Search

Survival rates for out-of-hospital cardiac arrest (OHCA) patients in the UK are low compared with other developed countries. UK ambulance services are in an important position to influence these survival rates by improving their ‘chain of survival’ (Nolan et al, 2006). A paramedic-led resource, with enhanced technical and non-technical skills specialising in OHCAs, has been shown to improve patient outcomes in this population group in the UK. The author proposes that this concept should be considered by all UK ambulance services to improve OHCA patient survival.

A patent airway linking the nose and mouth with the lungs is essential to life. In emergency care, individuals may experience airway difficulties for many reasons including major trauma, airway inflammation and altered consciousness. Airway management is therefore a core skill for paramedics and other practitioners working in prehospital care. This article reviews the anatomy and physiology of the airway before moving on to consider causes of airway obstruction. A look-listen-feel approach to airway assessment is described, followed by a discussion of techniques used to clear, open and maintain the airway. Commonly used airway devices including oropharyngeal, nasopharyngeal and supraglottic airways are evaluated, and their indications and insertion techniques discussed. The use of endotracheal intubation by paramedics is also evaluated.

Claire Main, Interim Manager of Critical Care and Major Trauma at Cardiff and Vale University Health Board and ANN UK executive board member, gives an update on acute kidney injury and the impact of the COVID-19 pandemic

Open fractures incur significant morbidity and mortality, and as such have standardised guidelines for their management. Photography of open fractures is an essential component of documentation in the treatment of open fractures as per the British Orthopaedic Association Standards of Trauma and National Institute for Health and Care Excellence guidelines. Smartphones have made photography easily accessible to the clinician, but serious concerns exist regarding data security and the consent process around the use of sensitive clinical images. This project sought to overcome this issue by developing a Caldicott-compliant hospital imaging protocol that allows clinicians to use their smartphone to upload open fracture images into the patient's permanent record. Implementation of the protocol was audited and resulted in the increase of safe and secure open fracture photographic storage to inpatient medical records. This protocol would be transferrable to other hospital trusts and could be adopted across major trauma networks.

Methoxyflurane (Penthrox®) is a fluorinated hydrocarbon, which when first used in general anaesthesia was noted to have strong analgesic properties in subanaesthetic dosage. More than 5 million doses have been sold for use in Australia since 1978 and have been found to have an excellent safety profile. After rigorous review by the Medicines and Healthcare Regulatory Agency, methoxyflurane was granted a product licence in 2015 in the UK and Europe for the relief of pain in patients with moderate-to-severe trauma. This paper presents the first reported case series of patients treated with methoxyflurane in the UK and Ireland in the prehospital environment. The results show a statistically significant improvement in patient pain scores at 1, 2 and 5 minutes following administration of methoxyflurane. With its use increasing in prehospital care and emergency departments, methoxyflurane is recognised as a useful adjunct to the choice of analgesia for trauma patients with moderate-to-severe pain.

Around 65 000 people experience a fractured neck of femur (NOF) each year in the UK. It is estimated that one in 10 patients with an NOF fracture will die within 1 month, and one in three will die within 1 year. The bill for NOF fracture, excluding substantial social care costs, is £1 billion per year. Given the exposure that ambulance services have to these patients, several aspects of NOF fracture care could be improved in the prehospital environment, which could also generate significant savings for the NHS. This article reviews the literature regarding NOF fracture care, and highlights aspects that affect ambulance services and prehospital care. A variety of these, including pain management, fast-track systems, fluid therapy and renal impairments, can be improved, but evidence specific to the prehospital environment is lacking.

Human factors affect paramedic practice and training. However, although there are frequent references to human factors in the literature, little evidence on this is available on those that influence student paramedic development. A personal experience as a student paramedic highlighted certain human factors unique to the role, most notably how interactions between students and mentors can affect a student's practice. Following this, the awareness and effect of human factors within the student paramedic role were investigated. Discussions regarding human factors that influence a student paramedic's development on practice placements remain in their infancy. The student paramedic role is unique and challenging, and involves developing a level of resilience that continues post registration. Because of the role's emotive nature, students need to increase their awareness and management of human factors to prevent them from affecting their practice. Equally, educators need to have a greater focus on encouraging and teaching coping strategies. Practitioners who work with students do so whether they choose to be a mentor or not and many may feel unprepared for the role. Interactions between students and clinician mentors are complicated and future research will be required to determine the best approach to aid student development in the placement environment.

