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Background: Ambulance callouts and conveyances continue to increase disproportionately to population growth. This is largely driven by low- and medium-acuity patients who do not require ambulance management. We aimed to estimate the proportion of patients paramedics have conveyed to an emergency department (ED) via ambulance whom they considered suitable for primary care, and understand the barriers that contributed to these decisions. Methods: A cross-sectional survey of registered paramedics in Victoria, Australia, was undertaken using an online questionnaire during 2022. Responses are presented using descriptive statistics, and logistic regression was used to identify associations between paramedic characteristics and barriers influencing primary care pathway referral. Results: A total of 367 responses were received. Of these, 70% of paramedics reported that at least half of the patients they conveyed to an ED were suitable for a primary care pathway. Paramedics reported high levels of confidence and support for primary care pathways in lieu of transport, however this had no correlation with their self-reported practice. The most common barrier to primary care pathway referral was limited access to a suitable primary care pathway (68%) followed by fear of an internal complaint, litigation or organisational pressure to convey patients to an ED (66%). Paramedics regarded themselves as more supportive of primary care pathway referral than those around them, including their peers, mentors, employers and university. They also reported that the COVID-19 pandemic had increased their personal support for primary care pathways, as well as organisational support from their employer, without corresponding increase in the broader medical and public communities. In fact, paramedics reported the COVID-19 pandemic had decreased support from the public and patients to refer patients to primary care pathways, and 57% of paramedics reported conveying a patient that had declined their primary care referral in the past week. Conclusions: Paramedics frequently convey to an ED patients who they believe are appropriate for a primary care pathway. Paramedics face practical barriers such as a lack of available primary care providers and perceived lack of cultural support that contribute to this practice. Paramedics are increasingly attending low- and medium-acuity patients, and paramedics in our survey self-reported that at least half of the patients they conveyed to an ED were appropriate for a primary care pathway. Notable barriers to primary care referrals included limited access to suitable primary care and fear of organisational repercussions or litigation following non-conveyance. This research has important implications for the educational, practical and organisational support given to paramedics regarding primary care diversion for suitable patients. [ABSTRACT FROM AUTHOR]

This systematic review aims to identify the diagnostic accuracy of posterior circulation stroke (PCS) by paramedics and the causes and duration of delay in its recognition. A systematic search using CINAHL Plus, MEDLINE, Scopus, and PubMed was performed. All databases were searched up to May 25, 2022. Studies were included where patients were adults, assessed by paramedics, and PCS was the primary diagnosis. Bias was assessed using the Newcastle-Ottawa Scale and the Effective Practice and Organization of Care tool. Results have been described by proportions, and both sensitivity calculations and subgroup analysis were performed utilizing MedCalc. A total of 797 titles/abstracts and a subsequent 87 full texts were screened, of which 15 were included. There were 5395 patients who were assessed by paramedics and had a confirmed diagnosis of PCS. Among five studies containing both true positive and false negative data, there were 98 (45.8%) true positives. PCS patients lost an average of 27 min (p < 0.001) compared to anterior stroke patients in the prehospital setting. One study revealed that educational intervention, including implementing the finger-to-nose test, increased the sensitivity for diagnosis from 45.8 to 74.1% (p = 0.039) and decreased the time from door to computed tomography from 62 to 41 min (p = 0.037). There is a substantial lack of evidence regarding the diagnosis of PCS by paramedics. Despite the low quality of evidence available, overall, the sensitivity for paramedic PCS diagnosis appears to be poor. Further investigation is required into paramedics' diagnosis of PCS and the use of educational interventions. Prospective Register of Systematic Reviews Registration Number: CRD42022324675. [ABSTRACT FROM AUTHOR]

Ketamine is a fast-acting, dissociative anesthetic with a favorable adverse effect profile that is effective for managing acute agitation as a chemical restraint in the prehospital and emergency department (ED) settings. However, some previously published individual studies have reported high intubation rates when ketamine was administered prehospitally. This systematic review aims to determine the rate and settings in which intubation following prehospital administration of ketamine for agitation is occurring, as well as associated indications and adverse events. We searched PubMed, Scopus, Ovid MEDLINE, Embase, CINAHL Plus, PsycINFO, the Cochrane Library, ClinicalTrials.gov, OpenGrey, Open Access Theses and Dissertation, and Google Scholar from the earliest possible date until 13/February/2022. Inclusion criteria required studies to describe agitated patients who received ketamine in the prehospital setting as a first-line drug to control acute agitation. Reference lists of appraised studies were screened for additional relevant articles. Study quality was assessed using the Newcastle-Ottawa quality assessment scale. Synthesis of results was completed via meta-analysis, and the GRADE tool was used for certainty assessment. The search yielded 1466 unique records and abstracts, of which 50 full texts were reviewed, resulting in 18 being included in the analysis. All studies were observational in nature and 15 were from USA. There were 3476 patients in total, and the overall rate of intubation was 16% (95% confidence interval [CI] = 8%–26%). Most intubations occurred in the ED. Within the studies, the prehospital intubation rate ranged from 0% to 7.9% and the ED intubation rate ranged from 0 to 60%. The overall pooled prehospital intubation rate was 1% (95% CI = 0%–2%). The overall pooled ED intubation rate was 19% (95% CI = 11%–30%). The most common indications for intubation were for airway protection and respiratory depression/failure. There is wide variation in intubation rates between and within studies. The majority of intubations performed following prehospital administration of ketamine for agitation took place in the ED. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities-the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing. [ABSTRACT FROM AUTHOR]

Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the 'safe zone' of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation. [ABSTRACT FROM AUTHOR]

Objective: Language that implies a conclusion not supported by the evidence is common in the medical literature. The hypothesis of the present study was that medical journal publications are more likely to use misleading language for the interpretation of a demonstrated null (i.e. chance or not statistically significant) effect than a demonstrated real (i.e. statistically significant) effect. Methods: This was an observational study of the medical literature with a systematic sampling method. Articles published in The Journal of the American Medical Association, The Lancet and The New England Journal of Medicine over the last two decades were eligible. The language used around the P‐value was assessed for misleadingness (i.e. either suggesting an effect existed when a real effect did not exist or vice versa). Results: There were 228 unique manuscripts examined, containing 400 statements interpreting a P‐value proximate to 0.05. The P‐value was between 0.036 and 0.050 for 303 (75.8%) statements and between 0.050 and 0.064 for 97 (24.3%) statements. Forty‐four (11%) of the statements were misleading. There were 40 (41.2%) false‐positive sentences, implying statistical significance when the P‐value was >0.05, and four (1.3%) false‐negative sentences, implying no statistical significance when the P‐value <0.05 (relative risk 31.2; 95% confidence interval 11.5–85.1; P < 0.0001). The proportion of included manuscripts containing at least one misleading sentence was 16.2% (95% confidence interval 12.0–21.6). Conclusions: Among a random selection of sentences in prestigious journals describing P‐values close to 0.05, 1 in 10 are misleading (n = 44, 11%) and this is more prevalent when the P‐values are above 0.05 compared to below 0.05. Caution is advised for researchers, clinicians and editors to align with the context and purpose of P‐values. [ABSTRACT FROM AUTHOR]