Volume 8 Issue 2

ABC of Alcohol

For those of you who have just committed to a ‘dry January’ as an attempt to offset any festive excesses, you have demonstrated a commendable self-control which many people are not so fortunate to be able to master. Any clinician working in the health service will be acutely aware of the impact that alcoholism has on general health, or indeed, specific medical conditions such as diabetes, hypertension, liver and renal pathologies.

A call for research into the link between professional practice and education

There is no universally accepted definition of the criteria that makes a profession, nor what factors contribute to professionalisation of a specific industry. Definitions by Greenwood (1984), van Mook et al (2009) and Mahony (2003) provide a brief comparison of the attributes of a profession and being professional. Greenwood (1984) offers a succinct definition of a profession, identifying they possess a systematic body of theory and community authority, while van Mook et al (2009) suggest it is expertise in a particular domain that contributes most to professionalism. Additionally, Mahony (2003) argues that the controlling of education is key to being a profession and being professional. Mahony (2003) further suggests having specialist knowledge with autonomy and specific professional ethics are essential elements in developing professionalism. The concept of professionalism is therefore interwoven with education.

Spotlight on Research

‘Meow meow’: patterns of toxicity in mephedrone useAs this paper intimates, patterns of recreational drug use are changing; while the vast majority of UK drug deaths are still related to opioids (European Monitoring Centre for Drugs and Drug Addiction, 2012), ‘traditional’ club drugs such as MDMA (Ecstasy) are showing a decreasing trend in use. Indeed, in its introduction, this paper presents some interesting data suggesting MDMA use has fallen from 79.3% to 48.4% among club goers during a 10-year period (1999–2009).Emerging evidence suggests that novel psychoactive substances (NPS) may be taking the place of older club drugs—in particular the synthetic cathiones such as mephedrone (also known as ‘meow, meow’, snow, bubbles). Paramedics are often the first-contact practitioners in calls involving recreational drug use and face increasing challenges in identifying the agents involved, relying on physical findings at scene.This paper offers case report data relating to the clinical patterns of toxicity related to mephedrone. During a 2-year period from 1 January 2007 until 31 December 2009, retrospective analysis of a clinical toxicology database from an inner city ED was conducted for self-reported use of mephedrone. The review gathered data on age, sex, physiological signs and symptoms, as well as other co-ingested drugs; additional analysis included length of stay and complications.There were 15 presentations relating to mephedrone use, all in 2009; 80% (n=12) were male, median age 29 years for males and 27 years for females. None of the presentations reported solely mephedrone use, with two people reporting concomitant NPS use. In terms of physiological findings Tables 1 and 2 provide quickly accessible findings, with tachycardia (40%) and agitation (53.3%) occurring with the greatest frequency.Overall, 60% were GCS 15 on presentation; of those with a GCS ≤8 concomitant CNS depressants had been used GHB/GBL (n=3) and opioids (n=1). Most (73.3%) were discharged following a period of observation or symptom control with fluids and anti-emetics; 20% (n=3) required benzodiazepines for agitation on presentation.This paper provides useful material for anyone interested in the management of toxicological emergencies, particularly NPS, and is written by field experts from the poisons unit at Guy's Hospital in London. As with most studies in this field, case studies are often the only way to gather data, thus small sample numbers pose a challenge. Furthermore, concomitant drug ingestion makes attribution of clinical findings to one agent difficult; this does not detract from the paper, which indicates amplification in the use of NPS and provides useful background as to the clinical findings.

Introducing the UK Ambulance Services Clinical Practice Guidelines 2016

Choice of formatThe UK Ambulance Services Clinical Practice Guidelines 2016 will be available in a number of formats, including a brand new interactive app, iCPG UK Ambulance Services.Key features of the app are:Updates published in real time as new guidance is issued and flagged to usersFunctionality to filter drug dosages by age, condition and administration routeFully searchableA quick look view format that highlights the most important algorithms, scales and diagrams that you need firstThe option to bookmark key guidelines and drugs.It will be available for Trusts to purchase for their members, or to individuals through Google Play and the iOS app store.If you would like any further information on the 2016 edition, please contact Class Professional Publishing by emailing info@class.co.uk.