Background: Cerebral oximetry allows non-invasive, real-time monitoring information of cerebral blood flow. It has recently been used to provide information about cerebral perfusion during resuscitation efforts in cases of cardiac arrest and may give an indication of neurological survival. Most of this information has been obtained during the hospital phase of treatment and little is known about cerebral flow in the prehospital phase. Methods: A systematic review was carried out, with the PubMed and EMBASE databases searched to identify clinical trials where cerebral oximetry monitoring was performed in the prehospital phase of out-of-hospital cardiac arrest. It aimed specifically to answer the following questions: is cerebral oximetry monitoring feasible in the prehospital environment? Can cerebral oximetry be used as a useful marker of the quality of cardiopulmonary resuscitation in the prehospital setting? Can cerebral oximetry be used to assist decisions around prognostication and futility for out-of-hospital cardiac arrest? Results: Five studies were identified for review. Feasibility was demonstrated in four of these. The usefulness of cerebral oximetry in monitoring cardiopulmonary resuscitation has not been well explored in out-of-hospital cardiac arrest. Similarly, data linking intra-arrest cerebral oximetry values and prognosis in out-of-hospital cardiac arrest is sparse. Conclusions: Cerebral oximetry is feasible in out-of-hospital cardiac arrest but its usefulness in guiding resuscitation attempts in this environment remains largely unknown.

Overview This article presents an overview of the additional aspects of history-taking that need to be considered when assessing patients presenting with a rash. This relies on strong underpinning anatomy and physiology knowledge to correlate the skin presentation to what may be happening pathophysiologically within the patient's skin. Four case studies are presented, with leading questions which are then explained. The overall aim of this article is to provide an introduction to key dermatological presentations for the paramedic as a starting point for more thorough reading and exploration on the subject.

Trauma is the leading cause of death for people in the UK and North America, especially for those aged 15–24 years. However, if early management regimes of permissive hypotension, high-flow oxygen and administration of tranexamic acid are applied, mortality risk can be reduced significantly. Acute traumatic coagulopathy (ATC) is an internal process that is initiated by significant or massive trauma because of hypoperfusion resulting in hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx. ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy—the ‘lethal triad’ of trauma. This article discusses the pathophysiology of ATC and treatment strategies via the management of the lethal triad.

Background: Paramedics new to research need to know how to optimise the quality of proposed research studies. A prehospital mixed-methods study design required guidance, not only from an academic perspective but also from experts within paramedicine. Paramedic engagement was defined as an exercise where paramedic researchers and paramedic clinical academics could be involved as advisory professionals. Aim: The aim of this paramedic engagement was the revision of a proposed research design on how senior clinical advisers determine futility in pulseless electrical activity in out-of-hospital cardiac arrest. Method: Five research paramedics and four clinical academics were interviewed by email using semi-structured questions. A generic qualitative inquiry with inductive content analysis was applied. Results: Paramedic engagement identified five themes: rewording the proposed study title; acknowledging that paramedics withdrew resuscitation; the implications of prolonged futile resuscitation; the need for autonomous paramedic decision-making; and improving research methodology. Conclusions: Professional paramedic engagement meant a number of complexities were identified within prehospital research and and pragmatic solutions were provided to the limitations in the proposed design. Novice researchers within paramedicine would benefit from early paramedic engagement to facilitate the design of research studies, provide guidance on methodology and identify limitations to improve the overall quality of prehospital research proposals.

Background: Pelvic circumferential compression devices (PCCDs) are a life-saving prehospital adjunct to trauma care. Correct positioning at the level of the trochanters maximises their efficacy. Methods: To examine the positioning of PCCDs in a regional trauma centre in England, a retrospective analysis of patients who had experienced major trauma was carried out over a 6-month period. The primary outcome of PCCD position was assessed using computerised tomography imaging and recorded as ‘high’, ‘centred’ or ‘low’ (depending on trochanter level). Secondary outcomes, including patient demographics, mechanism, pattern, number and types of injury were also collected. Results: Eighty-nine patients were identified with a PCCD in situ, in whom 28 (31%) devices were positioned too high and eight (10%) too low. There was no correlation between mechanism, pattern, number or type of injury and PCCD position. Conclusions: Despite published evidence on PCCD position and training for personnel, many PCCDs are still poorly placed. Further education for professionals involved in PCCD application is recommended.

Background: During recent conflicts in Iraq and Afghanistan, tourniquets were a useful tool in the management of non-compressible prehospital catastrophic haemorrhage. Recommendations for use within the civilian setting were then made. However, civilian research supporting this change in practice is limited. Aims: The aim of the research is to evaluate the utility of prehospital tourniquet application through description of the complications associated with use, as well as identification of mortality following prehospital application. Methods: A literature search was completed using PubMed and Embase for research studies on prehospital tourniquet use in extremity trauma. Study relevance was confirmed via their abstracts and final selection was made through reviewing the full publication. Data were extracted on mortality, complications, indication for use, effective application and application duration of tourniquet use. This was tabulated, and a descriptive analysis performed. Results: The research reported a mortality range of 3–14% with an associated complication rate of 2.1–32.4%. The effectiveness of prehospital application was in the 88.8–98.7% range, with tourniquet application durations of 48–103.2 minutes. Conclusions: The tourniquet should continue to be available to UK paramedics for the management of prehospital non-compressible catastrophic haemorrhage. Application is likely to provide a mortality benefit with limited morbidity and associated complications.

