Clinical Practice

Legal aspects of prescribing

Paramedic independent prescribing is in its infancy and there are limitations to the range of medicines that can be prescribed when compared with other professions undertaking independent prescribing. Medication and prescribing errors are common events within the NHS in England, resulting in a substantial number of litigation and fitness-to-practise proceedings against other professions in relation to prescribing and medicines management. It is foreseeable that paramedic independent prescribers...

Pulse oximetry to predict the onset of acute mountain sickness: a literature review

Acute mountain sickness (AMS) is a common illness affecting people ascending to high altitudes. AMS may progress rapidly, and can be fatal if symptoms are neglected, acclimatisation processes fail or if the ascent continues. For many patients with AMS or AMS symptoms, medical assistance is given by mountain rescue and allied health professionals. Currently, the prediction of AMS in the high-altitude environment relies upon recognising and tracking subjective symptoms. However, owing to...

Needle decompression in tension pneumothorax: anterior or lateral approach?

Background: For tension pneumothorax, the UK recommendation is to use a 14 g, 5 cm cannula to decompress the chest. Advice around site selection differs between using the second intercostal space (ICS) mid-clavicular line or the fifth ICS near the mid-axillary line. The aim of this literature review is to determine the best approach for needle decompression using a standard 14 g, 5 cm cannula. Methods: A systematic search of multiple databases was conducted, using inclusion and exclusion...

Patient-centred prescribing, autonomy and concordance

This article in the JPP Prescribing Paramedic series will focus on patient-centred prescribing, autonomy and concordance. Patient-centred prescribing means putting the patient at the centre of everything we do as clinicians. Autonomy means a patient has an inherent right to make decisions about their care. Concordance means the patient takes medication as prescribed, for the correct length of time. This article details how these three aspects of prescribing can be achieved by the paramedic...

Happy hypoxia in COVID-19: pathophysiology and pulse oximetry accuracy

Many patients with COVID-19 have presented to emergency departments with arterial hypoxaemia but without breathlessness; this is called ‘happy hypoxia’ or, more accurately, ‘silent hypoxaemia’. Hypoxaemia needs to be identified correctly in patients with COVID-19 as it is associated with in-hospital mortality. The aetiology of silent hypoxia is unclear, and the pathophysiological processes involved in the relationship between the response to hypoxaemia and the sensation of dyspnoea may explain...

Diabetic ketoacidosis in paediatrics: tools to assist in recognition of a sick child

Diabetic ketoacidosis (DKA), a complication of diabetes, is a medical emergency in children and is one of the main causes of childhood mortality. It is the first presentation of diabetes in 30–40% children with the condition, and is more common in younger children. However, it is commonly misdiagnosed as the signs and symptoms in children vary. Treatment should be given as soon as possible, and this is usually only possible in a hospital setting. Therefore, early recognition and transportation...

Focused ultrasound in out-of-hospital cardiac arrest by advanced paramedics

Background: This study describes and evaluates advanced paramedic practitioner (APP) use of focused cardiac ultrasound (FoCUS) in out-of-hospital cardiac arrest (OHCA), and relates ultrasound findings with decisions to terminate resuscitation. The authors report characteristics of patients who do/do not undergo a FoCUS examination by APPs, ultrasound probe positions used and whether FoCUS findings were associated with decisions to terminate resuscitation or to convey patients to an emergency...

Prescribing in mental health

Mental health disorders such as anxiety and depression are becoming increasingly prevalent and frequently pose some of the greatest challenges for the clinician, both in terms of communication and prescribing. Prescribing appropriately, safely and effectively depends upon the clinician's approach to the consultation and to the patient. This article discusses some methods of improving consultation and communication skills to maximise efficiency and safety of prescribing in mental health and...

Non-medical prescribing by paramedics in emergency, urgent and critical care

This article considers some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care. In contrast to primary care, advanced paramedics practicing in emergency settings are more likely to encounter patients who require an immediate supply or administration of medication and access to a range of controlled drugs. Furthermore, access to medical support for prescribing decision-making, restrictions on the prescribing of...

Clinical case review: out-of-hospital cardiac arrest following thyroid storm

Acute thyrotoxicosis (thyroid storm) caused by hyperthyroidism is a rare but severe endocrine imbalance which, in extreme cases, may lead to ventricular fibrillation and ultimately, without intervention, death. The authors attended such an incident and, following clinical interventions, achieved return of spontaneous circulation with a good outcome for the patient and subsequent hospital discharge.

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