Pre-hospital resuscitation: what shall we tell the family?

Cardiac arrest is a rarely attended event as a proportion of overall paramedic workload. When paramedics do attend such an event the management focus is largely concerned with clinical intervention and there may not be the capacity or appreciation for offering ongoing support to family members present. Indeed, even training may not have covered this element of care. Regardless of the prognosis for the patient, evidence suggests that there is benefit in directly involving relatives during the resuscitation. Engaging them with carefully considered and informed dialogue certainly seems humane at least. In which case, a structured and holistic approach should be employed where clinical care and emotional support go hand in hand.

Continuing Professional Development: Establishing an emergency airway

OverviewThis Continuing Professional Development (CPD) module will consider respiratory arrest in the pre-hospital setting and how the paramedic can establish an emergency airway. It will identify the common causes of respiratory arrest, as well as the key steps in performing a respiratory assessment. Details of the various airway management strategies are also outlined.Learning OutcomesAfter completing this module you should be able to:Provide a definition of respiratory arrest.Identify the common causes of respiratory arrest.Identify the key steps in performing a respiratory assessment.Outline how the paramedic can establish an emergency airway.

A critical appraisal of the assessment and management of psoriasis

Psoriasis affects a substantial number of the UK population. The chronic inflammatory skin disease that typically follows a relapsing and remitting course, resulting from the abnormal activation of T cells and associated increase in cytokines in affected tissues, can transpire at any age (Gould and Dyer, 2011). Plaque psoriasis is by far the most common type of the disease making up 90% of all cases and can result in all of functional, psychological and social morbidity (Basavaraj et al, 2011). Moreover, psoriasis has been linked with an increased risk of developing cardiovascular disease. There are a considerable amount of treatment options available for psoriasis, resulting in variance in practice within primary care, particularly concerning when to refer, drug monitoring and psychological support (Murphy and Reich, 2011). This is important to recognise within the paramedic profession as there is now an increased responsibility for paramedics to discharge patients within their own home and/or refer when necessary and safe to do so. Moreover, there is minimal knowledge on dermatology in the paramedic profession, further fortifying the importance of learning about the best treatment option for psoriasis. A stepwise approach to treatment is recommended, dependent on the severity of the disease (National Institute for Health and Care Excellence, 2012).

Diagnosing and imaging renal calculi: what can be done in the pre-hospital environment?

Renal colic is a common pre-hospital presentation that is often conveyed to hospital due to diagnostic uncertainty. The use of the STONE score and a greater understanding of computerised tomography (CT) requirement in the diagnostic process can aid the pre-hospital clinician in making an informed decision about the management of these patients.Case:A 48-year-old female presenting with symptoms of renal colic who was assessed, managed and treated at home.Methods:A literature search was carried out on Medline, Cinahl, BNI and Embase. In addition, searches of the NHS evidence database (www.evidence.nhs.uk) and the Cochrane Database of Systematic Reviews (www.cochrane.org) were completed.Results:The search yielded 536 results, each of which were browsed for relevance, duplicates removed and their references reviewed. 16 articles were relevant to the use of CT to diagnose renal calculi and four addressed the derivation and validation of the STONE score. These were critically reviewed and conclusions drawn about their applicability to the pre-hospital environment.Conclusions:The STONE score, when combined with clinical judgement and if applied to the right patient group, is an appropriate clinical decision tool to identify uncomplicated renal calculi. CT imaging of this low-risk patient group is not required to confirm diagnosis; however, delayed CT scanning is required to form a management plan.

Legal and professional boundaries: a case study

There are multiple legal issues which dominate the work of paramedics and healthcare professionals alike. For those professionally registered, such as paramedics, there is an added obligation of professional boundaries.This article will examine possible legal and issues within a hypothetical case study and discuss the possible conflicts associated with these issues. The article considers a range of legal and professional aspects which may crop up in the pre-hospital care environment including capacity to consent, informed consent, acting in the best interests of a patient, rights of a foetus, infant preservation, duty of care and negligence. Within pre-hospital care there is a necessity to make rapid decisions based upon these laws, and therefore it is important that all practitioners consider these.