Hazardous Area Response Team (HART) paramedics from a single ambulance service Trust were trained to administer ketamine up to 0.5 mg/kg for analgesia in the pre-hospital environment. The Trust's special operations department felt that, in doing so, patient care could be improved in both hazardous areas and regular pre-hospital clinical situations. After completing a written examination and scenario training on the relevant Trust patient group directive (PGD), HART paramedics were authorised from 4 July 2016 to administer ketamine autonomously. HART paramedics then retrospectively self-reported on the details of administration using a computerised auditing application called iAuditor. Data from 1 year of usage were then collated and analysed using Microsoft Excel with the aim of identifying current practice and developing recommendations for the future. Despite encountering complications, safe independent use of ketamine was demonstrated and was shown to be an effective analgesic agent in the majority of incidents. Suggested methods for developing and improving ketamine use by paramedics are discussed. Furthermore, a number of recommendations for optimising the Trust's ketamine PGD and the iAuditor template were identified. This work has provided the foundations for future audit and research.

The Mental Capacity Act 2005 is one of the key pieces of statutory legislation used in modern paramedic practice. To the unprepared, the Act can seem complex and daunting; but it is a powerful tool which helps paramedics to deal with often complex and challenging situations in a way which is both ethically and legally safe. What follows is a walk-through of the Act itself looking at the parts which are relevant to paramedic practice and discussing issues relating to them which, it is hoped, will enable paramedics and others involved in delivering pre-hospital emergency medical care to apply the Act with confidence in their practice.

This article provides an overview of hyperventilation syndrome (HVS). Hyperventilation is to breathe in excess of metabolic requirements; in the absence of an underlying organic cause, it is defined as HVS. Alternative terms used in literature are panic or anxiety attack, panic or anxiety disorder, dysfunctional breathing and breathing pattern disorder. This article explores HVS signs and symptoms beyond the familiar clinical signposts of tachypnoea, chest tightness, paraesthesia and anxiety. It will also discuss differential diagnoses and pre-hospital treatment of HVS, focusing on reassuring patients and assisting them in establishing a good respiratory pattern. Patients with HVS use a significant amount of hospital and emergency service resources, ideally placing paramedics to diagnose and treat HVS in the pre-hospital setting to avoid unnecessary and costly hospital admissions. Further research is needed to evaluate the pre-hospital prevalence and diagnostic accuracy of HVS, identify clear diagnostic criteria and design screening tools.

Background: Evidence to support device choice in intraosseous access is lacking in UK paramedic practice. Being unable to access the sternum with devices may result in under-treatment because of the inability to gain timely vascular access. This represents a shortcoming in current practice and a need for further research. Method: A literature review was conducted to find suitable studies and these were critically appraised. The data were synthesised to draw conclusions that could either influence practice or inform research. Study results were analysed in order to examine the following outcomes for devices most successful in terms of insertion rates; insertion times; ease of use; and flow rates. Cost-efficacy was also taken into consideration. Results: Forty-eight relevant articles were identified in the search and 18 were analysed. Of the 18 articles, 7 were randomised controlled trials and 11 were observational studies. Results varied widely with differences in reporting making the synthesis of data problematic. However, there was sufficient evidence to conclude that semi-automatic devices are superior to manual ones. Conclusion: Weaknesses in the evidence and inconsistencies between studies limited the conclusions that could be drawn. There is a strong mandate here for further research.

This exploratory study addresses the current paucity of knowledge available in UK paramedic practice in relation to cardiac auscultation. There is a recognised lack of data surrounding the efficacy, safety and relevance of patient assessment skills in the pre-hospital setting in general, and cardiac auscultation specifically. This study provides information about current paramedic practice, and provides a basis for further research in this area. An online survey was distributed using convenience and snowball sampling, receiving 328 responses within a 31-day period. The results show that many paramedics rarely, or indeed never, undertake cardiac auscultation and that many lack confidence in recognising normal and abnormal heart sounds. There is also a divided opinion among respondents who provided free-text answers, with some feeling that the skill of cardiac auscultation is vital in pre-hospital care and others firmly disagreeing. This research lays the groundwork for further developments in training, education and continuing professional development for paramedics.

For a paramedic, delivering a death notification (DN) is one of the most difficult and stressful messages they will have to communicate in practice. Stress and anxiety in both recipients and paramedics have been documented through a limited literature base. The current review seeks to understand the existing educational tools and training around DN, and evaluates the applicability of these in the pre-hospital environment.

