Volume 9 Issue 2

Paramedics under attack

‘It is currently an offence to assault a police officer, an immigration officer or a prison officer. It is not yet a specific offence to assault NHS workers, whether they are doctors, nurses or paramedics. Will we consider extending specific offence to our hardworking NHS staff?’ MP Oliver Dowden asked during recent Prime Minister's Questions. He was assured that the Health Secretary would look into specific reported cases. Meanwhile, the question compelled me to look at the related news and statistics over the past few years.

Heavy workload during the 2016/17 winter was entirely predictable

Trend in deathsFigure 1 compares the trend in deaths in England with those solely in Milton Keynes (as an example). A running 12-month total has been used to remove the effect of seasonality. As such, the saw-tooth patterns seen in the trends should not exist. Indeed, there is no official recognition by any government agency regarding this peculiar behaviour. In a running 12-month total, such saw-tooth behaviour can only arise when deaths switch on/off in a recurring high/low pattern. In the ‘high’ part of the pattern, deaths are consistently high for a 12-month period, after which they switch back to the ‘low’ or baseline state. In the period 2001 to 2012, total deaths in England were declining and this decline has masked several of the saw-tooth features. On the other hand, deaths in Milton Keynes have been increasing since this was a new town constructed in the late 1960s. The saw-tooth features are therefore easier to discern, especially for that leading to 12-months of higher deaths in 2005. As can be seen, Milton Keynes is affected to a different degree compared with the England average during these events, as are all local authority areas in the UK (Jones, 2015d). These differences arise due to the spread of the agent through the small social networks within the larger areas (Jones 2015b; 2016c). Also discerned from Figure 1 is a slightly earlier initiation of the 2016 outbreak in Milton Keynes compared with the England average.Figure 1.A running 12-month total deaths in England and Milton Keynes commencing at the 12-month period ending Dec-01. Data is from the Office for National Statistics.According to official Office for National Statistics (ONS) projections, deaths should be somewhere around 455 000 (Jones, 2016a), but are clearly much higher. The large peak which starts in 2014 and continues into 2015 seemingly arises from the interaction between the proposed infectious agent and influenza (Jones, 2016b). Beyond December 2016, the running total was supposed to go back to a baseline of around 455 000, but does not do so. Matters are then made worse by another outbreak of the proposed agent in early 2016 (Jones, 2016d), and Milton Keynes is affected worse than the England average. During all outbreaks, persons with Alzheimer's and dementia suffer the highest loss of life (Jones, 2016a).From Figure 1, it can therefore be deduced that workload this winter is going to remain unremittingly high, especially in case of an influenza outbreak like in January 2015. Based on early results from the southern hemisphere, a major influenza event looks possible (Filleul et al, 2016); however, as of the second week in January, influenza activity is still relatively low (Public Health England 2017).Magnitude of the 2016 eventIn Figure 2, the magnitude of the 2016 outbreak has been measured for local authority areas in England and Wales. ONS data was available up to November 2016 and the slope of the upward part of the saw-tooth has been used to evaluate the magnitude of the step-increase in deaths. As can be seen, the increase in deaths in a typical local authority ranges from 3%–30%. The wide range of increase in deaths is due to infectious heterogeneity, i.e. the infection travels along social networks, and hence affects variable numbers of people; especially those prone to death. The increase in deaths in London, which is populated with a greater population of young people, is typically only modest. In Figure 2, some 70% of local authority areas had experienced a statistically significant step-increase by October-16, the remaining 30% (many from London) being absent from Figure 2. An additional reason that London is affected less is that there is outward migration as people reach retirement age, and end-of-life care is transferred to typical retirement locations out of the city.Note that staff sickness absence also increases in the same step-like manner during these events (Jones, 2015c), as do A&E attendances and medical admissions (Jones, 2015c; 2016d, e). It would appear that this infectious agent likes to, as it were, kick you when you are down. Hence, from Figure 2, we deduce that workload pressures between locations are likely to be highly variable with hot spots, through to ‘not a lot happening here’.Effect on emergency admissionsHaving established that a sudden step-like increase in deaths has occurred, Figure 3 demonstrates that a matching step-like increase in emergency admissions has likewise occurred in early 2016, as it did in early 2014 (Jones, 2015a–d). Recall that in a running 12-month total, the step-increase in emergency admissions (and ambulance demand) occurs at the foot of the ramp, i.e. demand has already been running high for most of the year and continued to do so into the winter of 2016/17.Given that the agent leading to these step-like increases in deaths and admissions appears able to interact with influenza (Jones, 2016f), an influenza outbreak in early 2017 would only create a further increase in demand in addition to demand due to influenza alone.A likely agentBased on the spectrum of conditions affected during these events, it has been proposed that the ubiquitous immune modifying herpes virus (Cytomegalovirus) is likely to be involved (Jones, 2016c). Via immune manipulation, this virus appears to exacerbate existing medical conditions, and increases susceptibility to infection, especially for respiratory conditions (Jones, 2014b).Unravelling cause and effectMany seemingly have an opinion regarding why the 2016/17 winter has been so demanding for paramedics. Figures 1–3 have already demonstrated that an unprecedented step-increase in demand had occurred earlier in 2016. This is the primary cause. Secondary causes arise from the already dangerously high bed occupancy (Beeknoo and Jones, 2016), leading to issues such as access block in A&E and trolleys in the corridor. The 2014 outbreak and subsequent interaction with an influenza outbreak in January 2015 led to higher than expected emergency admissions throughout 2015 (Jones, 2016f), thereby providing a higher base for the 2016 outbreak. This has exacerbated already stretched staffing resources in A&E, i.e. a secondary contributory factor.Figure 2.Magnitude of the step-increase in deaths arising from the 2016 outbreak. Data is from the Office for National Statistics.Figure 3.Running 12-month total of emergency admissions (England). Data is from NHS Digital.

