment provided by UK NHS ambulance services.

HCPC renewal for paramedics and the importance of having appropriate indemnity insurance

As of 1 April 2015, the Health and Care Professions Council renewal process has required registrants to confirm that they have a professional indemnity arrangement in place if they are a practising paramedic. Martin Berry, executive officer, College of Paramedics, considers the implication this change in legislation has on staff and outlines the new medial malpractice and public liability insurance policy that is to be offered to all full members of the College.

Challenges of postpartum haemorrhage: a case study in the aeromedical retrieval environment

Postpartum haemorrhage is one of the main causes of maternal deaths worldwide. The presentation of this aetiology in the remote and rural setting presents significant challenges to both referring and retrieval clinicians. A safe, timely and robust response to transferring these patients direct to definitive care is necessary. This article considers the case of a 36-year-old female who presented to the Emergency Medical Retrieval Service with a slow but worsening onset of abdominal pain and persistent vaginal bleeding. The patient was 16 days postpartum following the uncomplicated birth of her third child. Treatment delivered to the patient is included in the case example and discussion given to challenges faced in the areomedical retrieval environment. Considerations during treatment, such as communication, resuscitation, investigation and monitoring are also presented.

Should the Kendrick Extrication Device have a place in pre-hospital care?

The Kendrick Extrication Device (KED) is described as an ‘emergency patient handling device designed to aid in the immobilisation and short transfer movement of patients with suspected spinal/cervical injuries’ (Ferno-Washington, 2001). The device that evolved in the late 1970s was originally intended to assist with the immobilisation and extrication of racing drivers from their cockpit (American Academy of Orthopaedic Surgeons et al, 2012; Trafford et al, 2014). Since then it has become adopted by many ambulance services as a tool intended to assist in the immobilisation and extrication of patients, particularly from road traffic collisions (RTC) and is a recognised piece of equipment among paramedics. However, its assimilation into the pre-hospital environment and overall appropriateness in patient care should be viewed with caution. This article comments on the potential adverse risks associated around delayed extrication, the impact on respiratory function and the potential for increased movement of the casualty. Additionally, it highlights the current lack of evidence to support its use.

A critical analysis and appraisal of the management of croup in the UK out-of-hospital environment

This article aims to explore the epidemiology, aetiology and pathophysiology of laryngotracheobronchitis (croup), a commonly presenting illness faced by paramedics attending young children in the community. In this article, current evidence surrounding pharmacotherapies for croup shall be discussed with relevance to paramedic practice. Furthermore, current dosages, routes of administration, cost-effectiveness and weight-based drug calculations will be outlined and debated alongside the current evidence base.

Considering the impact of an older, healthier population

Population ageing is arguably one of the greatest challenges facing contemporary society, due to its various social, economic and political implications. Ian Peate looks at the effect an increasing ageing society will have on health and social care, and outlines the importance for future service provision to reflect the needs of this growing population.

Musculoskeletal injury risks for ambulance workers

The provision of emergency and urgent care has been recognised for many years as exposing ambulance workers to high risks of muskuloskeletal injuries. Sue Hignett explores the common manual handling risks faced by paramedics and considers the role of human factors/ergonomics in occupational health and patient safety.

Book Review

Fundamentals of Paramedic Practice: A Systems ApproachTheory and application are two concepts I was sadly lacking in during my formative educational years! Fortunately, I appear to have outgrown such academic apathy and am now in a more informed position to appreciate a good paramedic text when I read one. This title would fall into that category, not least because it makes a distinction between the above.Learning outcomes for each chapter are succinctly presented and ‘Practice Insight’ boxes, while hardly revolutionary, contain some nuggets of sound advice and pertinent observations on different areas of paramedic practice. Similarly, self-test activities are not a new development in the literary world but are effective nonetheless, further enhanced by directing the reader to an additional online resource which accompanies the book. This sort of interactive publishing is becoming more common in paramedic literature and you'll hear no argument from me. Online resources permit a far broader exposure to a given topic and present a wealth of learning material not possible in the written form.The customary counterpoint is that the case studies presented are a touch shallow and resemble little more than a précis of incidents you may attend rather than any in-depth learning from a case example. This in fact reflects the age-old dichotomy for publishers of paramedic literature: breadth over depth. Consistent with paramedic practice in general, this is also a feature of this book. In terms of scope of practice, I would suggest this is best suited for student paramedics and the less-experienced clinician, but the give-away is in the title.Do not confuse that observation with a criticism of the content, it isn't. Overall this is packed with goodies: interactive resources, photographs, illustrations, glossaries of terminology, references, additional suggested reading and supplementary information in tabular format. The ability of the editors to combine all of these into a coherent whole is commendable in itself. Positive stuff.

Trauma Care questions current practice, engages in debate and looks to the future

ConclusionsThe take home point of the day appeared to be that paramedics are part of a patient-focused service, and that we must continue to educate and develop, question existing practice, and embrace an evidence-based culture for all to fully maximise patient care now and in the future. The profession is advancing rapidly, led by the College of Paramedics, and positive engagement with all key stakeholders will ensure a bright future. The collar is history, immobilisation is not required for all, and support needs to be available for both mental and physical health among the profession.Should you be interested in finding out more, you can search #traumacare2015 on Twitter or visit the Trauma Care UK website, where DVDs of the conference will be available in the near future: www.traumacare.org.uk/conference.

How will the election affect the NHS?

The outcome of the general election marks the first Conservative majority Government for 18 years. Despite polls anticipating results between Labour and the Conservatives to be tight, David Cameron's party achieved a convincing victory. So what effect will a Conservative majority Commons have on the NHS?

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