Background: Universities are now frequently exploring international placements and learning experiences for paramedicine students. This has given rise to questions about the quality and meaningfulness of overseas student experiences within the paramedic curriculum. Aim: This study investigates whether a university-organised overseas trip provided a useful clinical and cultural learning experience for undergraduate paramedicine students. Methods: A 60-question survey was administered to participants, with questions chiefly focusing on clinical and cultural experiences during the overseas trip. Statistical software was used to analyse continuous and categorical survey data. Findings: This international trip appears to have provided a very useful cultural learning experience, but a sub-optimal clinical learning experience for students (even despite child births, emergency room presentations and blood-draws). Conclusions: A validated survey instrument which builds upon current knowledge and literature could be used more widely to evaluate and better understand the dimensions of quality in overseas paramedic student placements.

In the pre-hospital setting, point-of-care ultrasound (POCUS) is a useful diagnostic tool that can provide additional clinical information to assist with pre-hospital management strategies and choice of hospital destination. Studies describing the clinical utility of paramedic-performed POCUS in the pre-hospital setting are lacking; however with the right training and education, paramedics are able to adequately obtain high-quality ultrasound images. Despite this, education programmes vary widely and a standardised approach is yet to be defined. The technology of ultrasound devices continues to evolve and in future, the transmission of ultrasound images to the receiving hospital should be a minimum requirement. While some studies report that POCUS influences pre-hospital management, data are lacking as to whether this improves patient outcomes. The authors have demonstrated the potentially significant role of POCUS in pre-hospital care; however this assessment modality does not replace physical examination, clinical experience and clinical decision-making.

Background: This article stemmed from a search for more understanding about how paramedics relate to urgent and primary care (U&PC). Methods: The current study is qualitative, involving interview with seven general practitioners (GPs) in Wirral, Merseyside. Their verbatim evidence was audio-recorded, transcribed and analysed. Findings: There were three superordinate themes established: variability of referrals; the value of referrals sometimes being overlooked; and the need for skills development to improve referrals. Conclusion: The paramedic skillset is essential for appropriate referrals as long as their limitations are considered by GPs, while future research should focus on how paramedic skill bases can evolve in the U&PC community.

Background: In secondary care, the urgency of review for transient ischaemic attack (TIA) has relied upon the use of the ABCD2 score, but this tool is not validated for use by emergency ambulance crews. There is a need to evaluate alternative care pathways for patients who might be eligible for direct referral to TIA clinics without prior conveyance to the emergency department (ED). Aim: The aim of this national survey was to describe current service provision across the UK for pre-hospital emergency care of patients with TIA. Methods: The authors approached all UK Ambulance trusts (n=13) by email, asking them to provide details of TIA patient referral pathways. Findings: Twelve ambulance services responded to the survey and nine reported that they had no current pathway; one had discontinued a pathway because of service reconfiguration; and three were currently using one. All pathways used the ABCD2 tool to screen patients and classified patients as low-risk if the ABCD2 score was 3 or below. Non-conveyance exclusion criteria varied. Although compliance with referral pathways was audited in an initial pilot in one service, no other evaluations of the effectiveness of pathways were reported. Conclusion: A minority of UK ambulance services report introducing referral pathways for low-risk TIA patients, avoiding initial assessment in the ED. Safety, effectiveness and acceptability of such pathways have not been evaluated to date.

Aim: The current study investigated the positive and negative psychological adaptations that are a result of secondary traumatic stress, and the role of resilience among paramedics and emergency medical technicians (EMTs). Methods: Emergency medical service (EMS) providers anonymously completed four validated questionnaires on: secondary traumatic stress, post-traumatic growth, resilience, and changes in outlook. Relationships between these constructs and demographics were explored. Findings: Overall, EMS participants reported a higher-than-average positive change in outlook. Resilience (p0.05) were detected between years of experience for any attributes analysed. Conclusion: Findings demonstrated significant correlations between secondary traumatic stress, resilience, post-traumatic growth, and changes in outlook in EMTs and paramedics.

Overview Ambulance clinicians are frequently called to patients who are approaching the end of their life. This article presents an overview of some of the issues that impact on the delivery of care to patients at the end of life, including symptom and urgent care needs in the last few days of life; preferences for care/place of care; and coordination of care. Each of these areas pose different challenges for ambulance clinicians. As a way of addressing some of the issues, this article outlines an online education package in end-of-life care, which has been specifically designed for ambulance clinicians in response to an analysis of their training needs. The learning outcomes and educational approach is described. The education aims to help equip ambulance clinicians with the knowledge and confidence that they need to deliver high-quality urgent end-of-life care.

Health professionals' compliance with hand hygiene remains a universal problem in health care. While poor hand hygiene is prevalent in the inpatient and hospital environments, these behaviours are also similar among emergency medical services (EMS) personnel. Studies in infection prevention and control practices and knowledge of transmission of the spread of multidrug-resistant organisms within the EMS have highlighted sub-optimal standards and a need for improvement. This article discusses the different products, procedures and strategies available to improve hand hygiene compliance in the EMS, and how applying learning theories to understand and improve behaviour can also be incorporated into the crusade to improve hand hygiene.

Paramedics have been regulated in the UK since 2003. Analysis shows that the profession has had consistently higher rates of self-referral to its regulator compared with other health and care professions. Between 2013 and 2016, the percentage of paramedics who self-referred averaged 50% of all cases, compared with 6% across all other health professions regulated by the Health and Care Professions Council (HCPC) and 10% across social workers in England. This article reports on possible reasons underlying this trend. Using a mixed-methods approach including a literature review, interviews, focus groups and case analysis, the study identified a number of possible contributory factors. These included pressurised work environments, variable guidance and support from employers, and work cultures of fear and conflict. The evolving nature of the profession was also cited. The research found that there was a cohort of cases that appeared inappropriate—where the referral was for a matter that did not require reporting. Actions are being taken to reduce such self-referrals to avoid the emotional distress and resource implications for those involved.

Traumatic cardiac arrest (TCA) is a rare event in the pre-hospital setting and has a varied aetiology. Paramedic management has changed significantly over the past 5 years. Chest compressions have been de-emphasised in guidelines, and the ‘HOT’ principles have been adopted. This principle stands for hypovolaemia; oxygenation; tension pneumothorax/tamponade. The recommendation is that these should be addressed prior to performing chest compressions. There may however be patient groups in TCA who benefit from chest compressions. A management plan including ‘no chest compressions’ for TCA is not supported in the evidence, and they should be commenced as soon as appropriate reversible causes have been addressed. In addition, chest compressions may take precedence over the administration of fluid if both cannot be performed simultaneously. Ambulance services may improve management of TCA by the introduction of an aide-memoire to support clinicians.

Correct initial management of thermal burns is key in promoting patient outcomes. Cooling burns with cool running water (CRW) for 20 minutes has been shown to accelerate the wound healing process, improve cosmetic outcomes and prevent burn progression. This literature review aims to increase understanding of this simple first aid (FA) intervention, help inform paramedic practice, and determine areas for further research. Three themes came to light following systematic searching of the available literature. As a result of a paucity in evidence, a wide range of topics relating to cooling burns have been explored. The topics look at how patients and carers may approach FA in burns, how pre-hospital practitioners currently manage burns patients, and the best methods to use for cooling burns. Findings suggest that there is need for improved education for the lay public and pre-hospital providers in order to improve burn outcomes through FA interventions. While CRW is supported as a beneficial intervention, further research is required into alternative cooling methods to enhance care and evidence-based practice.

Background: The success of pre-hospital research relies on positive engagement from paramedics. Without adequate participation and protocol compliance, trials will not succeed. Aims: The aims of the current research were to seek feedback from paramedics about trial participation and determine their views and preferences regarding a large-scale research study in future. Methods: Paramedics participating in REVIVE-Airways, a trial of airway management in out-of-hospital cardiac arrest, were sent a feedback questionnaire according to their study allocation. Findings: Of the total respondents, 99% were willing to participate in a further large-scale trial. Participants offered recommendations for future pre-hospital trials. Conclusion: There was strong support for further clinical trials of alternative airway management strategies during out-of-hospital cardiac arrest. Paramedics welcome opportunities to participate in research and receive feedback about trial progress and patient outcomes.

In 2015, the National Ambulance Lesbian Gay Bisexual and Transgender (LGBT) Network was founded to help improve the experiences of LGBT people who contact the ambulance service; expand the support offered to ambulance staff; and create a visible presence in the community. Since its formation, committee members, regional representatives and ambulance staff from across the country have worked tirelessly towards these core objectives, and to share best practice between regional ambulance LGBT networks. In August of 2017, the Network held its second annual conference to emphasise some of the health inequalities that LGBT people are known to experience when accessing health care. Over the course of the day, delegates were able to learn about interventions and support measures that are available through a series of workshops on issues such as dementia care and post-traumatic stress disorder. This conference report documents the success of the National Ambulance LGBT Network Conference 2017 and provides an overview of the engagement and support packages that are currently under development to support staff wellbeing and patient experience.

