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Background: Electronic palliative care coordination systems (EPaCCS) can provide a solution to support paramedic staff. It is important to understand what needs to be in place to maximise benefits and avoid harms when providing end-of-life care (EoLC). Aims: To review the evidence of what is currently known about the challenges of paramedics delivering high quality EoLC, and the current use of EPaCCS. Methods: Narrative review of the literature, focusing on the views and opinions of ambulance emergency staff referring to palliative and EoLC and/or current use and views of EPaCCS. Findings: The authors included five qualitative studies, addressing three themes: lack of access to patient information; proposed electronic solution; content of electronic system. Conclusion: EPaCCS can support ambulance-based emergency staff with EoLC. Research is required to identify the format that information should take within the EPaCCS and the essential content needed to inform staff decision-making. [ABSTRACT FROM AUTHOR]

Background/Aims: Most birth-related ambulance calls occur without difficulty, but in some cases, complications can arise. Paramedics' involvement in birth is infrequent; therefore, the knowledge and skills required to manage complications can atrophy over time, particularly without educational interventions. This may impact outcomes. The study's aims were to measure the knowledge, attitude, and practice of paramedics in managing obstetric cases. Methods: This cross-sectional questionnaire-based study was carried out with 264 paramedics. Spearman's measure of correlation was used to observe linear correlations between ranks of the observations. Results: The majority of participants were advanced care paramedics (81.1%). Participants reported infrequently attending births in the community, with under half feeling confident in managing these (44%). Antenatal complications and trauma in pregnancy were self-reported areas of weakness; this was consistent with assessed knowledge. Conclusions: Paramedics self-reported infrequently responding to obstetric calls and the majority lacked confidence in managing these. Few indicated an excellent level of obstetric knowledge, reporting a desire to receive more education in this area. Implications for practice: When paramedics lack confidence in managing obstetric emergencies, it can lead to delayed decision making, inadequate assessment, increased error rates and adverse maternal and neonatal outcomes. [ABSTRACT FROM AUTHOR]

In UK helicopter emergency medical services (HEMS), 20% of doctors and 24% of paramedics are women, yet women make up 49% of all doctors and 44% of all paramedics. One hundred and forty clinicians recruited through social media undertook an anonymous online qualitative survey exploring potential barriers and enablers, particularly for women, to following a career pathway into HEMS. Perceived barriers included: toxic, alpha, macho, boys' club HEMS cultures; bullying; discrimination; recruitment issues involving biases, fitness tests and degree of competition; HEMS communications depicting elitism and a lack of diversity; and poor work-life balance. Women feared skill fade and both women and men reported that exposure to traumatic incidents deterred them. Perceived enablers included: paid, rostered time to study and attend charity events; supportive or forgiving families; a lack of care commitments; and employers offering flexible working/contracts for less than full-time hours. This research may provide the opportunity for organisations to review diversity within their teams. A recommendations document has been produced that may help to close the gender gap within HEMS. [ABSTRACT FROM AUTHOR]

Burnout among the paramedic profession is an increasing problem and not enough is being done to improve the current climate. It is for this reason that paramedics should individually contribute to the reduction of this issue by developing their own leadership characteristics, such as emotional intelligence, social intelligence, and stress and conflict management. Evidence suggests that these qualities and behaviours reduce the possibility of being subject to burnout symptomology. Implementing positive stress and conflict-management strategies will create a healthcare environment, which will be more enjoyable to work in. Emotional and social intelligence increase the resilience of prehospital clinicians who are subject to occupational challenges on a daily basis. Wider influences such as ambulance trusts, health services and governing bodies have implemented strategies to tackle this issue but clinicians can lead the change from the front line. [ABSTRACT FROM AUTHOR]

Background: Since the COVID-19 pandemic and the introduction of the National Partnership Agreement: Right Care, Right Person in the UK, paramedics spend about 1.8 million hours per year managing people with mental health issues. The UK health service needs to address the urgent training requirements for paramedics to provide mental healthcare in emergency care provision. Aims: To identify and examine current research on how paramedics manage people with mental health issues. Methods: A scoping review was carried out using the five stages of Arksey and O'Malley's framework. A research question—'How do paramedics manage patients with mental health issues?'—was developed, databases searched, studies identified and data charted, summarised and reported. Findings: Fifteen papers were included, and five themes identified: perceptions and expectations; call triage and inter-service collaboration; communication skills; lack of education and training; and assessment and evidence-based interventions. Conclusions: There is global evidence of the deficiencies in paramedic education around mental health presentation and a need for evidence-based education and interventions to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Nocebic communication can impair patient outcomes and increase their risk of post-traumatic stress disorder. It could therefore be legitimately regarded as a patient safety issue. Aims: This study aimed to determine whether nocebic effects (negative outcomes) induced by potentially harmful word and language choices commonly occur in clinical practice involving paramedics and other emergency responders. Methods: Five publicly available televised excerpts of prehospital care encounters were reviewed. Cases typically involved the treatment of patients who had sustained serious traumatic injuries. The incidence of words and language patterns commonly associated with nocebo effects were collected using a template to enable relevant dialogue to be tracked and recorded. Results: Emergency responders, typically paramedics and doctors in these examples, frequently employed nocebic words and poor language pattern choices even though less harmful forms of communication were available and more clinically appropriate. Conclusions: Inappropriate nocebic effect-inducing language is frequently used by emergency response personnel, potentially inflicting avoidable pain and anxiety. [ABSTRACT FROM AUTHOR]

