Ambulance clinician assessment and management of transient loss of consciousness: a retrospective clinical audit

Introduction:Transient loss of consciousness (T-LOC) is thought to be underestimated and under-managed in the pre-hospital setting. This clinical audit aims to assess the compliance of ambulance clinicians against the National Institute of Clinical Excellence guidance on the management of patients with T-LOC.Method:Ninety-four patients' clinical records and electrocardiograms (ECGs) were reviewed to determine appropriateness of assessment and patient management.Results:In this limited sample, findings show standard assessments and history documented for all patients were equally well recorded for T-LOC patients, but those specific to T-LOC were not. The number of ECGs conducted and interpreted correctly was an additional area of concern.Conclusions:Further assessments and history specific to T-LOC are required in the pre-hospital setting to ensure any potentially serious causes are recognised and these patients are taken to hospital.

Continuing Professional Development: Management of sickle cell anaemia in the pre-hospital setting

OverviewThis Continuing Professional Development (CPD) module will provide the reader with an overview of the pathophysiology of sickle cell anaemia and how this causes acute painful crisis. The reader will also be reminded of the pre hospital management of this condition together with a recap of community-based treatments which help prevent exacerbations.Learning OutcomesAfter completing this module you should be able to:Describe sickle cell anaemia.Understand the pathophysiology of sickle cell anaemia.Outline an appropriate management strategy for a patient with acute painful crisis.

Spotlight on Research

Stroke recognition instruments: a systematic reviewWith the advent of stroke centres and the increasing use of reperfusion therapies in stroke management, the need to correctly identify strokes in a timely manner is vital in reducing subsequent patient mortality and morbidity.This highly detailed systematic review sought to establish the superiority, or otherwise, of validated stoke recognition instruments such as: ROSIER (Recognition of Stroke in the Emergency Room), LAPSS (Los Angeles Prehospital Stroke Screen) and FAST (Face Arm Speech Test). The review searched MEDLINE and EMBASE up to 10 August 2015, with no time or study design restrictions, and included abstracts from conference proceedings provided they were published in peer-reviewed journals.The reviewers, having begun with 5 622 papers, ultimately reviewed 21 publications (18 papers and 3 abstracts) containing seven stroke recognition instruments. Each was assessed for study population, instrument design, sensitivity, specificity, and where possible, negative and positive predictive values. Additional analysis sought to establish bias and additional cofounders.The review provides a rich and informative data set, easily accessible via two tables. A well written discussion raises thoughtful and interesting limitations to all seven instruments and ultimately suggests that no instrument demonstrates superiority. Indeed, those interested in delving beneath the statistical evidence which can, on the surface, appear impressive, will find much to admire in the forensic nature by which the researchers unpack the limitations of each stroke recognition instrument.This is an excellent review, one which posits many questions concerning the assessment of potential stroke patients, particularly in the pre-hospital setting. The fact that the paper does not reach a positive conclusion is arguably a strength and should not deter those interested in this particular condition.

Plan for quality improvement: the ‘Legal High’ Guide

‘Legal highs’ are responsible for increasing public mortality and A&E admissions. Research into these products are limited and prolonged processes. New legislations being enforced are potentially leading to new chemicals being manufactured and released for sale with no approved research of known effects. Front-line clinicians are untrained and unfamiliar with the effects of these new drugs and are limited in their practice to symptomatic treatment. This study intends to introduce the idea of a researched and referenced ‘Legal high’ guide through the medium of an ‘app’ or pocket guide for clinician education, safety netting and improved patient care.This article is an amended version of the winning poster entry of the UK Student Paramedic Conference 2015.

Is IV paracetamol as effective an analgesic as IV morphine for patients in non-cardiac pain? A literature review

Since the introduction of IV paracetamol to UK ambulance services in 2012 there has been some debate as to which is the better analgesic, IV paracetamol or IV morphine. This literature review was designed to compare the effectiveness of IV paracetamol and IV morphine and consider whether IV paracetamol has any morphine sparing effects. A clinical question was constructed asking: ‘Is IV paracetamol as effective an analgesic as IV morphine for patients in non-cardiac pain?’ and inputted into a variety of journal databases. This returned 2 952 articles, of which 60 abstracts were read and 9 were reviewed, after relevant exclusions were made. It was found that IV paracetamol is as effective as IV morphine and consistently causes fewer adverse reactions, if given as a stand-alone medication. The review suggests that IV paracetamol could significantly reduce the dose of IV morphine required for post-operative patients. The review recommends that paramedics should favour administering IV paracetamol rather than IV morphine, if the clinician is faced with a choice. Current guidelines need to be updated in line with current research that demonstrates the effectiveness and safety of IV paracetamol.

Exploring the role that autonomy plays in achieving a good death: a case study

Currently patients at the end of life, for numerous reasons, often dial 999 when they experience many symptoms that can impact upon their current quality of life, such as pain and breathlessness. These calls regularly elicit a high priority paramedic response, which when taken in context, may be inappropriate, and can often lead to transportation to hospital, which itself can be inappropriate, and or delay in the most appropriate care required. This is worsened somewhat by sporadic or non-existent community palliative care coverage in various areas.The concept of autonomy is key to patient care, but arguably more so at the end of life. This article will review the available literature and recent evidence in the context of an anonymised case study, to highlight how patient and family autonomy can guide and support the decisions made by paramedics in these cases, and the benefits and challenges this autonomy brings, in the current social context of health care.This case study aims to didactically explore the concept of an autonomous good death through an anonymised example from practice. In doing so, it will explore the surrounding concepts of advanced decision making, do not actively resuscitate orders, mental capacity, a good death, and a good-enough-death, and how autonomy guides all of these areas of care. In doing so paramedics may be better able to respond to some of the challenges they face in clinical practice, while attempting to provide the most appropriate care at the most appropriate time to those at the end of life.

Ambulance Care Essentials

So the dawn of another year is upon us. As I inexcusably missed last month's review I am tempted to cite an unfashionably out-of-season quip about much maligned mother-in-laws but my editorial instincts got the better of me.

London Trauma Conference addresses key questions in emergency medicine

The ninth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 8 December and 11 December 2015. A main programme of presentations, where speakers addressed a number of topical questions in trauma and emergency medicine, was supplemented by breakaway sessions held parallel to the main conference. The concurrent London Cardiac Arrest Symposium also returned for another year. The Journal of Paramedic Practice once again attended the Air Ambulance and Pre-hospital Care Day held on 10 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

Preview of The Larrey Society Conference—‘EMS…in times of crisis’

The Larrey Society's first annual conference takes place on 21 January. David Davis, the society's founder and chairman, gives a preview of what delegates can expect, including confirmed speakers and topics of discussion.

Special measures for struggling services

In November of last year, London Ambulance Service NHS Trust (LAS) became the first ambulance Trust to be placed under special measures following an inspection of the service by the Care Quality Commission (CQC) in June 2015. The overall rating given by England's chief inspector of hospitals, Prof Sir Mike Richards, was that the service was inadequate, and it was acknowledged that improvements were needed on safety, effectiveness, responsiveness and leadership (CQC, 2015b).