An audit of 4679 consecutive emergencies for an emergency care practitioner

Demographics

The audit covers 853 shifts (mostly 12 hours each but a few 10-hour shifts) and shows an average of 5.5 jobs per shift.

Of the 4 679 patients, 48.9% were male and 51.1% were female, which compares closely with the 2011 census data for the town where the data was collected, which reported a 50.02% male and 49.98% female population. The slight variation may be explained by the female population having a marginally longer life expectancy by 4.2 years (Office for National Statistics, 2011).

There is a marked break from the general population data though with age (See Table 1).

Clearly those over 65 years are over-represented, hardly a surprise as this is the patient group that would be expected to have the most health problems. By removing them from the sample study though the data can be broken down for those under 65 years (See Table 2).

So even after removing the confounding factor of those over 65 years, there is still a marked under-representation among the 5–16-year-old age demographic. Going one step further and looking at the data just for those under 16 years shows that this under-representation of the 5–16-year-old age group is still evident (See Table 3).

Although those under 5 years only comprise 34% of the children in the general population, they account for over 51% of the children encountered by the ambulance service. A similar trend was noted in the National Service Framework for Children, which stated that ‘in a typical year, a pre-school child will see their general practitioner about six times, while a child of school age will go two or three times’ (Department of Health, 2003).

Minor Trauma

Minor trauma is the most common call type identified by the audit. Minor trauma is defined here as that which can be usually managed at scene, although notable exceptions would be deliberate self-harm, where there is also a psychiatric element that needs managing, and minor crush injuries, which typically involve a finger shut in a car door, which will require an x-ray to manage.

Much of this minor trauma involves wounds that require management. The various treatment options open to the ECP for wound management include skin glue, steri-strips and sutures.

Falls

Falls are a very common reason for 999 calls, especially from the elderly. Of the falls recorded in the audit the majority were falls with minor head injuries, but also common were non-injury falls and falls with a minor injury other than a head injury. The use of advanced wound care (for the ambulance service at least) such as skin glue, steri-strips, and suturing, along with referral pathways to community based crisis teams (1.2%, n=57) have made it possible to treat the vast majority of these patients at home and avoid the previous situation where an elderly person would be taken to hospital in the middle of the night just to have a five minute wound care procedure.

Trauma/orthopaedic

This section is the traumatic injuries that usually require treatment in hospital, e.g. suspected fractures and wounds which are too complex to be managed in the community.

Respiratory/shortness of breath

The fourth largest single category is patients presenting with respiratory problems or shortness of breath (SOB). The most common presentation within this group is chest infections, but also common is chronic obstructive pulmonary disease (COPD), although this is often a primary co-morbidity with chest infection presentations. Less common and perhaps surprisingly uncommon is asthma, especially in children. Asthma is regarded as the most common chronic illness in childhood (Boyd et al, 2009), yet only 1.7% of children encountered (n=422) presented with asthma (n=7).

Respiratory problems are an area where ECPs can make a big difference. There are many treatment options open to the ECP, especially when managing infective complications such as chest infections. In the audit it can be seen that Amoxicillin, our primary antibiotic to use for chest infections, had been dispensed 39 times, with Augmentin and Clarithromycin (other potential treatment options) being dispensed a total of 35 times. Also in this category is croup, a condition which can usually be treated at home with the administration of a single dose of steroids; for a total of 23 presentations there are 24 uses of Prednisolone (although some of these would have been for COPD patients).

Cardiac/chest pain

The fifth most common type of call is to chest pain. The largest single presentation in this group is non-specific pain, this is typically a patient aged over 40 years presenting with vaguely cardiac sounding pain for which no cause can be identified or has been previously diagnosed. The occurrence of actual acute myocardial infarctions is very rare, at just 6.1% of chest pain calls (or 0.4% of the total calls).

Gastro-intestinal (GI)/abdominal pain

The most common presentation for abdominal pain is pain for which a specific cause cannot be identified. One interesting statistic in these figures is the relative rarity of appendicitis, often described as being one of the ‘most common surgical emergencies’ (Simon et al, 2010)—it only appears 13 times (4% of abdominal pain calls). This may in part reflect the difficulty in diagnosing the condition, meaning that many cases were possibly classified as non-specific pain.

Collapses

Collapses are here differentiated where a clear aetiology can be identified (such as for simple faints and vaso-vagal collapses), but most commonly there is no clear cause.

Psychiatric

The management of psychiatric patients often falls to the ambulance service and EDs. This partly reflects the difficulties in accessing community psychiatric services (with only 15 successful referrals recorded in the audit).

Neurology

The most common neurological presentations are seizures and cerebro-vascular accidents (CVAs). The management of these conditions is well within the normal scope of paramedic practice.

Road traffic collisions (RTC)

Road traffic collisions make up a small but significant amount of the work of the ambulance service—4.1% of the total patients seen. The majority of these incidents (55%) occur in urban areas, with 33.9% in rural areas and just 11.1% on motorways.

RTCs these days tend to be less serious than they were in the past, with reported accidents and injuries having dropped significantly since the mid 1990s (Department for Transport, 2011). As a result, of the 194 patients encountered in RTCs, 63% were treated at scene and only 36% needed to go to hospital. Fatal RTCs are exceptionally rare, with only two instances recorded in the audit.

Genito-urinary (GU)

By far the most common GU presentation is urinary tract infections. This is a condition where the ECP can make a real difference by initiating treatment immediately in the community and thus avoiding unnecessary hospital admissions. The use of antibiotics for UTIs (Trimethoprim and Nitrofurantoin) is recorded 62 times, which is only just over half the number of presentations. The reason for this is that often ECPs are called to patients who are feeling unwell because of a UTI which is already being medicated, and sometimes these patients are too frail to be treated at home and so are admitted to hospital where treatment is initiated.

Drink/drugs

Commonly seen as being what paramedics spend most of their time dealing with, in fact patients presenting as drunk as their primary problem only account for 2.7% of presentations. However, the presence of alcohol as a significant factor across all jobs is recorded at 9.5% (n=446), which is in line with other studies (Martin et al, 2012).

Assaults

Assaults are fairly evenly split between those that can be treated at scene and those that require the victim to go to hospital (usually because they are drunk and have a head injury).

Endocrine

The most common endocrine disorder encountered in emergency care is diabetes and is typically managed in the community.

Cardiac arrest

The public perception is perhaps that we deal with cardiac arrests day in day out but the reality is that they are far less common. There were a total of 55 (1.2%) cardiac arrests identified in the audit, cardiac arrest being here specifically what are termed ‘working’ arrests, i.e. where BLS/ALS is undertaken for at least some period of time. The demographics and aetiologies of the arrests encountered break down as follows:

Others

There are a number of other patient presentations that do not fit into any of the above categories but are common enough to be worth a mention.

Back pain was seen 96 times (2.1%), this is typically treated at scene with the use of oral analgesics such as Codeine (n=93), Diclofenac (n=39), Paracetamol (n=63, which is lower than some other analgesics as patients often have their own, the audit recording drugs dispensed), Diazepam (n=45), and Tramadol (n=28).

Viral illness was seen 85 times (1.8%) and again is typically treated at scene with advice. Viral illness would here be defined as a mild illness with the presence of an infection (typically fever, coryza) with no treatable focus identified (i.e. chest infection, UTI etc.).

Panic attacks were encountered 83 times (1.8%) and again are usually treated at scene. Some are classical ‘hyperventilation syndrome’, a recognised condition requiring treatment, the rest are usually preceded by the consumption of alcohol and the belief that one's drink has been ‘spiked’.