Irecently presented at the College of Paramedic Conference hosted in University of Western England in December 2011. I was approached afterwards by a couple of students from another UK academic institution who explained that they had not been taught the (CABCDE) Structured Approach method of patient assessment (Halliwell et al, 2011). The students themselves seemed very able and willing to understand and embrace the simple concept that unless haemorrhage is controlled there is no point in securing Airway or Breathing. This concept is not new, being proposed by Hodgetts et al in 2006, and adapted in my own Trust in 2007.
In addition, the students seemed willing to accept the concept of using the same CABCDE algorithm for all cardiac arrests, since there is little point doing chest compression if the blood continues to pour onto the foor. I was impressed with their openness and honesty, but as an educator I was left wondering...is this not a significant failing of their education? I believe the answer is absolutely.
My personal thoughts are that haemorrhage control is a basic first aid skill, and I feel that paramedics and others practitioners in pre-hospital care who are not taught to control haemorrhage should not really be in the position of treating patients. For me, key skills such as the use of tourniquets for limbs and packing for other (non tourniquetable) areas must become standard skills for all paramedics; along with the skills to seal open holes in chests, and understand the concepts of adequate ventilation.
At the time of writing we have just witnessed a terrorism attack in the beautiful City of Liege, Belgium. At least 4 people were killed and 122 injured. My thoughts go out to the medics involved with this incident who faced significant challenges.
With shrapnel and bullet wounds once again being an issue on the streets of Europe, as paramedics we really need a refocus with regards to our ability to undertake point of wounding care. I feel that it is not just the military who are facing this type of issue, and we can definitely learn a great deal from them. The military use a structured CABCDE approach because it works, it is systematic, thorough, and easy to remember at a time of crisis. It has a basis in hypothetico-deductive reasoning, (Whewell, 1837) and is underpinned by science and research; but most importantly it has been proven to be effective.
‘as prof essi onals we need the equipment to be available, and if we don’t have the kit we surely have a professional duty to raise our concerns with our employers’
At the same conference I asked some of the delegates whether they have the kit to treat catastrophic haemorrhage, and if they knew how to pack wounds. I was horrified that the answer was not, an across the board, yes.
Anecdotally, it seems that some UK ambulance services have not put arterial tourniquets onto front line vehicles, preferring to give them to HART or other specialist teams. To me this strategy seems flawed as we have other events that create massive haemorrhage. In my Trust we use the arterial tourniquets about 20 times a year; and when they are used the use is always appropriate with lives are being saved.
This year UK ambulance services have been served with Rule 43 Coroners Actions (1984) for not managing haemorrhage adequately. I am aware of two cases where coroners challenged Trusts this year; and I therefore feel that as paramedics we need the tools and the knowledge to do our jobs. I appreciate the most common message I hear from paramedics is ‘ ... we don’t do trauma’, but is that something to be proud of? Shouldn’t the message be changed to ‘we can do anything with the right knowledge and tools’?
The Health Profession Councils guidance on Performance, Conduct and Ethics (2008) suggests that we have to,
“As autonomous and accountable professionals, make informed and reasonable decisions about our practice to make sure that we meet the standards that are relevant to our practice. This might include getting advice and support from education providers, employers, professional bodies, colleagues and other people to make sure that you protect the wellbeing of service users at all times.”
I believe that it is time to start a revolution:
Most importantly for me we need to understand that our students are our future, and if we are not teaching them the latest thinking at the beginning of their careers we will be perpetuating the creation of poor clinicians. Structured approaches, I feel, give students the ability to use a template to frame the rest of their learning.
Pre-hospital care requires us as clinicians to use latest evidence, and at the time of writing we are awaiting publication of the new JRCALC guidelines for 2012; we hope to see these in April 2012. The JRCALC guidelines are consensus guidelines, with reviewers utilizing the latest guidelines to inform best practice. This approach is not unusual, it is how the resuscitation guidelines produced by our own Resuscitation Council UK, the European Resuscitation Council, and the American Heart Association are developed. Guidelines, and education are still not enough, however, as professionals we need the equipment to be available, and if we don’t have the kit we surely have a professional duty to raise our concerns with our employers.
I go to very few conferences these days, unfortunately, but like many of you reading this article I do try and read and research areas of best practice. For me, the recent College Of Paramedic Conference has highlighted that despite having national groups reviewing the best possible clinical practice, the Directors of the Clinical Care group being an example, we are still far from having standardized practice in the UK.