Background: Apprenticeships are key to ensuring that private and public employers can recruit and develop workforces. The degree apprenticeship in paramedic practice allows learners to continue academic study while participating in on-the-job training. Objectives: The aim of this UK-based scoping review is to identify the barriers and challenges in practice-based education, and link the findings to paramedic degree apprenticeships. Methods: A scoping review was undertaken to examine the literature on degree apprenticeships and the barriers and challenges within practice-based education. Findings: Six studies were reviewed. None were specific to paramedicine, so analysis and evaluation were drawn from other professions. Three main themes were identified: role of the mentor/practice-based educator; stakeholder collaboration; and apprentice support. Conclusion: Employers are key to the collaborative design of apprenticeship, yet multiple issues in terms of their working with higher education institutions exist. The interpretation of apprenticeship-specific terminology used to assess competence, and the subjective definition of expected standards were key concerns of practice educators. Employers need to provide education to practice educators to support the facilitation of learning and assessment. Responsibility for the success of apprentices lies with both employer and learner. More research is needed on barriers for each stakeholder. Employers require clearer guidance regarding funding and expectations. [ABSTRACT FROM AUTHOR]

Background: Homeless individuals are vulnerable and have a higher burden of illness. Barriers to care exist and experiences can be negative, contributing to increased morbidity and mortality. The experiences of homeless individuals accessing healthcare through ambulance services is underexplored. Aims: The study aims to describe why homeless individuals access healthcare through ambulance services and identify lived experiences. Methods: A narrative literature review was undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology, with Critical Appraisal Skills Programme tools used to assess quality before thematic synthesis. Results: Twenty-three studies were included. Six themes were identified including frequency of ambulance use and clinical characteristics, why healthcare is accessed through ambulance services and the experiences of homeless individuals and paramedics. Conclusions: Evidence relating to homeless individuals accessing healthcare through ambulance services is limited. However, it is clear this group uses these services more often than non-homeless individuals, likely because of their higher chronic illness burden. Services should be developed to meet the needs of homeless individuals and to help ensure demand on ambulance services is manageable and affordable. [ABSTRACT FROM AUTHOR]

Establishing advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) is a demanding part of the paramedic role. While aspects of these patients' care have been well researched, examination of how the full ALS bundle is completed is lacking. This study aims to explore paramedics' experience of establishing ALS in OHCA through individual semi-structured interviews to identify potential themes and transferable learning. Findings in the areas of dispatch, en-route planning and on-scene care as well as around training were identified through thematic analysis. There are several issues on which individuals and organisations can critically reflect to improve practice. [ABSTRACT FROM AUTHOR]

Paramedics working in a traditional ambulance service role infrequently see patients who are critically ill or injured; in addition, pressures on hospitals have caused long waiting times, further lowering exposure to all patient groups and reducing how often paramedics use their clinical skills, potentially negatively impacting performance in practice. This study sought to establish the competence of paramedics in a set of skills that included frequent and infrequent as well as simple and complex procedures. They took part in a scored clinical scenario in which they used these skills. The study also sought to explore paramedics' perception of how difficult these skills were. Participants generally scored well; however, in some instances, elements of skills were missed or performed out of sequence. The pressure created by the scenario appeared to negatively impact performance. [ABSTRACT FROM AUTHOR]

Background: Suspected stroke is a common scenario among care home residents, who are typically older and have more complex health needs than the general population. Aims: The aim of this study was to describe the care of suspected stroke patients according to their residential status. Methods: Retrospective secondary analysis was carried out using a clinical record dataset from a UK ambulance service that described the care of patients labelled as having a suspected stroke between December 2021 and April 2022. Findings: Care home patients were older (median age 86 (interquartile range (IQR) 79–91) years) than those in their own homes (median age 75 (IQR 63–83) years; P≤0.001), with more comorbidities (median of five (IQR 3–6) versus median of three (IQR 2–5); P≤0.001) and taking more medications (median of six (IQR 4–9) versus median of four (IQR 1–7); P≤0.001). They were more likely to have difficulties completing the face, arms, speech, time test (17/170 (10%) versus 39/1305 (3%); P≤0.001) and present with facial droop (85/153 (55.6%) versus 506/1266 (40%); P≤0.001). Ambulance on-scene time was longer at care homes (median 41 (IQR 32–49.5) minutes versus median 35 (IQR 27–45) minutes; P≤0.001). Conclusion: Clinician awareness of characteristics associated with residential settings may be important for delivering emergency stroke care. Research is needed to optimise ambulance assessment for care home patients. [ABSTRACT FROM AUTHOR]

Background: In the prehospital setting, the incidence of seriously unwell children is low and emergency medical staff have repeatedly expressed concerns about their confidence and knowledge with regard to assessing children. The paediatric observation priority score (POPS) was designed in response to concerns about the identification of seriously unwell children. The ambulance service in this study began to implement POPS in 2018. Aim: To examine the use and documentation of POPS by ambulance staff in a Welsh health board. Methods: A retrospective cross-sectional study was carried out, covering 121 paediatric patients over 3 months with data collected from patient clinical records. Findings: Patient observations were well documented (77.7%), score accuracy was high (82%) and the majority of patients were pre-alerted appropriately (80% of POPS 7). Statistically significant associations were drawn between patient age and observations as well as between POPS and patient outcomes. However, compliance with POPS was only 32.3%. Conclusion: Although the use of POPS is relatively low, children mainly did have relevant observations recorded and when POPS was used, it was accurate. Education and training would improve compliance. Future research recommendations include investigating the education and confidence of emergency medical staff regarding paediatric patients. [ABSTRACT FROM AUTHOR]

A case-based discussion around values-based practice illustrates how the elements of values-based practice can be used to: navigate a challenging situation in practice; examine how it intersects with legal considerations; and offer both opportunities and challenges to clinicians. [ABSTRACT FROM AUTHOR]

Background: Registered health professionals have a responsibility to facilitate learning in the workplace and those who are supporting students should have the skills and knowledge to take on this role. Paramedics are now working in a variety of healthcare settings. Regulatory bodies recognise that students should have opportunities to develop their supervision skills before qualifying, so practice supervisor training was implemented into the final year curriculum at one university. Aim: To explore the value of incorporating practice supervisor training into the curriculum. Methods: Final-year student paramedics were provided with practice supervisor training as part of their degree. This training was delivered over three seminars before the students' final preregistration placement. Students were invited to provide anonymous feedback via an evaluation form. Findings: A significant number of students felt prepared to take on the practice supervisor role when qualified. Conclusion: Practice supervisor training, when delivered as part of the curriculum, is of benefit to students. [ABSTRACT FROM AUTHOR]

Background: With the expansion of specialist non-traditional community paramedic roles, education programmes need to be fit for purpose, evidence-based and informed by industry and community requirements. Aims: To evaluate the effectiveness of a community paramedic short course in improving knowledge, skills and confidence in undertaking a community paramedic role. Methods: Educational intervention evaluation of a short course on community paramedicine. Findings: All participants increased their mean scores for knowledge, skills and confidence. The biggest areas of improvement were seen in areas not historically taught or practised in paramedicine such as falls assessments, ear/nose/throat assessment and care, gastrointestinal assessment and care, and troubleshooting urinary catheters and specialist equipment. Conclusion: This type of education is successful in improving knowledge, skills and confidence. However, exposure to patients with specialist community health care needs and adequate support in the novice phase is fundamental for the consolidation of education. [ABSTRACT FROM AUTHOR]

Background: Paramedics undertake visually demanding tasks, which may be adversely affected by low lighting conditions. Aims: The study aimed to: identify difficulties paramedics experience carrying out tasks in low light; and establish occupational health standards and adjustments that may improve working practices. Methods: A scoping review was undertaken informed by a professional panel of paramedics recruited through social media. A meta-analysis was conducted assessing visual acuity under different light levels. Findings: Difficulty in driving and in assessing/treating patients under low light conditions were reported. Sixty relevant studies were identified for review. Visual acuity reduces with decreasing luminance, causing increasing difficulties in performing critical tasks. Conclusion: Visual function testing can assess paramedics' visual health and ability to undertake critical tasks. Adjustments may help to improve conditions. Regular occupational health assessments could identify paramedics who need support. Further research should explore levels of visual function and practical adjustments needed for safe clinical practice. [ABSTRACT FROM AUTHOR]

Background: Fascia iliaca blocks (FIBs) are an efficacious form of prehospital regional anaesthesia for patients with neck of femur fracture. Current prehospital use is limited. Aims: The primary aim of this study was to assess procedural confidence among allied health professionals. The secondary aim was to examine concerns related to prehospital use of FIB. Methods: This was a qualitative study that analysed semi-structured interviews. Two recognised groups were involved: paramedics and advanced practitioners. Results: A total of 12 semi-structured interviews were conducted. Four factors were found to contribute to procedural confidence. All practitioners felt confident to perform the FIB. In its secondary aim, to identify concerns related to FIBs, the study found three major themes: risk of doing harm; receiving adequate training; and procedural governance. Conclusions: Procedural confidence was high. Training and governance were highlighted as barriers to procedural expansion. Research is required to assess feasibility. [ABSTRACT FROM AUTHOR]

Silver trauma patients, defined as those aged >65 years who have traumatic injuries, are a complex group because physiology alters with age leading to difficulties with assessment. This is exacerbated within the prehospital setting as environmental factors and ambulance delays increase the risk of complications. This article focuses on the pathophysiology and application of clinical guidelines on three aspects of prehospital silver trauma: neurology, osteology and haemorrhage. Neurologically, silver trauma patients have a higher risk of traumatic brain injury and are harder to assess because of age-related cognitive decline. Regarding osteology, older people, particularly postmenopausal women, are at a higher risk of vertebral fracture, with many going undiagnosed. Haemorrhage is also influenced, as geriatric patients typically experience occult bleeding or rebleeding several days after an event when crews have left. Despite these risks, prehospital guidelines often offer little support for clinicians in making holistic, clinically sound decisions for their patients. [ABSTRACT FROM AUTHOR]

Background: Acute myocardial infarction (AMI) accounts for 43% of deaths related to ischaemic heart disease, with ST-segment elevation myocardial infarction (STEMI) accounting for 25%-40% of all AMI presentations. Given the impact of these diseases, there is a strong prehospital focus on early identification, treatment and transport of patients with acute coronary syndrome. The main aim of the STEMI system of care is to reduce the time to reperfusion of the myocardium, thereby improving morbidity and mortality rates. Therefore, the identification of STEMI by paramedics can have a dramatic effect on patients' long-term health outcomes. Ambulance Victoria paramedics play a crucial role in the care provided to AMI patients across the state, with the assistance of a computer-automated interpretation of 12-lead electrocardiograms (ECGs) to aid STEMI identification. Objectives: This study's objective is to analyse the diagnostic capability of the computer-automated interpretation to diagnose STEMI in the out-of-hospital setting. Methods: Quantitative data from January 2018 to December 2019 was sourced from the Victorian Ambulance STEMI Quality Initiative. These data were periodically matched with hospital outcome and diagnosis data from the Victorian Cardiac Outcomes Registry to compare provisional paramedic diagnoses with the final hospital diagnoses. Results: Of the 5269 cases of suspected STEMI, 765 (14.5%) could be matched with outcome data. Of these 765 cases, 88.9% were correctly identified as STEMI. The remaining 10% were categorised as either non-STEMI or unstable angina. No data were available for 1.1%. Conclusions: The diagnostic capability of the Zoll Inovise 12L interpretive algorithm to diagnose STEMI in the out-of-hospital setting appears safe and feasible. However, because of limited data matching paramedic findings with patient outcomes in hospital, no hard conclusions can be drawn. Furthermore, there is no way to ascertain how many false positives the Zoll monitor is interpreting. Further investigation is required to assess the true diagnostic capability of the Zoll Inovise 12L interpretive algorithm. [ABSTRACT FROM AUTHOR]

Background: Pain is one of the commonest symptoms in patients of all ages presenting to ambulance services. Children in pain make up a relatively small proportion of the number of those attended by prehospital care and pain management is needed in only 40% of cases. This might go some way to explain why the management of paediatric pain is perceived to be poor. Aim: The primary aim of this study was to explore the experiences of UK paramedics in treating children in pain. Methods: A phenomenological study was undertaken using a purposeful sample of UK paramedics (n=12) to explore their experiences and decision-making during the treatment of children in pain. Results: Five themes became apparent through analysis—preparation and education; adaptation and change of approach; organisational and legal factors; support and guidance; familial and carer impact—with some crossover between themes noted. Conclusion: Clinicians are aware of multimodal techniques for managing pain in children but are often less confident in the use of pharmacological than non-pharmacological management methods. Advances in the use of technology in practice have enabled clinicians to use alternative measures to manage children in pain. However, while using these methods, practitioners lack confidence that they are meeting social expectations of their roles. [ABSTRACT FROM AUTHOR]

Background: An estimated 27% of ambulance personnel experience general psychological distress. The relationship between work and mental health is complex. Aims: This study aimed to explore whether and to what extent individual factors affect the mental health of ambulance personnel. Methods: Four UK NHS ambulance trusts facilitated recruitment of ambulance personnel (n=160). Well-validated measures were used to collect data on the predictor variables: the Perceived Stress Scale; the Satisfaction with Life Scale; and the Brief Resilience Scale. Mental health, assessed according to response to trauma measured by the Impact of Events Scale Revised (IES-r), and anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS), were the outcome measures. Findings: Regression models demonstrated that all predictor variables accounted for nearly half of the variance in each outcome (P<0.01). Conclusions: A significant proportion of variance was accounted for by individual factors. This assists in understanding the impact and role of individual factors in the mental health of this occupational group. Future research could inform intervention development. [ABSTRACT FROM AUTHOR]

Background: Calcium depletion in haemorrhagic shock is associated with pathophysiology detrimental to survival. Aim: The purpose of this systematic literature review was to determine whether paramedic administration of calcium for haemorrhagic shock could reduce trauma morbidity and mortality. Method: The MEDLINE and CINAHL databases were searched for publications relevant to hypocalcaemia management in traumatic haemorrhage. Findings: Fourteen peerreviewed articles met the inclusion criteria. These examined incidence, morbidity, mortality and treatment options for hypocalcaemia associated with traumatic haemorrhage. Paramedicine can play a key role in managing hypocalcaemia early and determining the effect this has on improving patient outcomes from severe trauma. Conclusion: The findings in this review link hypocalcaemia to poor yet potentially modifiable outcomes in trauma. Ambulance services should consider empiric treatment with calcium when shocked patients are expected to receive blood transfusion for traumatic haemorrhage. [ABSTRACT FROM AUTHOR]

Background: The emergence of new technology and innovation has seen dedicated simulation centres being designed and built to assist with the development of a range of professionals within the ever-changing healthcare setting. Focusing on the university environment, this study examined the extent to which paramedic students perceive these simulation centres as efficient and effective learning spaces. Methods: Using evaluation research, data were collected from 33 students studying paramedic science at a London university. An online questionnaire was used to measure student engagement, perceived value, impact and sustainability of a simulation centre. Findings: Participants primarily perceived the simulation centre as having high value and a good impact on their learning and development, although some concerns were raised regarding its utilisation and general usability. Conclusion: While large-scale simulation centres seem beneficial to learning, they need to be fully integrated into the curriculum to maximise their impact on preparing students for their forthcoming role. [ABSTRACT FROM AUTHOR]

Background: The prognostic role of lactate in out-of-hospital cardiac arrest (OHCA) remains unclear. Aims: To explore serum lactate as a predictor of return of spontaneous circulation in patients experiencing OHCA after arrival at hospital. Methods: This 13-month prospective observational cohort study involved patients aged ≥18 years. Serum lactate levels were measured during cardiopulmonary resuscitation before ROSC. Patients were divided into two groups by lactate level: Group 1, low (≤9.9 mmol/l) and Group 2, high (≥10 mmol/l). Findings: 105 patients were included, 50 in group 1 and 55 group 2. Median lactate were 7.4 mmol/l and 14.2 mmol/l respectively. More patients in group 1 were found with ventricular fibrillation (40% versus 14.5%; P≤0.01), obtained ROSC more quickly (37 minutes 38 seconds versus 39 minutes 13 seconds; P=0.79) and achieved short-term survival (survived >24 hours) (40% versus 23.5%; P=0.32), versus group 2; prediction of survival did not reach statistical significance. Conclusion: Lower lactate levels in OHCA appear to be associated with better short-term outcomes but the cut-off points regarding survival remain unclear. [ABSTRACT FROM AUTHOR]

Remote simulation in education predates the COVID-19 pandemic, and its more widespread contemporary use can help inform future teaching practices. This article outlines the development of a remote-facilitated mental simulation (RFMS) delivered to second-year paramedic science students at a UK university. This was created using Sprick et al's simulation design model: preparation, briefing, simulation activity, debriefing, reflection and evaluation. Mental simulation is a teaching modality where participants mentally rehearse processes rather than practical skills. Speaking thoughts aloud helps learners to reflect on their thought processes and decision-making. While studies on remote simulation involve a facilitator viewing participants interacting with a simulation, in this study the participants were observers and the facilitator interacted with the simulation equipment. This arrangement may increase access to simulation for learners who do not have access to such facilities. Participants were engaged through group activities and psychological fidelity was maintained by providing real-time streaming of patient observations. The RFMS was evaluated positively by respondents. [ABSTRACT FROM AUTHOR]

Background: Prehospital traumatic pain is common, but the quality of pain management in these patients is poor. Current practice recommends morphine as the first-line analgesia in major trauma but this carries high risks and is often contraindicated. Alternative paramedic-administered analgesia does not provide adequate pain relief or may be contraindicated. As a result, many patients remain in pain. Analgesic ketamine is used safely and effectively in international civilian and military settings and by paramedics with additional training, education and qualifications. Aim: The study had two aims. Namely, these were to find out whether intravenous ketamine: provides effective relief of prehospital traumatic pain in adults; and is safe for prehospital administration by non-specialist paramedics. Method: Three databases, CINAHL, MEDLINE and AMED, were searched to identify articles published between 2009 and 2021. Exclusion criteria were applied and results subjected to critical appraisal and evaluation. Findings: Four studies were included in the review. Two themes were identified for thematic analysis: therapeutic effectiveness; and the safety of IV ketamine administration by paramedics. The evidence drew predominantly homogenous conclusions, but was substandard regarding external validity, which limited the quality of these conclusions. Conclusion: Ketamine provides effective pain relief in line with morphine and is safe for paramedics to administer. However, clear gaps in the evidence mean the research questions are not fully answered, so changes to current paramedic practice cannot be recommended. [ABSTRACT FROM AUTHOR]

Paramedic independent prescribing offers an opportunity to improve patient access to medications. However, incomplete, unclear or incorrectly written prescriptions can cause harm to patients. This article in the Prescribing Paramedic series considers: the legal requirements a prescription must meet for prescription-only medicines and controlled drugs; common errors that may occur during prescription writing and potential solutions; and best practice recommendations for prescribers to follow when writing a prescription to minimise errors. The advantages and disadvantages of electronic prescribing are discussed. [ABSTRACT FROM AUTHOR]

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 could also find themselves subject to legal action. This article considers a fictitious scenario where a patient suffers harm as a result of a prescribing decision and the legal implications for the prescriber. [ABSTRACT FROM AUTHOR]

Paramedics make decisions as part of their everyday role but often, the theory behind clinical decision-making is not discussed in depth. This article explores the theories of decision-making as they apply to a clinical case. With the increasing use of technology in healthcare, the introduction of human reliability analysis is becoming more pertinent. [ABSTRACT FROM AUTHOR]

Home visiting is traditionally carried out by GPs but it is becoming increasingly difficult for GPs to do, and many doctors want it removed from their contract. This is opening up a space for the paramedic profession, with paramedics carrying out home visits and designing future primary care services. Paramedics working within primary care can possess the knowledge, leadership and complex skills needed for home visiting, and some are independent prescribers; they can lead acute home visiting services (AHVS). AHVS require effective triage and access to electronic patient records, are underpinned by robust clinical governance and engage in clinical audits. Future primary care paramedic services could include online, video and face-to-face consultations, care home ward rounds, remote triage and home visiting. However, paramedics' contribution to general practice has not been fully evaluated and it may take time for this to become a norm. Regardless, primary care paramedicine has an opportunity to be innovative, shaking off risk-averse protocols for more enlightened practices, and lead the profession. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Isolated traumatic brain injury (TBI) accounts for 30% of injury-related deaths globally, with significant cost to individual health, lifestyle and the economy. Despite advances in prehospital trauma care, frontline paramedics have limited options to manage cerebral oedema and herniation. Prehospital osmotherapy could limit cerebral oedema and subsequent secondary brain injury, but uncertainties remain of its benefit to patient outcomes. Aim: This study aimed to explore whether prehospital osmotherapy such as hypertonic saline (HTS) could improve mortality and neurological outcomes in adults with severe isolated TBI compared with other products. Methods: Multiple electronic databases (PubMed, MAG Online Library, EMBase and Cochrane Library) were searched to investigate the impact of prehospital osmotherapy on mortality and neurological outcome. Findings: 9005 articles were identified, with six articles fully meeting the research aim. The majority of literature was high quality with an overriding consensus that administration of prehospital HTS or other hyperosmolar products had limited benefit to patient mortality and neurological outcome in isolated TBI. Conclusion: High-quality literature demonstrated that there is no current strong argument to adopt prehospital osmotherapy for isolated TBI. Paramedics should prioritise managing hypoxia and hypotension, which have proven impacts on long-term mortality and neurological outcomes. Future research should focus on the benefits of the expansion of rapid sequence intubation to advanced paramedics and appropriate analgesia (ketamine) for paramedics to enhance isolated TBI management in UK paramedic practice. However, paramedics should not disregard the importance of fundamental basic resuscitation skills in isolated TBI. [ABSTRACT FROM AUTHOR]

Background: Studies suggest that blood lactate differs between survivors and non-survivors of out-of-hospital cardiac arrest who are transported to hospital. The prognostic role of lactate taken during out-of-hospital cardiac arrest remains unexplored. Aims: To measure the association between lactate taken during out-of-hospital cardiac arrest, survival to hospital and 30-day mortality. Methods: This is a feasibility, single-centre, prospective cohort study. Eligible for inclusion are patients aged ≥18 years suffering out- of-hospital cardiac arrest, receiving cardiopulmonary resuscitation, in the catchment of Newcastle or Gateshead hospitals, who are attended to by a study-trained specialist paramedic. Exclusions are known/apparent pregnancy, blunt or penetrating injury as primary cause of out-of-hospital cardiac arrest and an absence of intravenous access. Between February 2020 and March 2021, 100 participants will be enrolled. Primary outcome is survival to hospital; secondary outcomes are return of spontaneous circulation at any time and 30-day mortality. [ABSTRACT FROM AUTHOR]

Background: Virtual reality (VR) technology is emerging as a powerful tool in medical training and has potential benefits for paramedic education. Aim: The aim of this paper is to report the development of ParaVR, which uses VR to maintain paramedics' skills. Methods: Computer scientists at the University of Chester and the Welsh Ambulance Services NHS Trust (WAST) developed ParaVR in four stages: identifying requirements and specifications; alpha version development; beta version development; and management--development of software, further funding and commercialisation. Results: Needle cricothyrotomy and needle thoracostomy emerged as candidates for the prototype ParaVR. The Oculus Rift head-mounted display was combined with Novint Falcon haptic device and a virtual environment crafted using 3D modelling software, which was ported to the Oculus Go virtual reality headset and the Google Cardboard VR platform. Conclusion: VR is an emerging educational tool with the potential to enhance paramedic skills development and maintenance. The ParaVR programme is the first step in the authors' development, testing and scaling up of this technology. [ABSTRACT FROM AUTHOR]

Background: Paramedics work in high-pressure environments and experience traumatic events, which contribute to high levels of occupational and post-traumatic stress. Such stress can result in alcohol and substance misuse in other health professionals, but this relationship has not been examined in paramedics. This review is the first exploration of the literature on this. Methods: A systematic literature review was conducted using PRISMA guidelines, with databases searched using terms relevant to paramedics and alcohol/substance use. Studies were analysed using descriptive statistics for quantitative data and thematic analysis for qualitative information. Findings: Eleven studies were identified. Nine studies examined alcohol use; seven examined substance use; five examined both. Alcohol and smoking may be linked to occupational stress. Conclusions: The nature and extent of alcohol and substance use in relation to occupational and post-traumatic stress among paramedics need further investigation to facilitate advice and support. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to evaluate the 'think aloud' teaching exercise's ability to develop clinical reasoning skills of student paramedics, and to ascertain its feasibility as an ongoing method to enhance clinical reasoning teaching and potentially alleviate problems around applying theoretical learning to practice. Methods: A qualitative approach was taken to seek the opinions and experiences of students taking part in the activity to determine levels of enjoyment, how relatable it was to students, and awareness of the skills it was intended to develop. Data collected via an online survey tool were analysed to identify themes and comments. Findings: Student enjoyment and engagement were evident, and the exercise permitted independence of thought and working, promoting self-appraisal among students of the effectiveness of the working strategy. Conclusion: The results of this case study indicate that the think aloud exercise could be effective in developing students' clinical reasoning skills. It complements established teaching strategies, such as core lectures, seminars and supervised practice. [ABSTRACT FROM AUTHOR]

Background: Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights. Case presentation: An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP. Conclusions: Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of intravenous (IV) antibiotics for the treatment of sepsis in UK prehospital emergency care is not fully understood. In addition, the views of the key clinical decision-makers in ambulance services have not been documented. Aims: This study aimed to provide contemporary, primary data on the opinions of medical directors from across the UK on the use of IV antibiotics to treat sepsis in prehospital emergency care. Methods: A qualitative methodology was used. During semi-structured telephone interviews, participants were encouraged to share their personal and professional views on the use of IV antibiotics to treat sepsis in ambulance services. The interviews were recorded and transcribed, and a thematic content analysis using the principles of grounded theory was carried out. Findings: Five themes emerged: barriers and enablers; early sepsis recognition; accurate and consistent National Early Warning Score (NEWS) scoring; the need for primary evidence; and standardisation of equipment and protocols. A range of opinions were suggested, with an emphasis on rapid transfers and the need for further evidence. Conclusion: There is a drive for early sepsis diagnosis and pre-alerting the receiving hospital. However, there are potential barriers to standardising the approach if paramedics were to collect blood samples and administer IV antibiotics. Additionally, in the absence of UK data on the effectiveness of this treatment, many key decision-makers are reluctant to consider it as a standard approach. Despite this, there is some strong support for using benzylpenicillin for the treatment of suspected sepsis. [ABSTRACT FROM AUTHOR]

Background: Sepsis is a life-threatening illness that requires early recognition and treatment. In Ireland, mortality, while improving, remains at 17% for adults and in a range of 2–4% in children aged under16 years. Prompt, accurate recognition of severe sepsis in the prehospital period could improve outcomes in patients with severe sepsis. Aim: This study aimed to audit the prehospital care of patients with sepsis against national Irish sepsis clinical practice guidelines and identify areas for improvement. Methods: A retrospective analysis of all Dublin Fire Brigade patient care reports over a 1-week period was carried out and patients with potential sepsis and potential severe sepsis were identified. Care was assessed against the national prehospital clinical practice guidelines. Call-taking and dispatch information were cross-checked. Findings: The incidence of potential sepsis was 3.7%. It is a condition of extremes of age; 8.5% of patients were aged less than 1 year and 58% were aged above 65 years. While 48% of calls were categorised as high priority, about one-third (32%) were put in a low-priority category, and 37% of the latter were potential cases of severe sepsis. The most common chief complaints at the call-taking stage were 'breathing problems' and 'sick person'. Conclusion: Potential sepsis is not infrequent and call-taking information may not capture the potential or severity of sepsis. Education must emphasise the risk in old and young patients. To ensure patients receive timely advanced interventions, call-taking and dispatch systems should ensure that practitioners with the skills to identify and manage sepsis are dispatched to these patients. [ABSTRACT FROM AUTHOR]

The paramedic profession in the UK evolved from a small number of pilot programmes in the early 1970s that focused on training selected NHS ambulance crews in advanced resuscitation techniques. Similar initiatives occurred almost simultaneously in the United States, Australia, New Zealand and Canada. This case study focuses primarily on the UK, and England in particular. The purpose of the initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity and became fully professionally recognised and regulated as allied health professionals, becoming an example of the phenomenon termed 'disruptive Innovation'; this is something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in NHS ambulance services which, in comparison, have lagged behind and also failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, and hampered these practitioners' ability to make full use of their skills. The consequence of this has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover. Parallel developments in medical personnel deployment have increased the quantity of medical labour available to patients with serious or life-threatening injuries, with medical staff added to helicopter emergency medical crews. While many patients with urgent conditions would have benefited from general practitioners being available out of hours, proportionally fewer doctors are available to fulfil this role today and those that are attracted to working with the ambulance service often prefer to respond to cases involving major injury. For these reasons and given the reality that the ambulance service is morphing into primarily an urgent care organisation, de-emphasising the transport aspect of the service, changes are needed to its model of operation and to staff management and support. [ABSTRACT FROM AUTHOR]

Background: Clinical feedback provision to health professionals is advocated to benefit both clinical development and work engagement. Aim: This literature review aims to develop recommendations for effective clinical feedback provision by examining mechanisms that exist specifically for ambulance clinicians. Method: A systematic search of contemporary literature identified 15 research papers and four articles, which were included for review and narrative synthesis. Findings: The initial identification of practice that requires improvement, together with an understanding of the practitioners' baseline attitudes, is important. While minimising resource demands will improve sustainability, repeated interaction with clinicians will benefit effectiveness. Provision should be balanced and timely, and who delivers feedback is significant. Clinical outcome feedback not restricted to specific conditions requires further consideration of which incidents will initiate feedback and what information will be supplied. Conclusion: Feedback has been shown to improve clinical performance but demonstrating subsequent benefits to patient outcomes has proved more difficult. [ABSTRACT FROM AUTHOR]

The prehospital emergency airway management is a key moderating factor for patient survival and mortality rates. There has been much debate around the optimum method of prehospital emergency airway management. This commentary critically appraises a recent systematic review which assesses the harms and benefits of three different airway management strategies for a range of emergency clinical scenarios. Commentary on: Carney N, Totten AM, Cheney T et al. Prehospital Airway Management: A Systematic Review. Prehosp Emerg Care. 2021;1–12. https://doi.org/10.1080/10903127.2021.1940400 [ABSTRACT FROM AUTHOR]

Introduction: The average rate of survival following an out-of-hospital cardiac arrest (OHCA) in the UK was 7–8% at the start of 2019. An estimated 60 000 OHCAs are attended by UK ambulance services annually and, despite developments in prehospital and post-resuscitation care, there are significant variations in survival between regions and countries. Aims: This study aims to identify the potential for care pathways, evaluate UK practices and review the evidence for direct referral of OHCA patients to dedicated cardiac arrest centres. Methods: Evidence was gathered from 20 articles identified through a systematic search of articles related to OHCA and post-resuscitation care, as well as from NHS England in relation to performance and outcomes. Results: Between April 2018 and January 2019, 30.6% of patients experiencing an OHCA had a recorded ROSC (return of spontaneous circulation), and 10.2% survived. However, the 58.7% compliance with the post-ROSC care bundle by ambulance services suggests variations in the delivery of post-resuscitation care. At present, UK ambulance services stabilise and transfer OHCA patients with ROSC to the nearest emergency department, which may not provide specialist services. Holland and Norway report survival rates of 21% and 25% respectively, and operate a centralised approach to post-resuscitation care through designated cardiac arrest centres, which provide specialist care that helps to improve the likelihood of survival. While no randomised controlled trials have been carried out in relation to cardiac arrest centres, it is recognised that the quality of care in the post-resuscitation phase is important, as this is when the highest proportion of deaths occur. Conclusion: Further research into specific care pathways and centralised care should be carried out, and an OHCA post-resuscitation care pathway should be developed to improve the delivery of care and survival. [ABSTRACT FROM AUTHOR]

Paramedics are the primary providers of prehospital care to children in an emergency. However, they deal with children's emergencies infrequently, and consistently report a lack of confidence in this area. The Royal College of Paediatrics and Child Health standards state that clinicians with Advanced Paediatric Life Support (APLS) training or equivalent must be available at all times to deal with emergencies involving children. While APLS is widely recognised as the gold standard in paediatric training, it focuses on in-hospital providers of paediatric life support, so may not adequately meet the needs of prehospital providers. The Paramedic Advanced Resuscitation of Children (PARC) course attempts to condense the most important aspects of APLS for paramedics into a simulation-based programme that is practical and cost effective. Evaluation of the views of the eight paramedics who took part in the pilot revealed that they felt more confident in managing children's emergencies after attending the course. The PARC course may be a simple, cost-effective method to improve paramedics' confidence in dealing with emergencies involving children. [ABSTRACT FROM AUTHOR]

Background: Work integrated learning (WIL) activities—sometimes termed student placements, practice-based learning, cooperative education or workplace learning activities—are embedded into university course curricula to prepare students for future professional environments. Aims: This study evaluates an interdisciplinary and multiagency WIL activity undertaken by university students (n=14). Methods: Pre- and post-activity survey instruments were used to gain perspectives on student expectations and experiences relating to the WIL activity. The survey instruments were based on five common themes of quality within WIL activities. Findings: The WIL activity facilitated professionally relevant learning, delivered diverse experiences, and enabled the development of professionally meaningful relationships. Discussion: A pilot evaluation instrument for similar undergraduate paramedic WIL programmes is presented for further consideration. Limitations of the study are also discussed. [ABSTRACT FROM AUTHOR]

Aim: The current review investigates the impacts of paramedic work on the family system. Paramedics are taking time off or leaving through stress, and career decisions could be influenced by this perceived impact. Method: A systematic literature review was conducted and the literature critiqued. Two themes were identified: emotional labour and work-family fit. Results: Paramedics rely on families for emotional support, putting them at risk of vicarious trauma. The historical male coping culture of paramedic practice deters processing at work, detrimentally carrying this processing into the home environment. Additionally, several shift characteristics contribute to work-family conflict, child-rearing conflict and difficulties maintaining a social life. Conclusions: Key organisational culture change is needed from denigrating staff for showing emotions and struggling to find work-life balance, to one that improves experiences at work and therefore at home as well. Recent movement towards almost equal gender balance may present a particular opportunity to deliver culture change. Further research is required to better understand the impact that shift work has on the family. [ABSTRACT FROM AUTHOR]

Background: Ambulance clinicians must make time-critical decisions concerning treatment and resuscitation. Little is known about the impact of the presence (or absence) of do-not-attempt cardiopulmonary resuscitation (DNACPR) decision forms in the community. Aims: To investigate ambulance clinicians' experiences of DNACPR documentation and views concerning potential future changes. Methods: This multi-methods study used semi-structured face-to-face interviews (n=10) and an online questionnaire (n=123) Findings: Ambulance clinicians report that a statistically significant increase in numbers of community DNACPR forms has occurred in recent years. Most state they have not had formal DNACPR education and experience difficulties in making clinical judgments about patients at the end of life, reporting inappropriate CPR attempts and poor communication among stakeholders. Conclusion: Assessment of patients near the end of life with (and especially without) a DNACPR is challenging for ambulance clinicians. Education about resuscitation recommendations needs to be integrated into training and a national approach should be taken to decisions and their documentation. [ABSTRACT FROM AUTHOR]

Background: Both the National Institute for Health and Care Excellence (NICE) and Public Health England have made smoking cessation a health promotion priority but the paramedic's potential impact in this important area has yet to be fully realised. Aim: This article proposes an evidence-based quality improvement intervention that can be adopted by paramedics at an individual, service-wide or national level to promote smoking cessation. Methodology: Building on a structured literature review and using the three fundamental questions and a Plan Do Study Act cycle, we propose a quality improvement strategy and evaluation methodology suited to the aims of the article. Discussion: Very Brief Advice is an evidence-based, effective and time-efficient way of reducing harm from smoking and improving quality of life for patients, saving NHS money as well as increasing paramedic job satisfaction. [ABSTRACT FROM AUTHOR]

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 prescriber, detailing strategies to ensure a consultation and prescribing decision is patient-centred while respecting autonomy, and how concordance can be improved. The article uses a patient consultation as a framing device to detail how these essential aspects of prescribing can be achieved. [ABSTRACT FROM AUTHOR]

Pharmacokinetics is not only relevant to those undertaking a non-medical prescribing course but it is also important information for any paramedic, as a knowledge of pharmacokinetics is critical to understanding why our medications do what they do and how their effects may vary on a patient-to-patient basis. [ABSTRACT FROM AUTHOR]