Irish Journal of Paramedicine
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Use, outcomes and policy on the placement of Automated External Defibrillators on commercial aircraft for the management of in-flight cardiac arrest: a scoping review
Full text linkABSTRACTIntroduction Automated external defibrillators (AEDs) are increasingly available in public places for the treatment of cardiac arrest. Some commercial aircraft carry an AED, but little is known about international policies and requirements. The aim is to review policy regarding AED placement on commercial aircraft, summarising reported incidence and outcomes of AED utilisation for individuals experiencing an in-flight cardiac arrest (IFCA).MethodsA scoping review was undertaken. Online databases (Medline and CINAHL) were searched using prespecified terms to identify reports evidencing use, outcome and policy of AEDS for IFCA on commercial aircraft. Reports were screened and data extracted following scoping review extraction methods. Data were analysed to describe incidence of AED use and outcomes following IFCA, and policies regarding AED placement on commercial aircraft.Results 9 observational studies were identified. 8 reported instances of successful shock delivery using AED. No published reports of safety incidents involving in-flight AED use were found. 7 studies reported survival following AED use: of these, 6 reported administration of a shock for IFCA survivors, whilst 1 study reported deployment of an AED without shock delivery. Overall, survival following in-flight AED use was 9%, with 37% survival reported where patients presented with shockable rhythm. Only one policy mandating AED placement on commercial aircraft was identified.ConclusionDespite the small, retrospective and observational nature of the reports identified, findings suggest in-flight AED use is feasible and associated with improved outcomes from IFCA.Keywords: cardiac arrest; defibrillators; AED; aircraft; flight
Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review
Full text linkIntroductionEarly identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting. MethodsIn December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken. ResultsA total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS. ConclusionThis review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes.
A photo-elicitation study of paramedics’ perceptions of mental illness.
Full text linkThe number of people with mental illness who are treated by paramedics is increasing and there are a variety of factors that can affect how well this service demand is met. One such factor is paramedics’ perceptions of mental illness. Photo-elicitation was used to explore how paramedics felt about mental illness and to generate new ways of thinking about this important aspect of paramedicine practice and education. Highlighted is that paramedics can feel helpless and under-prepared in treating people with mental illness and that two concepts of ancient Greek origins — aporia and phronesis — offer a useful way forward in thinking about and responding to this
Esmolol for the treatment of refractory ventricular fibrillation: a systematic review and meta-analysis
Full text linkIntroduction: In light of recent research the efficacy of current advanced life support treatments has been questioned. Ventricular fibrillation refractory to standard therapy is a presentation which may benefit from an updated approach to management, with the b1-adrenoreceptor antagonist esmolol considered a therapy which may confer benefit. This systematic review and meta-analysis aimed to summarise the available evidence for esmolol in refractory ventricular fibrillation and identify if it may have any role in ACLS guidelines.Methods: The Cochrane Library, MEDLINE, CINAHL and EMBASE were systematically reviewed, along with trial registries and the grey literature. Studies were included in the review and subsequent meta-analysis if they examined adult patients in cardiopulmonary arrest with ventricular fibrillation refractory to at least three attempts at defibrillation and one dose of adrenaline or anti-arrhythmic therapy, who subsequently received intravenous esmolol.Results: 2,617 results were obtained with 12 full-text articles reviewed for inclusion. Ultimately, two unique results fulfilled the inclusion criteria. A total of 66 patients were included in the meta-analysis, of whom 22 received esmolol. Esmolol appears to improve to survival to hospital admission (RR 2.63, 95% CI 1.37-5.07, p=0.004), temporary (RR 2.34, 95% CI 1.09-5.02, p=0.03) and sustained ROSC (RR 2.63, 95% CI 1.37-5.07, p=0.004) and favourable neurological status at hospital discharge (RR 3.44, 95% CI 1.11-10.67, p=0.03). The use of esmolol also appeared to likely confer a benefit in survival to hospital discharge (RR 2.82, 95% CI 1.01-7.93, p=0.05). However, significant bias was observed across all outcomes and overall these results were considered to be of low to very low certainty.Conclusion: The use of esmolol in refractory ventricular fibrillation appears to improve survival to hospital admission, temporary and sustained ROSC and neurological status at hospital discharge, but not survival to hospital discharge. However, these results should be interpreted with caution in light of the limitations of included studies and the subsequent impact of these limitations on the outcomes included in the meta-analysis. Further high-quality, prospective research is required prior to recommending esmolol for use in refractory ventricular fibrillation
Improving Critical Listening skills in EMT Students
