Respect the mother: lessons from women's experiences of unplanned, out-of-hospital childbirth
This Australian study used a narrative inquiry methodology to explore experiences of women who give birth while in the care of paramedics. Themes from this study surrounded communication, consent, respect and empathy, and confidence and trust in paramedic care. While many positives emerged, there were also areas for improvement. In communication, there was a broad spectrum of responses from one participant who described her paramedic as ‘amazing’ to another who said she had to shout in order for the paramedic to listen.
Many women said that the paramedic did not ask permission to carry out procedures or assessments on them or their babies and gave examples of IV insertion completed during a contraction without consent, and blood glucose tests on a baby with no discussion or consent from the mother.
Perhaps unsurprisingly, women had mixed levels of confidence in the paramedic's ability to manage the birth. Some expressed complete confidence due to the paramedic's demeanour and self-assuredness in the situation, while others had little confidence, especially when the paramedic told them they were inexperienced in managing childbirth. The lessons: involve the mother in decision-making, seek consent—and be nice!
Non-technical skills; the key to improving teamwork in out-of-hospital cardiac arrest?
Current UK prehospital resuscitation guidance advocates the use of non-technical skills for paramedics when managing an out-of-hospital cardiac arrest (OHCA). Yet it is unclear if the recommended non-technical skills of leadership, teamwork, decision-making, communication and situation awareness are relevant to the management of an OHCA or fully understood by paramedics. This scoping review sought to establish a literature base and identify non-technical skills relevant to ad-hoc teams managing an OHCA. Using a recognised framework, 12 articles were identified and reviewed. The majority were from in-hospital studies using ad-hoc teams, not dissimilar to out-of-hospital ad-hoc teams, yet limited literature directly related to OHCA management. The review identified a variety of non-technical skills associated with ad-hoc teams managing a cardiac arrest, from leadership to team hierarchy; however, only three were common across studies: leadership, communication and teamwork. Several barriers to the use of non-technical skills were identified, including a lack of training and understanding, poor communication and ineffective leadership. These barriers were often linked to cognitive overload and poorly performed CPR, and appeared to be related to unfamiliar teams. It was recognised that paramedics had low exposure to OHCA and that simulation was beneficial for practising non-technical skills. It was also found that a hands-off leader improved team performance and reduced time off the chest. Overall, this is an under-developed area and further research is required.
TXA for gastrointestinal bleeding? Probably not!
A systematic review and meta-analysis of randomised controlled trials published in 2012 showed a large reduction in all-cause mortality with TXA; however, the studies were small with potential for selection bias so did not fully address the question.
The recently published HALT-IT Trial (HALT-IT Trial Collaborators, 2020) was an international, multicentre, randomised, placebo-controlled trial that recruited over 12 000 patients from 164 hospitals across 15 countries. Patients were enrolled if the responsible clinician was uncertain about whether to use TXA, were aged above the minimum age considered an adult in their country (either 16 years and older or 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal (GI) bleeding. Patients either received a loading dose of TXA followed by slow infusion for 24 hours, or matched-placebo. The primary outcome was death due to bleeding within 5 days of randomisation.
Results showed that death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the TXA group and in 226 (4%) of 5981 patients in the placebo group. TXA did not reduce death from GI bleeding so the treatment cannot be recommended for these patients.