Letters to the Editor

Response to Johnston (2016) Journal of Paramedic Practice 8(1): 36–40Dear editor,Johnston (2016) makes a convincing argument for an app to assist paramedics in the guidance for suitable care pathways after diagnosing overdose of ‘Legal Highs’ and is a worthy winner of the student medical poster competition. I would be grateful if he considered further improvements to his app concept and the web-based content supporting it.He correctly identifies the difficulties with updating rapidly changing and geographically differing information about the various substances. I heard from a freelance colleague on the south coast of an app awaiting licensing and some development for the more mainstream recreational drugs. This app has input from police/Government chemical analysts and is updated to give local information. With a highly mobile population, it may be helpful to identify a purchase location or web address to assist in identifying the strengths and composition of the widely varying substances, as identified by Home Office laboratories. Paramedics could add to this process by an employer controlled means of collecting randomised data—for example: ‘herbal ecstasy, Bristol, hypotension resistant to fluid bolus.’ This would be relatively easy for updating to the app via either clinical support desk or directly via users themselves. Part of the database supporting the app would, of course, need to have supplier web location and/or street location information sources.The second improvement would be the use of a ring binder rather than bound book, in much the same way UK Ambulance Services Clinical Practice Guidelines used to be provided. This would enable printing of updated information to be rapidly added to the guidelines by those paramedics without smart technology. With the increased roll out of electronic patient report forms, this of course becomes less of an issue, as the app could easily be incorporated into this new technology.Johnston has used two current topics of direct interest for paramedics to attempt to improve patient outcomes. Let us hope his imaginative and ingenious thinking continues. Full credit to him in the earliest stages of his career.

Is there a future for independent prescribing by advanced paramedics?

Definition of advanced practiceThe CHM feel that the definition of advanced practice is not sufficiently robust, and that the perceived scope of practice is too wide for advanced paramedics to safely prescribe. The College of Paramedics describes advanced practice, and this definition was included in the submission to the CHM, but there is no standard and consistent definition of advanced practice across different healthcare professions. As paramedics, we have a further challenge in the wide range of roles and role titles that exist in different practice settings. While professional nomenclature may appear a minor issue for some, the basis for consistency in practice level can only be achieved if the role titles are simplified and used appropriately—allowing absolute clarity of what advanced practice is. Paramedics who progress through the career framework continue to be paramedics, and the diverse range of job titles that have proliferated have, in some examples, appeared to make generic the different professions that are engaged in a multi-professional healthcare model. We should be proud to be paramedics, regardless of where we are working, and I feel that it is not an understatement to say that this lack of consistency and resistance to consensus has been a contributor to our inability to demonstrate a definition of advanced practice sufficient to reassure the CHM.The original case for need that was produced by NHS England in collaboration with the College of Paramedics refers to independent prescribing by advanced paramedics as a way to reduce the impact that the limitations of the current mechanisms have on patient care. Across the differing levels of practice, exemptions are fit for purpose in emergency and critical care, and the use of patient group directions (PGD) have a utility for patients with urgent care needs, but are limited in the very patients for whom changes to healthcare delivery is aimed at for the future.Patients living independently or in supported living in the community, with one or more long-term health conditions, within an increasingly ageing population, are at the heart of the new models of care. It is increasingly apparent that paramedics provide care for these patients at times of crisis—either as 999 calls to ambulance services, attendance by out-of-hours providers, or in community- or acute-based urgent care settings. The usefulness of PGDs decreases as the patient becomes older and more co-morbid, and the basis for independent prescribing addresses these issues through proposing improved decision making and care planning options available to prescribers. The proposal for independent prescribing is limited to paramedics practising at advanced level—hence the need for increased clarity in role titles.

Ensuring patients get the right response

Bosses at the Welsh Ambulance Service NHS Trust (WAST) will breathe a sigh of relief as the first full set of data to be published measuring clinical care, operational efficiency and patient experience for the service since the implementation of a new clinical response model, were largely positive.

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