Full text linkIntroduction: Although the importance of EMT students utilizing critical listening skills is apparent, there is little research focused on EMT students or EMTs and critical listening. Ensuring EMT students develop critical listening skills can be an asset that reaches beyond the goal of improving their education. It also has the potential to improve the quality of care they go on to deliver. EMTs may have the only verbal contact with the patient while they are still conscious, or with bystanders that witnessed the incident, or family members/health aides that can give vitally important information on the patient’s condition. If an EMT is not adept at critical listening, vital information may be lost, and the repercussions can be serious. This project was designed to determine whether EMT student critical listening ability and class performance would improve from engaging in critical listening exercises.Methods: Critical listening exercises were emphasized during an EMT course by assessing student knowledge of the Patient Assessment module through two listening exercises modelled after the Ferrari, Lynch, and Vogel Listening Test that measures for critical listening skills. The Patient Assessment module was assessed twice within four weeks in a test-retest design.Results: The data analysis of a total of n = 51 students’ performance in the pre and post-assessments yielded positive results and showed students significantly improved their listening ability within the four-week period. An overall score increase of 34.50 % was found between the pre and the post assessment results. Moreover, the data analysis showed that as the result of the listening exercises, students scored significantly higher in the section of the certifying exam that included critical listening exercises than in all other sections.Conclusion: The results suggest performing critical listening exercises and assessments can help EMT students properly develop critical listening skills and improve performance
Defining mentorship in prehospital care: a qualitative analysis of the characteristics of prehospital mentors
No full textIntroduction: This study sought to begin to define the current understanding of the term mentor within the prehospital environment (emergency medical services or EMS) as described by nomination letters written by mentees for a newly launched prehospital mentor award.Methods: A new paramedic mentor award was created in the fall of 2015 to recognize outstanding mentors in prehospital care. In the spring of 2016, nineteen nomination letters were received from registered prehospital professionals detailing why their mentor should receive the mentor award. Written text from the nominations for this peer nominated award were analyzed using thematic and content analysis (n=19) to identify the current understanding of mentorship within emergency medical services, desirable qualities of prehospital mentors, and what a successful mentoring relationship looks like in the prehospital environment from the perspective of mentees. Results: Mentees and nominated mentors had varying years of experience, worked in diverse practice areas within prehospital care and represented varying scopes of practice. Three themes were identified from thematic analysis of the nomination letters 1) nominators seek to emulate their mentors, 2) mentors create a safe and nurturing environment, and 3) mentors act as advocates. In addition, content analysis was used to identify a number of desirable professional and personal traits of prehospital mentors.Conclusion: This study describes the qualities of prehospital mentors and identifies a number of common elements in a successful mentoring relationship (from the perspective of the mentee). These results highlight exceptional mentoring that is already occurring within the prehospital care environment. This research has the potential to provide guidance to those who aim to support both formal and informal mentoring within the prehospital care environment
Clinical presentations and practitioner levels appropriate for the introduction of ‘Treat and Referral’ into the Irish Emergency Medical Service: a survey of consultants in emergency medicine.
Full text linkObjectives: Overcrowding in emergency departments (EDs) is an international issue and ambulance bypass is seen as one element of the solution to a complex problem. Irish EDs are not immune to this healthcare crisis, which, together with increased off-load delays for ambulances, is one catalyst for the introduction of Treat and Referral (paramedic non-ED disposition decision). The confidence of consultants in emergency medicine in paramedics and advanced paramedics offering Treat and Referral to patients presenting with hypoglycaemia or seizure was explored. Other specific clinical presentations were also investigated for suitability for Treat and Referral and a consensus was sought on an upper age limit for such patients. Methods: Public-sector consultants in emergency medicine in Ireland at the time of the study, were invited to complete an online survey. A 62% response was received from the targeted population. Results: Confidence was expressed in advanced paramedics offering Treat and Referral to patients with hypoglycaemia or seizure by the majority (78%) of respondents. However, confidence was reduced for paramedics (53%). Six of the twelve specific clinical presentations received clear support as suitable for Treat and Referral, with the remaining receiving reducing support and ‘falls in the elderly (without injury)’ was opposed. There was no consensus on an upper age limit for patients being offered Treat and Referral. Conclusions: Support for the highest level of EMS practitioner in Ireland, advanced paramedic, to expand their scope of practice to include Treat and Referral was identified. Clinical presentations have been identified that would be conducive to a Treat and Referral clinical care pathway. A trial implementation period may be essential to build confidence in the programme before a universal roll out
The influence of paramedic qualification level on the administration of analgesia in the prehospital setting
Full text linkBackgroundUndertreatment of pain has been reported in the paramedic literature, and reasons for these disparities are not well understood.AimsAs the qualification level of the paramedic may affect analgesia administration, the primary aim of this study was to determine the impact of paramedic qualification on the provision of any analgesia for patients reporting pain.MethodsRetrospective study of de-identified patient care records from one Australian ambulance service over a period of 6 months. