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Introduction: Pre-alerts from paramedics to trauma centers are important for ensuring the highest quality of trauma care. Despite this, there is a paucity of data to support best practices in trauma pre-alert notifications. Within the trauma system of Ontario, Canada, the provincial critical care transport organization, Ornge, provides pre-alerts to major trauma centers, but standardization is currently lacking. This study examined the satisfaction of trauma team leaders' (TTLs) satisfaction with current trauma pre-alerts and their preferences for logistics, content, and structure. Methods: This was a quantitative survey of TTLs at adult and pediatric trauma centers across Ontario, Canada. Recruitment was through email to trauma directors, with follow-up efforts to target low-response sites to achieve good geographical representation. The survey was completed online and contained a combination of single or multiple-choice questions, Likert scales and free text options. Results: In total, 79 TTLs from adult and pediatric lead trauma centers across Ontario responded to the survey, which took place over a 120-day period. The survey achieved good geographical representation. Given the current processes, TTLs describe moderate satisfaction with room for improvement (median score 3, IQR 3–4 on a 5-point Likert scale). Their overall preference was for timely and direct communication, with some concerns about multiple channels of communication around logistics. Most TTLs agreed on the important and less important content details found in common standardized framework tools. For structure, 28/79 TTLs strongly preferred the cognitive aid ATMIST, 13/79 preferred IMIST-AMBO, and 8/79 preferred MIST or SBAR as the most useful. Conclusions: There is room for improvement through standardizing communication and streamlined pre-alert channels. Some disagreements exist between TTLs, particularly regarding logistics. Further research should examine TTL satisfaction after implementing the change in the pre-alert notification framework, which can address localized issues through stakeholder meetings with individual TTLs. [ABSTRACT FROM AUTHOR]

Abstract Introduction Pre-alerts from paramedics to trauma centers are important for ensuring the highest quality of trauma care. Despite this, there is a paucity of data to support best practices in trauma pre-alert notifications. Within the trauma system of Ontario, Canada, the provincial critical care transport organization, Ornge, provides pre-alerts to major trauma centers, but standardization is currently lacking. This study examined the satisfaction of trauma team leaders’ (TTLs) satisfaction with current trauma pre-alerts and their preferences for logistics, content, and structure. Methods This was a quantitative survey of TTLs at adult and pediatric trauma centers across Ontario, Canada. Recruitment was through email to trauma directors, with follow-up efforts to target low-response sites to achieve good geographical representation. The survey was completed online and contained a combination of single or multiple-choice questions, Likert scales and free text options. Results In total, 79 TTLs from adult and pediatric lead trauma centers across Ontario responded to the survey, which took place over a 120-day period. The survey achieved good geographical representation. Given the current processes, TTLs describe moderate satisfaction with room for improvement (median score 3, IQR 3–4 on a 5-point Likert scale). Their overall preference was for timely and direct communication, with some concerns about multiple channels of communication around logistics. Most TTLs agreed on the important and less important content details found in common standardized framework tools. For structure, 28/79 TTLs strongly preferred the cognitive aid ATMIST, 13/79 preferred IMIST-AMBO, and 8/79 preferred MIST or SBAR as the most useful. Conclusions There is room for improvement through standardizing communication and streamlined pre-alert channels. Some disagreements exist between TTLs, particularly regarding logistics. Further research should examine TTL satisfaction after implementing the change in the pre-alert notification framework, which can address localized issues through stakeholder meetings with individual TTLs.

INTRODUCTION: Over 70,000 cases of Proximal Femoral Fracture (PFF) occur annually in the United Kingdom (UK), primarily affecting the elderly. These injuries are associated with high morbidity and mortality, and often see inadequate pain management in the prehospital setting. The Fascia Iliaca Compartment Block (FICB), a regional anaesthesia technique, is the gold standard of care in Emergency Departments (ED). This review aims to assess the literature on paramedic-performed FICB for suspected PFF in the prehospital setting, highlighting benefits and challenges to guide future practice and policy in the ambulance sector. MATERIALS AND METHODS: A rapid scoping review was conducted following the Joanna Briggs Institute (JBI) methodology, with modifications for this project’s limitations. A systematic search of the databases CINHAL, PubMed, EMBASE, and Medline was performed. A synthesis matrix was created to extrapolate data from the included studies and allow for a coherent interpretation of results. Each included study was subject to a critical appraisal conducted using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Data was extracted from three studies and two reports which identified four key themes emerged: paramedic competency in performing FICB, patient perspectives, adverse events, and training and governance. Studies showed paramedics can competently perform FICBs in prehospital settings. Verbal pain scores were lower following an FICB compared to standard care with IV morphine, which required more supplementary morphine for break-out pain. Concern for causing harm was a consistent theme among the paramedics performing FICB, particularly in precipitating an adverse event sequela. Adverse events were more common in non-FICB groups, with only one case of local anaesthetic toxicity in the FICB group, which was correctly managed by the paramedic. CONCLUSIONS: Paramedics can competently perform FICB in the prehospital setting, showing promising results in pain relief compared to intravenous morphine. However, higher-level research is needed for confirmation. Patients generally tolerated paramedic-led FICB well, with minimal concerns. Training and governance remain significant barriers to implementing FICB in local ambulance services.

Background: Prehospital detection and triage of stroke patients mostly rely on the use of large vessel occlusion prediction scales to decrease onsite time. These quick but simplified scores, though useful, prevent prehospital providers from detecting posterior strokes and isolated symptoms such as limb ataxia or hemianopia. Case report: In the present case, an ambulance was dispatched to a 46-year-old man known for ophthalmic migraines and high blood pressure, who presented isolated visual symptoms different from those associated with his usual migraine attacks. Although the assessment advocated by the prehospital guideline was negative for stroke, the paramedic who assessed the patient was one of the few trained in the National Institutes of Health Stroke Scale assessment. Based on this assessment, the paramedic activated the fast-track stroke alarm and an ischemic stroke in the right temporal lobe was finally confirmed by magnetic resonance imaging. Discussion and conclusions: Current prehospital practice enables paramedics to detect anterior strokes but often limits the detection of posterior events or more subtle symptoms. Failure to identify such strokes delay or even forestall the initiation of thrombolytic therapy, thereby worsening patient outcomes. We therefore advocate a two-step prehospital approach: first, to avoid unnecessary delays, the prehospital stroke assessment should be carried out using a fast large vessel occlusion prediction scale; then, if this assessment is negative but potential stroke symptoms are present, a full National Institutes of Health Stroke Scale assessment could be performed to detect neurological deficits overlooked by the fast stroke scale. [ABSTRACT FROM AUTHOR]

Objective: Following recent changes to the German Narcotics Act, this article examines prehospital analgesia by paramedics using piritramide vs. nalbuphine + paracetamol. Material and methods: Prehospital analgesia administered by paramedics from the Fulda (piritramide) and Gütersloh (nalbuphine + paracetamol) emergency services was compared regarding pain intensity at the beginning and end of the mission, measured using the numeric rating scale (NRS). Additionally, an analysis of the resulting complications was carried out. Results: In this study 2429 administrations of analgesia were evaluated (nalbuphine + paracetamol: 1635, 67.3%, initial NRS: 8.0 ± 1.4, end of NRS: 3.7 ± 2.0; piritramide: 794, 32.7%, initial NRS: 8.5 ± 1.1, end of NRS: 4.5 ± 1.6). Factors influencing NRS change were initial NRS (regression coefficient, RC: 0.7075, 95% confidence interval, CI: 0.6503–0.7647, p < 0.001), treatment with nalbuphine + paracetamol (RC: 0.6048, 95% CI: 0.4396–0.7700, p < 0.001). Treatment with nalbuphine + paracetamol (n = 796 (48.7%)) compared to piritramide (n = 190 (23.9%)) increased the odds of achieving NRS < 4 (odds ratio, OR: 2.712, 95% CI: 2.227–3.303, p < 0.001). Complications occurred in n = 44 (5.5%) with piritramide and in n = 35 (2.1%) with nalbuphine + paracetamol. Risk factors for complications were analgesia with piritramide (OR: 2.699, 95% CI: 1.693–4.301, p < 0.001), female sex (OR: 2.372, 95% CI: 1.396–4.029, p = 0.0014), and age (OR: 1.013, 95% CI: 1.002–1.025, p = 0.0232). Conclusion: Compared with piritramide, prehospital analgesia with nalbuphine + paracetamol has favorable effects in terms of analgesic efficacy and complication rates and should therefore be considered in future recommendations for paramedics. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Over 70,000 cases of Proximal Femoral Fracture (PFF) occur annually in the United Kingdom (UK), primarily affecting the elderly. These injuries are associated with high morbidity and mortality, and often see inadequate pain management in the prehospital setting. The Fascia Iliaca Compartment Block (FICB), a regional anaesthesia technique, is the gold standard of care in Emergency Departments (ED). This review aims to assess the literature on paramedic-performed FICB for suspected PFF in the prehospital setting, highlighting benefits and challenges to guide future practice and policy in the ambulance sector. MATERIALS AND METHODS: A rapid scoping review was conducted following the Joanna Briggs Institute (JBI) methodology, with modifications for this project's limitations. A systematic search of the databases CINHAL, PubMed, EMBASE, and Medline was performed. A synthesis matrix was created to extrapolate data from the included studies and allow for a coherent interpretation of results. Each included study was subject to a critical appraisal conducted using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Data was extracted from three studies and two reports which identified four key themes emerged: paramedic competency in performing FICB, patient perspectives, adverse events, and training and governance. Studies showed paramedics can competently perform FICBs in prehospital settings. Verbal pain scores were lower following an FICB compared to standard care with IV morphine, which required more supplementary morphine for break-out pain. Concern for causing harm was a consistent theme among the paramedics performing FICB, particularly in precipitating an adverse event sequela. Adverse events were more common in non-FICB groups, with only one case of local anaesthetic toxicity in the FICB group, which was correctly managed by the paramedic. CONCLUSIONS: Paramedics can competently perform FICB in the prehospital setting, showing promising results in pain relief compared to intravenous morphine. However, higher-level research is needed for confirmation. Patients generally tolerated paramedic-led FICB well, with minimal concerns. Training and governance remain significant barriers to implementing FICB in local ambulance services. [ABSTRACT FROM AUTHOR]

Background: Point-of-care ultrasound (POCUS) is steadily growing in use in prehospital emergency medicine. While currently used primarily by emergency physicians, POCUS could also be employed by paramedics to support diagnosis and decision-making. Yet to date, no paramedicine-targeted POCUS curricula exist in Germany. Furthermore, given time and resource constraints in paramedic training, it is unclear whether paramedics could feasibly learn POCUS for prehospital deployment. Hence, this study outlines the development and implementation of a comprehensive POCUS curriculum for paramedics. Through this curriculum, we investigate whether paramedics can attain proficiency in POCUS comparable to other user groups. Methods: In this prospective observational study, we first developed a blended learning-based POCUS curriculum specifically for paramedics, focusing on basic principles, the RUSH-Protocol and ultrasound guided procedures. Participants underwent digital tests to measure their theoretical competence before (T1) and after the digital preparation phase (T2), as well as at the end of the on-site phase (T3). At time point T3, we additionally measured practical competence using healthy subjects and simulators. We compared the theoretical competence and the practical competence on a simulator with those of physicians and medical students who had also completed ultrasound training. Furthermore, we carried out self-assessment evaluations, as well as evaluations of motivation and curriculum satisfaction. Results: The paramedic study group comprised n = 72 participants. In the theoretical test, the group showed significant improvement between T1 and T2 (p < 0.001) and between T2 and T3 (p < 0.001). In the practical test on healthy subjects at T3, the group achieved high results (87.0% ± 5.6). In the practical test on a simulator at T3, paramedics (83.8% ± 6.6) achieved a lower result than physicians (p < 0.001), but a comparable result to medical students (p = 0.18). The results of the study group's theoretical tests (82.9% ± 9.2) at time point T3 were comparable to that of physicians (p = 0.18) and better than that of medical students (p < 0.01). The motivation and attitude of paramedics towards the prehospital use of POCUS as well as their self-assessment significantly improved from T1 to T3 (p < 0.001). The overall assessment of the curriculum was positive (92.1 ± 8.5). Conclusion: With our tailored curriculum, German paramedics were able to develop skills in POCUS comparable to those of other POCUS learners. Integration of POCUS into paramedics' training curricula offers opportunities and should be further studied. [ABSTRACT FROM AUTHOR]

Introduction: Various early warning score tools have been developed to identify clinical deterioration in patients. This study assessed the predictive capacity of the National Early Warning Score 2 (NEWS-2) in the prehospital setting to predict death within 24 hours and 30-day intensive care unit admission. Methods: A single-center observational retrospective study was conducted in the emergency medical services (EMS) of King Abdulaziz Medical City, Riyadh, Saudi Arabia. We included adult patients (> 18 years) who attended the emergency medical service. The primary outcome was 24-hour death and 30-day intensive care unit admission. Sensitivity, specificity, and negative/positive predictive values (NPV/PPV) were determined. Results: The study comprised 1,343 eligible patients. NEWS-2 exhibited a sensitivity of 20% and a specificity of 80% for predicting 24-hour death and a sensitivity of 10% and a specificity of 80% for predicting 30-day intensive care unit admission. The area under the curve for predicting death was 0.529, and for intensive care unit admission was 0.456. Conclusion: Our study underscores the limited utility of NEWS-2 as a predictor of 24-hour death and 30-day intensive care unit admission in adult patients utilizing the emergency medical service. Further extensive studies are warranted to corroborate this study's findings. [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]

Objective: Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. Methods: A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017–2021) and Wellington Free Ambulance (2018–2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. Results: There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population‐years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. Conclusions: A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Workplace violence (WPV) against healthcare professionals (HCPs), including student paramedics, is a global concern, with reported incidents ranging from physical to psychological abuse. The prehospital environment, characterised by its high-risk nature, presents unique challenges for student paramedics during clinical placements. To explore the extent and nature of WPV experienced by student paramedics during clinical placements, assess the impact of WPV on their training and psychological well-being, and identify existing support mechanisms and training provisions. MATERIALS AND METHODS: Included were research or review articles specifically exploring WPV experienced by student paramedics during clinical placements. Exclusions were applied to articles not focusing on student paramedics, those not in English, and publications outside the specified time frame. A comprehensive search strategy was used across the databases CINAHL, Medline, EMBASE, EMCARE, and PubMed, supplemented by grey literature searches via Google Scholar and citation searching. Data extraction was facilitated through a synthesis matrix and themes were identified and analysed. RESULTS: From 417 records identified, six articles were included, all conducted in Australia, revealing themes such as the risk and effects of WPV, lack of reporting, the role of the practice educator (PEds), and preparedness for WPV. Freedom of Information (FoI) requests to English Ambulance Services highlighted inconsistencies in recording WPV incidents and variability in support provided to student paramedics. CONCLUSIONS: WPV significantly impacts student paramedics' educational experience and psychological health. There is a crucial need for improved education on WPV, standardised reporting mechanisms, and enhanced support systems. Collaborative efforts between ambulance services and higher educational institutions (HEIs) are essential to address these challenges and ensure a safer learning environment for student paramedics.

People who use drugs (PWUD) face stigmatizing treatment and substandard care during all stages of their health care journey, including in the prehospital setting by Emergency Medical Services (EMS) providers. Drawing on the professional and lived experience of the authors, we have developed a training with an intended audience of Emergency Medical Technicians (EMTs) and Paramedics in Massachusetts that will orient them to harm reduction philosophy. The training is delivered online through an asynchronous platform housed at Boston University School of Public Health and centers around several themes including the impact of fentanyl on the drug supply, the role of harm reduction in mitigating the impacts of drug criminalization, and ensuring that EMS providers have access to tools and best practices for improving overdose response, pain management, documentation, and respectful language. The training has been approved for Massachusetts Office of Emergency Medical Services (OEMS) continuing education credit and will be offered for free. We plan to evaluate changes in participant knowledge and attitudes and overall acceptability of the training among EMS providers in Massachusetts. [ABSTRACT FROM AUTHOR]

Background and purpose: Timely prehospital stroke recognition was explored in the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) by implementation of stroke education for paramedics and use of the National Institutes of Health Stroke Scale (NIHSS) through a mobile application. The study tested triage and facilitated communication between paramedics and stroke physicians. To complement the quantitative results of the clinical trial, a qualitative approach was used to identify factors that influence triage decisions and diagnostic accuracy in prehospital stroke recognition experienced by paramedics and stroke physicians. Method: Semi‐structured qualitative individual interviews were performed following an interview guide. Informants were recruited from the enrolled paramedics and stroke physicians who participated in the ParaNASPP trial from Oslo University Hospital. Interviews were audio recorded, transcribed verbatim and approached inductively using the principles of thematic analysis. Results: Fourteen interviews were conducted, with seven paramedics and seven stroke physicians. Across both groups two overarching themes were identified related to triage decisions and diagnostic accuracy in prehospital stroke recognition: prehospital NIHSS reliably improves clinical assessment and communication quality; overtriage is widely accepted whilst undertriage is not. Conclusion: Paramedics and stroke physicians described how prehospital NIHSS improved communication quality and reliably improved prehospital clinical assessment. The qualitative results support a rationale of an application algorithm to decide which NIHSS items should prompt immediate prenotification rather than a complete NIHSS as default. [ABSTRACT FROM AUTHOR]

Emergency medical services (EMS) are a vital component of the health system and provide pre-hospital emergency care and specialised transport for patients requiring access to health facilities, thereby contributing to universal health coverage and improving health outcomes. Evidence regarding the current state of EMS within South Africa to fulfil this role is lacking and was the motivation for this review. Our objective was to describe the current state of EMS in South Africa. A literature search was conducted using keywords, BOOLEAN operating terms, and eligibility criteria on Sabinet, EBSCOhost, Google Scholar, ProQuest, Medline, PubMed, and ScienceDirect databases to find articles related to the components of the EMS system in South Africa. The articles were critically assessed, and six themes emerged: leadership and governance; resources; preparedness (knowledge, attitude, and practices) of the emergency care provider; health and safety; training; and communications. Challenges were found in all themes at a provincial EMS level despite improvements in legislation, leadership, and governance from the National Department of Health. These themes demonstrate that all components in the EMS system are not functioning optimally and may be affecting its contribution to improving universal health coverage and health outcomes. The current state of EMS appears to be constrained and requires greater leadership and governance from the Provincial Departments of Health to improve poorly functioning components of the EMS system. Significance: The current state of EMS in South Africa lacks efficiency in its role to provide emergency care and transportation for patients wanting to access health facilities. Poorly functioning components of the EMS system have been identified and provide an opportunity for health authorities to make improvements so that the goal of universal health coverage and improved health outcomes can be realised.

Introduction: Unvaccinated emergency medical services (EMS) personnel are at increased risk of contracting coronavirus disease 2019 (COVID-19) and potentially transmitting the virus to their families, coworkers, and patients. Effective vaccines for the severe acute respiratory syndrome coronavirus 2 virus exist; however, vaccination rates among EMS professionals remain largely unknown. Consequently, we sought to document vaccination rates of EMS professionals and identify predictors of vaccination uptake.Methods: We conducted a cross-sectional survey of North Carolina EMS professionals after the COVID-19 vaccines were widely available. The survey assessed vaccination status as well as beliefs regarding COVID-19 illness and vaccine effectiveness. Prediction of vaccine uptake was modeled using logistic regression.Results: A total of 860 EMS professionals completed the survey, of whom 74.7% reported receiving the COVID-19 vaccination. Most respondents believed that COVID-19 is a serious threat to the population, that they are personally at higher risk of infection, that vaccine side effects are outweighed by illness prevention, and the vaccine is safe and effective. Despite this, only 18.7% supported mandatory vaccination for EMS professionals. Statistically significant differences were observed between the vaccinated and unvaccinated groups regarding vaccine safety and effectiveness, recall of employer vaccine recommendation, perceived risk of infection, degree of threat to the population, and trust in government to take actions to limit the spread of disease. Unvaccinated respondents cited reasons such as belief in personal health and natural immunity as protectors against infection, concerns about vaccine safety and effectiveness, inadequate vaccine knowledge, and lack of an employer mandate for declining the vaccine. Predictors of vaccination included belief in vaccine safety (odds ratio [OR] 5.5, P=

Christian Angelo I Ventura,1 Edward E Denton2,3 1Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; 3Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USACorrespondence: Christian Angelo I Ventura, Tel +1 732 372-2141, Email cventu12@jhmi.eduAbstract: Emergency Medical Services (EMS) is likely to experience transformative changes due to the rapid advancements in artificial intelligence (AI), such as OpenAI’s ChatGPT. In this short commentary, we aim to preliminarily explore some profound implications of AI advancements on EMS systems and practice.Keywords: EMS, artificial intelligence, prehospital, machine learning, EMT, paramedic

Background: A high concentration of inspired supplemental oxygen may possibly cause hypercapnia and acidosis and increase mortality in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Even so, patients with AECOPD are being treated with high oxygen flow rates when receiving inhalation drugs in the prehospital setting. A cluster-randomised controlled trial found that reduced oxygen delivery by titrated treatment reduced mortality—a result supported by observational studies—but the results have never been reproduced. In the STOP-COPD trial, we investigate the effect of titrated oxygen delivery compared with usual care consisting of high flow oxygen delivery in patients with AECOPD in the prehospital setting. Methods: In this randomised controlled trial, patients will be blinded to allocation. Patients with suspected AECOPD (n = 1888) attended by the emergency medical service (EMS) and aged > 40 years will be allocated randomly to either standard treatment or titrated oxygen, targeting a blood oxygen saturation of 88–92% during inhalation therapy. The trial will be conducted in the Central Denmark Region and include all ambulance units. The power to detect a 3% 30-day mortality risk difference is 80%. The trial is approved as an emergency trial. Hence, EMS providers will include patients without prior consent. Discussion: The results will provide evidence on whether titrated oxygen delivery outperforms standard high flow oxygen when used to nebulise inhaled bronchodilators in AECOPD treatment. The trial is designed to ensure unselected inclusion of patients with AECOPD needing nebulised bronchodilators—a group of patients that receives high oxygen fractions when treated in the prehospital setting where the only compressed gas is generally pure oxygen. Conducting this trial, we aim to improve treatment for people with AECOPD while reducing their 30-day mortality. Trial registration: European Union Clinical Trials (EUCT) number: 2022-502003-30-00 (authorised 06/12/2022), ClinicalTrials.gov number: NCT05703919 (released 02/02/2023), Universal trial number: U1111-1278-2162. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Workplace violence (WPV) against healthcare professionals (HCPs), including student paramedics, is a global concern, with reported incidents ranging from physical to psychological abuse. The prehospital environment, characterised by its high-risk nature, presents unique challenges for student paramedics during clinical placements. To explore the extent and nature of WPV experienced by student paramedics during clinical placements, assess the impact of WPV on their training and psychological well-being, and identify existing support mechanisms and training provisions. MATERIALS AND METHODS: Included were research or review articles specifically exploring WPV experienced by student paramedics during clinical placements. Exclusions were applied to articles not focusing on student paramedics, those not in English, and publications outside the specified time frame. A comprehensive search strategy was used across the databases CINAHL, Medline, EMBASE, EMCARE, and PubMed, supplemented by grey literature searches via Google Scholar and citation searching. Data extraction was facilitated through a synthesis matrix and themes were identified and analysed. RESULTS: From 417 records identified, six articles were included, all conducted in Australia, revealing themes such as the risk and effects of WPV, lack of reporting, the role of the practice educator (PEds), and preparedness for WPV. Freedom of Information (FoI) requests to English Ambulance Services highlighted inconsistencies in recording WPV incidents and variability in support provided to student paramedics. CONCLUSIONS: WPV significantly impacts student paramedics' educational experience and psychological health. There is a crucial need for improved education on WPV, standardised reporting mechanisms, and enhanced support systems. Collaborative efforts between ambulance services and higher educational institutions (HEIs) are essential to address these challenges and ensure a safer learning environment for student paramedics. [ABSTRACT FROM AUTHOR]

Stroke identification is a key step in acute ischemic stroke management. Our objectives were to prospectively examine the agreement between prehospital and hospital Modified National Institutes of Health Stroke Scale (mNIHSS) assessments as well as assess the prehospital performance characteristics of the mNIHSS for identification of large vessel occlusion strokes. Method: In this prospective cohort study conducted over a 20-month period (11/2016-6/2018), we trained 40 prehospital providers (paramedics) in Emergency Neurological Life Support (ENLS) curriculum and in mNIHSS. English-speaking patients aged 18 and above transported for an acute neurological deficit were included. Using unique identifiers, we linked the prehospital assessment records to the hospital record. We calculated the agreement between prehospital and hospital mNIHSS scores using the Bland-Altman analysis and the sensitivity and specificity of the prehospital mNIHSS. Results: Of the 31 patients, the mean difference (prehospital mNIHSS-hospital mNIHSS) was 2.4, 95% limits of agreement (-5.2 to 10.0); 10 patients (32%) met our a priori imaging definition of large vessel occlusion and the sensitivity of mNIHSS ≥ 8 was 6/10 or 0.60 (95% CI: 0.26-0.88) and the specificity was 13/21 or 0.62 (95% CI: 0.38-0.82), respectively. Conclusions: We were able to train prehospital providers to use the prehospital mNIHSS. Prehospital and hospital mNIHSS had a reasonable level of agreement and and the scale was able to predict large vessel occlusions with moderate sensitivity.

Abstract Background Paramedicine presents students with numerous challenges, including factors threatening their wellbeing. Over the last two decades studies have illustrated that paramedics and paramedic students are more likely to have mental disorders than the general population. These findings suggest that course-related factors could be important in contributing to poorer mental health. However, few studies have examined factors related to stress in paramedic students, and none of these have included paramedic students from cross-culture. To address this, the present study (1) explored paramedicine students’ training experiences and other education-related factors that could affect their wellbeing, and (2) illustrated the possible differences and similarities between two cultures (Saudi Arabia and the UK) to determine whether the students’ cultural environment influenced factors related to their wellbeing. Methods A qualitative exploratory research design was used. Twenty semi-structured interviews were conducted with paramedicine students from the United Kingdom and Kingdom of Saudi Arabia (ten participants from each country). Reflexive thematic analysis was employed as the analytical approach in this study. Results Four major themes were identified which captured the contributors to paramedic students’ stress levels: (1) exposure to potentially traumatic events, (2) relationships and communication, illustrating the student’s personal and professional experiences with others, (3) programme atmosphere, demonstrating the challenges and support students encounter during their coursework and training, and (4) career, elucidating the pressure of future career expectations and predictions. Conclusion The study revealed contributors to stress were similar in both countries. Better preparation can help to reduce the negative impacts of the possible traumatic events encountered on placements and supportive relationships, especially with proctors, can boost student wellbeing. Universities are able to address both these factors and help foster a positive environment for paramedicine students. As such, these results should help educators and policymakers when identifying and delivering interventions to support paramedic students.

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]

Abstract Background The optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics’ attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting. Methods This was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss’ kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses. Results Two hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics’ estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents’ composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21–4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09–0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied. Conclusion Results of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision.

Background: Paramedicine presents students with numerous challenges, including factors threatening their wellbeing. Over the last two decades studies have illustrated that paramedics and paramedic students are more likely to have mental disorders than the general population. These findings suggest that course-related factors could be important in contributing to poorer mental health. However, few studies have examined factors related to stress in paramedic students, and none of these have included paramedic students from cross-culture. To address this, the present study (1) explored paramedicine students' training experiences and other education-related factors that could affect their wellbeing, and (2) illustrated the possible differences and similarities between two cultures (Saudi Arabia and the UK) to determine whether the students' cultural environment influenced factors related to their wellbeing. Methods: A qualitative exploratory research design was used. Twenty semi-structured interviews were conducted with paramedicine students from the United Kingdom and Kingdom of Saudi Arabia (ten participants from each country). Reflexive thematic analysis was employed as the analytical approach in this study. Results: Four major themes were identified which captured the contributors to paramedic students' stress levels: (1) exposure to potentially traumatic events, (2) relationships and communication, illustrating the student's personal and professional experiences with others, (3) programme atmosphere, demonstrating the challenges and support students encounter during their coursework and training, and (4) career, elucidating the pressure of future career expectations and predictions. Conclusion: The study revealed contributors to stress were similar in both countries. Better preparation can help to reduce the negative impacts of the possible traumatic events encountered on placements and supportive relationships, especially with proctors, can boost student wellbeing. Universities are able to address both these factors and help foster a positive environment for paramedicine students. As such, these results should help educators and policymakers when identifying and delivering interventions to support paramedic students. [ABSTRACT FROM AUTHOR]

Abstract Background Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating—with a high associated mortality rate—and survivors likely to be more dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment. Methods We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs). Discussion The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context. Trial registration ISRCTN15831813 . Registered on 22 September 2021.

Christian Angelo I Ventura,1– 3 Edward E Denton,3– 5 Jessica Anastacia David,6 Brianna J Schoenfelder,7 Lillian Mela,8 Rebecca P Lumia,9 Rachel B Rudi,3 Barnita Haldar3,10 1Department of Graduate Medical Sciences, Boston University School of Medicine Boston, Boston, MA, USA; 2Department of Health, Behavior and Society (Incoming), Johns Hopkins Bloomberg School of Public Health Baltimore, Baltimore, MD, USA; 3EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA; 4Department of Emergency Medicine, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA; 5Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA; 6Department of Biochemistry and Microbiology, Rutgers University New Brunswick, Brunswick, NJ, USA; 7Department of Neuroscience, Temple University Philadelphia, Philadelphia, PA, USA; 8Department of Nursing, Simmons University Boston, Boston, MA, USA; 9Department of Biology, Northeastern University Boston, Boston, MA, USA; 10Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham School of Medicine Birmingham, Birmingham, AL, USACorrespondence: Christian Angelo I Ventura, Tel +1 (732) 372-2141, Email venturachri@gmail.com; cventura@bu.eduAbstract: This study aimed to analyze prehospital Emergency Medical Services (EMS) response to the COVID-19 pandemic in the US through a brief systematic review of available literature in context with international prehospital counterparts. An exploration of the NCBI repository was performed using a search string of relevant keywords which returned n=5128 results; articles that met the inclusion criteria (n=77) were reviewed and analyzed in accordance with PRISMA and PROSPERO recommendations. Methodical quality was assessed using critical appraisal tools, and the Egger’s test was used for risk of bias reduction upon linear regression analysis of a funnel plot. Sources of heterogeneity as defined by P < 0.10 or I^2 > 50% were interrogated. Findings were considered within ten domains: structural/systemic; clinical outcomes; clinical assessment; treatment; special populations; dispatch/activation; education; mental health; perspectives/experiences; and transport. Findings suggest, EMS clinicians have likely made significant and unmeasured contributions to care during the pandemic via nontraditional roles, ie, COVID-19 testing and vaccine deployment. EMS plays a critical role in counteracting the COVID-19 pandemic in addition to the worsening opioid epidemic, both of which disproportionately impact patients of color. As such, being uniquely influential on clinical outcomes, these providers may benefit from standardized education on care and access disparities such as racial identity. Access to distance learning continuing education opportunities may increase rates of provider recertification. Additionally, there is a high prevalence of vaccine hesitancy among surveyed nationally registered EMS providers. Continued rigorous investigation on the impact of COVID-19 on EMS systems and personnel is warranted to ensure informed preparation for future pandemic and infectious disease responses.Keywords: EMS, COVID-19, prehospital, pandemic response, EMT, paramedic

BACKGROUND:A significant increase in false positive ST-elevation myocardial infarction (STEMI) electrocardiogram interpretations was noted after replacement of all of the City of San Diego's 110 monitor-defibrillator units with a new brand. These concerns were brought to the manufacturer and a revised interpretive algorithm was implemented. OBJECTIVES:This study evaluated the effects of a revised interpretation algorithm to identify STEMI when used by San Diego paramedics. METHODS:Data were reviewed 6 months before and 6 months after the introduction of a revised interpretation algorithm. True-positive and false-positive interpretations were identified. Factors contributing to an incorrect interpretation were assessed and patient demographics were collected. RESULTS:A total of 372 (234 preimplementation, 138 postimplementation) cases met inclusion criteria. There was a significant reduction in false positive STEMI (150 preimplementation, 40 postimplementation; p

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]

Introduction: Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Methods: Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage. Results: The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke). Conclusion: There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them.

Background: CPR-Induced Consciousness is an emerging phenomenon with a paucity of consensus guidelines from peak resuscitative bodies. Local prehospital services have had to implement their own CPR-Induced Consciousness guidelines. This scoping review aims to identify prehospital CPR-Induced Consciousness guidelines and compare or contrast their management options. Objective: The purpose of this scoping review is to identify and compare as many prehospital CPR-Induced Consciousness guidelines as feasible, highlight common management trends, and discuss the factors that might impact CPR-Induced Consciousness guidelines and the management trends identified. Design: To search for prehospital CPR-Induced Consciousness guidelines, a bibliographical search of five databases was undertaken (MEDLINE, EMBASE, Cochrane, Scopus, and CINAHL plus). Also included was a grey literature search arm, comprised of four search strategies: 1. Customised Google search, 2. Hand searching of targeted websites, 3. Grey literature databases, 4. Consultation with subject experts. Results: Our search extracted 23 prehospital CPR-Induced Consciousness guidelines and one good practise statement from the International Liaison Committee on Resuscitation. Of the 23 prehospital guidelines available, we identified 20 different ways of treating CPR-Induced Consciousness. Midazolam was the most frequently used drug to treat CPR-Induced Consciousness (14/23, 61%), followed by Ketamine (11/23, 48%) and Fentanyl (9/23, 39%). Conclusion: Prehospital CPR-Induced Consciousness guidelines are both exceptionally uncommon and vary substantially from each other. This has a flow-on effect towards data collection and only serves to continue CPR-Induced Consciousness’s relatively unknown status surrounding both knowledge of, and the effect CPR-Induced Consciousness treatment has on cardiac arrest outcomes.

Background: The optimal application of spinal motion restriction (SMR) in the prehospital setting continues to be debated. Few studies have examined how changing guidelines have been received and interpreted by emergency medical services (EMS) personnel. This study surveys paramedics' attitudes, observations, and self-reported practices around the treatment of potential spine injuries in the prehospital setting.Methods: This was a cross-sectional survey of a North American EMS agency. After development and piloting, the final version of the survey contained four sections covering attitudes towards 1) general practice, 2) specific techniques, 3) assessment protocols, and 4) mechanisms of injury (MOI). Questions used Likert-scale, multiple-choice, yes/no, and free-text responses. Exploratory factor analysis (EFA) was used to identify latent constructs within responses, and factor scores were analyzed by ordinal logistic regression for associations with demographic characteristics (including qualification level, gender, and years of experience). MOI evaluations were assessed for inter-rater reliability (Fleiss' kappa). Inductive qualitative content analysis, following Elo & Kyngäs (2008), was used to examine free-text responses.Results: Two hundred twenty responses were received (36% of staff). Raw results indicated that respondents felt that SMR was seen as less important than in the past, that they were treating fewer patients than previously, and that they follow protocol in most situations. The EFA identified two factors: one (Judging MOIs) captured paramedics' estimation that the presented MOI could potentially cause a spine injury, and another (Treatment Value) reflected respondents' composite view of the effectiveness, importance, and applicability of SMR. Respondents with advanced life support (ALS) qualification were more likely to be skeptical of the value of SMR compared to those at the basic life support (BLS) level (OR: 2.40, 95%CI: 1.21-4.76, p = 0.01). Overall, respondents showed fair agreement in the evaluation of MOIs (k = 0.31, 95%CI: 0.09-0.49). Content analysis identified tension expressed by respondents between SMR-as-directed and SMR-as-applied.Conclusion: Results of this survey show that EMS personnel are skeptical of many elements of SMR but use various strategies to balance protocol adherence with optimizing patient care. While identifying several areas for future research, these findings argue for incorporating provider feedback and judgement into future guideline revision. [ABSTRACT FROM AUTHOR]

Non‐transport to a hospital after emergency medical services (EMS) encounters for falls is common. However, incident factors associated with non‐transport have not been well studied, especially beyond older adults. The objectives of this study are to (1) describe trends in fall‐related EMS utilisation among adult patients from 2010 to 2018; (2) describe incident characteristics by age; and (3) identify incident factors associated with non‐transport following a fall. This retrospective observational study includes prehospital clinical records data on falls from a large ambulance service in Minnesota, USA. Multivariable logistic regression was used to assess the independent association between non‐transport and the following factors: sex, age, race, previous fall‐related EMS encounter, incident location and primary impression. Of 62,835 fall‐related encounters studied, 14.7% (9,245) did not result in transport by EMS. Fall calls were less common among younger people and the location and medical conditions primarily treated by an EMS provider during a 9‐1‐1 call differed greatly from those occurring among patients 65 and older. Factors most strongly associated with an increased risk of non‐transport in the multivariable model were a primary impression of 'No apparent illness/injury' (OR = 34.5, 95% CI = 30.7–38.7), falling in a public location (OR = 2.09, CI = 1.96–2.22) and having had a fall‐related EMS encounter during the prior year (OR = 1.15, CI = 1.1–1.2). Falls that occur in public locations, in patients with a previous fall, or result in no clinical detection of apparent illness or injury have a significantly increased odds of non‐transport. Non‐transport fall incidents in the United States require significant agency resources. Knowledge about the incident factors associated with non‐transport calls is informative for development of alternative models for prehospital care delivery and initiatives to better serve patients. [ABSTRACT FROM AUTHOR]

Providing care to methamphetamine‐related callout events in the prehospital environment is often complex and resource‐intensive, requiring staff to manage agitation and violence‐related side effects of methamphetamines. In Australia, emergency responders are increasingly required to attend events related to methamphetamines, even though reports suggest methamphetamine use across Australia has declined. The aim of the study was to explore Australian police and paramedic experiences attending methamphetamine‐related events. A qualitative descriptive phenomenology design was employed using semi‐structured interviews with employed police (10) and paramedics (8) from Australia. Data were analyzed using thematic analysis. Participants described the complexities associated with providing prehospital care to people affected by methamphetamines. Participants described associated domestic/family violence, increased levels of violence, challenges with communication, and responder emotional and psychological distress and physical injury. Violence associated with methamphetamine use is a critical factor in prehospital care. Workplace violence and family/domestic violence are important issues that require further research to ensure families and staff are well supported and have the services they need to continue responding to people affected by methamphetamine use. [ABSTRACT FROM AUTHOR]

Abstract Background Drug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it. Methods We conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie. Results There were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt, Conclusion Specialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention.

Background: Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating-with a high associated mortality rate-and survivors likely to be more dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment.Methods: We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs).Discussion: The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context.Trial Registration: ISRCTN15831813 . Registered on 22 September 2021. [ABSTRACT FROM AUTHOR]

Medical personnel such as those working in emergency medical systems are in direct contact with the patient or the injured and are exposed to workplace violence. This study aimed to determine workplace violence against prehospital paramedical personnel and factors related to this type of violence in Iran. The cross-sectional study was conducted in 72 prehospital emergency centers affiliated with Kerman University of Medical Sciences in 2019. Using a researcher-made questionnaire, we assessed workplace violence and factors associated with this type of violence in prehospital paramedical personnel with a census method (N = 308). Data were analyzed using descriptive statistics including mean and standard deviation (SD), frequency, percentage, and analytic statistics, such as the Kolmogorov–Smirnov, ANOVA, t test, and multiple linear regression tests. The results of this study showed that the most frequent types of workplace violence were verbal violence (47%), physical violence (32.50%), cultural violence (16%), and no violence (4.50%), respectively. From the perspective of paramedical personnel, the total mean score of workplace violence was at a moderate level (52.19 ± 10.72). The most important factors affecting workplace violence from the perspective of paramedical personnel were "lack of awareness of people about the duties of emergency medical personnel" and "lack of specialists in prehospital (city or road) bases." Majority of the paramedical personnel believed that "no reaction and observance of patients and their families' rights" were the most important types of reactions. They also believed that violence was normal at the workplace and should not be considered in emergency medical services. Results suggest that national and local policies in Iran should provide prehospital paramedical personnel with various training courses about how to decrease the rate of workplace violence, promote public health, and decrease their psychological stresses and occupational burnout. [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]

Introduction: Endotracheal intubation (ETI) in the prehospital setting poses unique challengeswhere multiple ETI attempts are associated with adverse patient outcomes. Early identificationof difficult ETI cases will allow providers to tailor airway-man agement efforts to minimizecomplications associated with ETI. We sought to derive and validate a prehospital difficult airwayidentification tool based on predictors of difficult ETI in other settings.Methods: We prospectively collected patient and airway data on all airway attempts from 16Advanced Life Support (ALS) ground emergency medical services (EMS) agencies from January2011 to October 2014. Cases that required more than two ETI attempts and cases where analternative airway strategy (e.g. supraglottic airway) was employed after one unsuccessful ETIattempt were categorized as “difficult.” We used a random allocation sequence to split the datainto derivation and validation subsets. Using backward elimination, factors with a p3 (2.15, 1. 19-3.88), limited neckmovement (2.24, 1.28-3.93), trismus/jaw clenched (2.24, 1.09-4. 6), inability to palpate thelandmarks of the neck (5.92, 2.77-12.66), and fluid in the airwa y such as blood or emesis (2.25,1.51-3.36). This was the most parsimonious model and exhibited good fit (Hos mer-Lemeshowtest p = 0.167) with an AUC of 0.68 (95% CI [0.64-0.73]). When applied to the validatio n set,the model had an AUC of 0.63 (0.58-0.68) with high specificity for identifying di fficult ETI if >2factors were present (87.7% (95% CI [84.1-90.8])).Conclusion: We have developed a simple tool using five factors that may aid p rehospitalproviders in the identification of difficult ETI.

Introduction: Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Methods: Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage. Results: The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke). Conclusion: There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them. [ABSTRACT FROM AUTHOR]

Abstract Background Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Abstract Background Previous studies have shown that prehospital insertion of peripheral vascular access is highly variable. The aim of this study is to establish the proportion of peripheral vascular access placement and its use with regard to both the severity of cases and the main problem suspected by the paramedics involved. Over-triage was considered to have taken place where peripheral vascular access was placed but unused and these cases were specifically analysed in order to evaluate the possibility of improving current practice. Methods This is a one-year (2017) retrospective study conducted throughout one State of Switzerland. Data were extracted from the state’s public health service database, collected electronically by paramedics on RescueNet® from Siemens. The following data were collected and analyzed: sex, age, main diagnosis suspected by paramedics and the National Advisory Committee for Aeronautics score (NACA) to classify the severity of cases. Results A total of 33,055 missions were included, 29,309 (88.7%) with a low severity. A peripheral vascular access was placed in 8603 (26.0%) cases. Among those, 3948 (45.9%) were unused and 2626 (66.5%) of these patients had a low severity score. Opiates represent 48.3% of all medications given. The most frequent diagnosis among unused peripheral vascular access were: respiratory distress (12.7%), neurological deficit without coma or trauma (9.6%), cardiac condition with thoracic pain and without trauma or loss of consciousness (9.6%) and decreased general condition of the patient (8.5%). Conclusions Peripheral vascular access was set in 26% of patients, nearly half of which were unused. To reduce over-triage, special attention should be dedicated to cases defined by EMS on site as low severity, as they do not require placement of a peripheral vascular access as a precautionary measure. Alternative routes, such as the intra-nasal route, should be promoted, particularly for analgesia, whose efficiency is well documented. Emergency medical services medical directors may also consider modifying protocols of acute clinical situations when data show that mandatory peripheral vascular access, in stroke cases for example, is almost never used.

Introduction: Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients.Methods: We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings.Results: Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted.Conclusion: There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient’s passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking.

Aim: Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence. Methods: A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR). Results: Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients. Conclusion: Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA. [ABSTRACT FROM AUTHOR]