Major haemorrhage remains the highest preventable cause of death following trauma, accounting for 30–40% of trauma mortality ( Kauvar et al, 2006 ). Therefore, pre-hospital intervention is a key aspect of paramedic practice. Paramedics are often first on the scene and have a range of local and systemic treatment options. Pre-hospital medical advances, such as the introduction of tranexamic acid, allow paramedics to deliver a higher standard of care. In addition, the number of patients on anticoagulants and antiplatelet drugs is increasing; therefore, knowledge of how these drugs interact with the haemostatic response would be beneficial. It is important that paramedics fully understand the mechanisms of drugs interacting with the haemostatic response, and the theory underpinning the management of major haemorrhage ( Kreuziger et al, 2012 ). This enables paramedics to understand why they are administering the care they are providing. This article gives a detailed overview of two physiological responses to major haemorrhage: haemostasis and blood pressure. This is followed by an explanation of how these systems are deranged and altered by major haemorrhage through pathophysiological consequences. Finally, recent research covering advances in the understanding of how deranged coagulation occurs is also discussed.

Background: Studies investigating the transfer of endotracheal intubation skills from simulation training to out-of-hospital patient scenarios are limited. Aims: The aim was to evaluate the outcome of endotracheal intubation simulation training among paramedics and the safe transfer of skills to out-of-hospital cardiac arrest (OHCA) patients. Methods: Paramedics participated in a 1-day simulation training course including five Airtraq endotracheal intubation attempts using three different types of mannequins (n=15 attempts). Performance and outcome of transfer of intubation skills to patients were monitored for the next 35 months. European Resuscitation Council international advanced cardiopulmonary resuscitation guidelines ( Nolan et al, 2005 ) were followed to ensure patient safety. Findings: Endotracheal intubation was attempted in a total of 417 patients with OHCA by 51 (96%) of the 53 participating paramedics. In 366 (88%) patients, intubation was successfully performed in the first or second attempt. Aspiration, airway secretion, a high modified Cormack Lehane score and insecure verification of tube placement were the most common reasons for failed intubation. Conclusion: Endotracheal intubation with Airtraq in adult patients with OHCA can be performed safely by paramedics after receiving a 1-day simulation-based training course.

Background: Refractory ventricular fibrillation (RVF) in out-of-hospital cardiac arrest (OHCA) poses a significant challenge to paramedic teams and is further confounded by an absence of specific guidance on the management of this patient category. Objective: To conduct a systematic literature review to determine whether double sequential defibrillation (DSD) improves patient outcomes in adult OHCA. Methods: Electronic searches of CINAHL, MEDLINE and AMED databases were carried out, using EBSCOhost (2017) and a subsequent filtering process. Results: Three case series and two cohort studies provided the highest category of evidence to evaluate. DSD is offered as a potentially feasible RVF treatment strategy throughout. However, results are consistently limited by varying protocol and small study groups and DSD success is likely multifactorial. Conclusion: The current systematic literature review indicated that no confirmed association existed between DSD and improved OHCA outcomes. More robust research is required to eliminate profound limitations and consider contributing factors to DSD.

Background: The current study describes the design and implementation of a residential aged care facility placement, and reports student experiences using an attitudinal survey across two cohorts. Method: Placements in January 2014 and 2015 were surveyed to identify barriers and enablers to student learning. Descriptive analysis was used to report the frequency of responses for categorical variables. Chi-square tests were used to analyse change in item rank by year. Content analysis was used to analyse text responses. Results: Initial 2014 results show that 75.4% of respondents agreed that they were able to achieve the required learning outcomes during this placement, with 72.8% agreeing that the placement improved their knowledge of community-based care for the elderly. Students tended to agree that the placement improved their confidence as practitioners, and that the experience helped to improve communication skills. Conclusion: This initiative showed that it is possible to enable learning outcomes that are directly related to core paramedic competencies. The placement was associated with improved understanding of age-related health problems. In addition, the placement provided opportunities to observe the role of health professionals in the maintenance of an older individual's health, social and spiritual needs.

The current article describes how an innovative approach to mental health training for student paramedics can prepare the future workforce with the skills and knowledge needed to provide high-quality care. Action research methodology is used to describe the delivery and evaluation of the placement, identifying its key and sustainable learning impacts for all involved. Key to its success was the co-production of the placement from beginning to end, including service users and qualified paramedics. The outcome of the placement enabled students to develop the confidence and ability to provide compassionate person-centred care as well as the skills to cultivate self-care and resilience.

Paramedics are trained to perform endotracheal intubation (ETI), though a step-wise airway management approach has led to the use of supraglottic airway devices (SGAs), often in place of ETI. The current article considers airway management by paramedics during cardiopulmonary resuscitation (CPR). A case-note review relating to adult out-of-hospital cardiac arrests was carried out, with the collection of data over the period of a year, in one region of the UK. The results indicate that airway management is inconsistent during CPR, though simple adjuncts are used successfully. In a cohort of 2779 patients, in resuscitated cardiac arrest, attempts to intubate were made in less than half of the patients. Less than a third of patients were successfully intubated. Reasons for not attempting intubation need further investigation, alongside reasons for unsuccessful attempts.

Aims: The aims of the current research were to investigate the most appropriate out-of-hospital opioid for adults with traumatic pain. Providing adequate analgesia has multiple benefits both during and post injury. Methods: The literature search was carried out using multiple databases to identify relevant out-of-hospital research with additional grey literature to support. The main themes encountered were intravenous morphine compared to intravenous fentanyl, and the contrast between them. Discussion: There were no significant differences in effectiveness or adverse effects. Intranasal application was thought to be favoured where intravenous access was unobtainable. Conclusions: Further research is required to establish which is the most appropriate opioid. This could include a greater focus on the onset time, duration and optimal dose. Increased education and organisational focus would need to be addressed alongside a change in drug formulary for the out-of-hospital clinician.

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this instalment, Rory McKelvin discusses the application of splints to fractures and sets out a best practice step-wise approach to assessment, decision-making and application in prehospital settings

The aim of the current research was to review the first-line response to patient falls in the independent care sector in North East England. The authors used an online questionnaire via ‘Survey Monkey’ software package, and a convenience sample of 24 of 32 independent care sector homes from South Tyneside, representing a 75% response rate. Policies and guidelines for falls were investigated and the findings highlight the disparate responses to incidences in care-home settings. Despite 96% having a policy on falls, only 80% included an assessment of possible injury or harm and 13% included no direct guidance for staff when residents fall. The most common action was to ring emergency services to move patients, even in the absence of physical injury. There was considerable ambiguity around the assessment of injuries and whose responsibility this was, particularly in falls with potentially non-visible injuries. Ambiguity was also present in the management of falls, where there was overlap between accident and falls policies. The current research highlights the need for policy standardisation. There is a potential fiscal impact on emergency ambulance services when they are contacted as the first-line response for falls regardless of the occurrence of injury. This has implications on staff education and the strategic planning of emergency ambulance services. Further consideration on the suitability of falls policies is urgently required.

Winter is near and the media shall soon begin its yearly forewarnings of undue strain that the season brings upon the NHS. In this news feature, Alistair Quaile examines whether these warnings are genuine or mere hyperbole, and considers the causes of winter pressure, as well as what the NHS can do to combat these seasonal demands.

Rapid drug-induced vasodilation is essential in treating coronary medical emergencies. Through oral or sublingual administration of glyceryl trinitrate (GTN), changes occur in cyclic guanosine monophosphate (cGMP) levels, as well as a reduction in blood pressure. Patients who require GTN treatment may also take vasodilatory medication for other medical conditions, including erectile dysfunction (ED). Current guidance in the UK contraindicates GTN use alongside sildenafil (commercially known as Viagra) and other related drugs, owing to the likelihood of life-threatening hypotension. Therefore, it is essential that paramedics and emergency responders establish whether patients have taken sildenafil within the past 24 hours before administering GTN. This article identifies the action mechanisms of both drugs, and provides an evidence-based explanation for co-administration outcomes; a dramatic drop in blood pressure which can potentially be fatal. This article also reflects on the challenges faced by paramedics when considering administration of GTN to determine whether sildenafil has been taken within the past 24 hours.

The role of transthoracic echocardiography (TTE) is one of the top five research priorities in prehospital critical care ( Fevang et al, 2011 ). TTE is a non-invasive diagnostic tool in cardiac arrest, using ultrasound images to visualise the real-time activity of the heart ( Hernandez et al, 2008 ). TTE has the potential to reduce the time between the onset of cardiac arrest and appropriate therapy. There are several reversible causes of cardiac arrest that can be identified by TTE in the pre-hospital environment. The method and value of identifying pulmonary emboli (PE), cardiac tamponade and hypovolaemia will be discussed. Equally, TTE can exclude certain reversible causes, indicating that the cardiac arrest is of an irreversible nature and the resuscitation attempt is futile. The application of TTE in this context will be reviewed in depth, from the current literature to the physical practicalities. As such, the aim of the present study is to clarify the role of TTE in patients suffering out-of-hospital cardiac arrest.

A summary of the support given to paramedic students who attended the Manchester Arena bombing in May 2017.

Paramedics are frequently called to people with acute mental health problems and often assist in caring for and transporting individuals subject to police powers under the Mental Health Act 1983 , sections 135 and 136. Those powers will change when Chapter 4 of the Policing and Crime Act comes into force this autumn. In this short article featured for World Mental Health Day, Richard Griffith considers the impact of amendments to police powers on paramedic practice under the Mental Health Act 1983 introduced by the Policing and Crime Act 2017 , Part 4, Chapter 4.