Paramedics and their role in end-of-life care: perceptions and confidence

Background:Studies have highlighted paramedics are inadequately prepared to care for patients who are at the end of their life, due to the historical focus of their training on acute medical management. This appears to cause conflict with paramedic perceptions of their role.Objective:To gain an understanding of paramedics' perceptions, confidence and concerns towards dealing with end of life care patients and their families.Design:An online survey comprising open and closed questions was distributed to all paramedics in a regional ambulance service in the north of England. Demographic data included: National Health Service (NHS) grade, personal experience, education and training to contextualise the data. A total population sample across differing organisational roles was used for paramedics in a regional ambulance service in the north of England. Responses were obtained from 182 staff.Results:NHS grade and length of service as a paramedic influenced the participant's confidence and concerns when dealing with end of life patients. A large number of participants (n=126, 70%) identified validity of documentation as a concern with 83 (46%) highlighting fear of litigation and 90 (50%) identifying that conflict with families was a concern. Support from other services was viewed as a contributing factor to increased paramedic involvement in end of life care.Conclusion:Most paramedics viewed end of life care as central to their role, but there was a need for further specific education to help enable paramedics to feel more confident, competent and supported in ensuring patients receive optimal care.

Informed consent in paramedic practice

Informed consent is a concept that has grown in importance over the last 40 years. It is now a key concept in modern healthcare practice and underpins all patient encounters. Any consent to assessment or treatment should be gained in an informed manner and failing to do so can lead the clinician open to accusations of negligence. Despite this many clinicians have only a vague or incorrect understanding of the concept of informed consent and what does, and does not, constitute it. The following article attempts to clarify the latest thinking in English law regarding informed consent drawing largely from the United Kingdom Supreme Court (UKSC) ruling on the subject in 2015. There then follows a discussion of a number of areas where paramedic practice in particular may be failing to meet modern standards of informed consent. It will be argued that consent in paramedic practice is often poorly sought and documented and that paramedic practice often becomes ‘defensive’ and in doing so fails to meet the required standards for informed consent.

The new Red 1 ambulance response time definition: evaluating clinical impact

Rapid identification of patients with life-threatening conditions is the main priority for any ambulance telephone triage system. Historically there has been a focus on the identification of patients in cardiac arrest; however, the clinical benefits of early recognition of patients in peri-arrest could be considered equally important. An expanded definition of the highest priority response, Red 1, was introduced to identify patients who are critically unwell, at high risk of cardiac arrest, and who would benefit clinically from the fastest level of response from the ambulance service.An evaluation of the impact of the new Red 1 definition was completed in South Western Ambulance Service NHS Foundation Trust during 2013. It demonstrated that the new Red 1 definition was more sensitive than the previous Red 1 definition in identifying patients in cardiac arrest and those at high risk of out-of-hospital cardiac arrest. The total number of patients who required resuscitation decreased by 11.7% under the new Red 1 definition, supporting the hypothesis that more patients are captured by the new Red 1 definition and a more rapid response diminishes their likelihood of experiencing a cardiac arrest.

‘Secondary spine injury’: how language affects future research and treatment

Secondary spine injury can refer to neurologic deterioration resulting either from the clinical course of the original insult or from additional trauma. Early studies on the pre-hospital management of potential spinal injuries observed this distinction; later studies did not. This commentary argues a) that the convention of ascribing all cases of neurologic deterioration to additional movement or improper handling is unsupported, and b) that future research into best practices in the pre-hospital management of potential spinal injuries should adopt specific terminology to distinguish between the different senses of secondary spine injury.

Crisis resource management in relation to empowering people to speak up in emergency medical service clinical practice settings

Teamwork and effective communication have been identified as key principles in Crisis Resource Management (CRM) in the context of emergency care medicine. The aim of CRM is to ultimately improve patient safety and prevent at-risk situations or events. These principles optimise patient safety and benefits.Pre-hospital emergency care in Qatar is provided by the national Ambulance Service (HMCAS). Their operations are labour intensive, and depend on the professional readiness and communication of their culturally diverse practitioners. Structures within HMCAS are hierarchical, which may be a deterrent to effective communication in Qatar. Emergency medical care (EMC) practitioners may not be forthcoming with their concerns to the detriment of patient safety. These factors can create an environment which is not conducive to effective communication, and may inherently suppress free expression of speech in emergency situations and day-to-day working practices.Managers should therefore be encouraged to create an environment whereby practitioners can speak up, irrespective of culture, nationality, or the presence of more senior or experienced colleagues.CRM principles are well incorporated as part of the EMC's orientation programme and specialised professional development courses. Regular training involving all role players (including supervisors) in different settings, and appropriately simulated scenarios that call for application of CRM principles is required to further improve the quality of EMC service in Qatar.

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