This article is a review of literature conducted in as systematic manner using the PRISMA statement as a basis for its methodology to answer the following question: How can EtCO2 measuring assist with CPR attempts in SAR Helicopter paramedic practice?’ Results revealed that CO2 coming out of an ET tube indicates that it is in the correct position. An EtCO2 value of 2 that falls by ≥ 25% of the baseline are the variables most significantly correlated with not achieving ROSC. Diminishing EtCO2 readings may be an indication to increase CC depth, or change a tiring CC provider to optimise CPR attempts. A sudden rise in EtCO2 is a highly specific but non-sensitive marker of ROSC.

Background: Qualitative research involving paramedics and their involvement in end-of-life (EoL) care has already been published, but there have been no published attitudinal studies specifically relating to do not attempt cardiopulmonary resuscitation (DNACPR) orders and paramedics working in the pre-hospital setting in the UK. Objective: To gain an understanding of paramedic attitudes towards an increasingly common aspect of paramedic practice, focusing specifically on the pre-hospital environment and identifying any corelation between gender, length of service, and level of educational attainment. Design: A paper-based questionnaire was distributed to all paramedic grades, operational out of two ambulance stations of a regional NHS ambulance service in March 2017. The questionnaires were designed using a combination of free-text boxes and Likert scales. A total of 33 questionnaires were issued and 11 completed questionnaires were returned. Results: Respondents indicated the importance of communication in relation to DNACPR orders, as well as the role of allied health professionals and family members in the process. Respecting the patient's wishes was considered paramount, as was educational provision surrounding DNACPRs. Conclusion: The majority of respondents reported that they were comfortable incorporating DNACPR orders in their clinical practice, although more modest responses were returned regarding the level of education received in this area of paramedicine.

Introduction: Paramedics can find themselves called to digit dislocations. This is challenging as a dislocation can present in various ways, bringing residual damage to tissue and underlying structures from prolonged displacement. The aim is to limit impact on the welfare of the patient and the paramedic's objective is always to get the dislocation reduced as soon as a possible in a quick and safe manner. Dislocation: The most common dislocation of the digit is at the proximal interphalangeal joint (PIPJ), also known as the ‘coach's finger’. PIPJ injuries are commonly seen in ball sports; the dislocation is mainly dorsal in presentation, and normally closed and stable. It is vital that the paramedic undertakes an in-depth digit assessment in order to be equipped with an appropriate treatment plan for the presentation, which can manage the dislocated digit. Discussion—pain relief: While there has been extensive study of systemic analgesia in emergency medical services (EMS), there is little out-of-hospital research on digit ring blocks and the use of regional anesthetics by paramedics in the pre-hospital setting. X-ray: The evidence is contradictory as some insist that X-ray must be carried out pre-reduction, where other authors state that reduction first is acceptable, but only after a thorough assessment. Reduction: There is a distinct lack of evidence for out-of-hospital digit reduction, too sparse for any robust argument to be built. Conclusion: The suggestion is that reduction of the PIPJ dislocation in the out-of-hospital arena is not supported, owing to a lack of evidence. Until more studies are carried out and patient follow-up is proved to be negative with no ongoing digit impact, this skill needs to be undertaken in appropriate locations supported by X-ray.

Background: As a result of some of the factors discussed within this systematic review, UK Paramedics are more likely to manage postpartum haemorrhage (PPH) within the out-of-hospital setting. This systematic review attempts to address the question: ‘Is it suitable for TXA to be implemented within the UK paramedic management of out-of-hospital PPH?’ Methods: Randomised control trials (RCTs) focusing on the effect of TXA upon blood loss during PPH were included within this review. A search strategy was created and applied to databases. Critical analysis of the included studies was carried out, and data were presented within tabular format and discussed through the use of narrative synthesis. Results: Eight RCTs were included within this systematic review. All studies found a significant reduction in the volume of blood loss during PPH when TXA was administered. Discussion: Although TXA was found to significantly reduce the volume of blood loss during PPH, existing evidence is insufficient to support its use within the UK paramedic out-of-hospital management of PPH. Without the presence of studies which are solely focused on the target population, it is difficult to generalise the findings directly to the UK out-of-hospital paramedic management of PPH. This systematic review does however support and supplement the findings of past and current research based upon the relationship between TXA and PPH.

This ‘day-in-the-life’ article is the author's first-person account of his experiences as a paramedic working in an inner-city GP practice, while training to be an advanced clinical practitioner. The author aims to illustrate the range and complexity of the role of paramedics based in primary care, and how this role is developing beyond the traditional scope of paramedic practice. The article presents actual patient encounters, which reflect a typical working day in primary care. Through this approach, the author hopes to demonstrate how paramedics can complement and extend the skills of an established primary care team. Furthermore, studying advanced clinical practice at postgraduate level provides new and extended clinical skills and knowledge, allowing paramedics to work with greater autonomy.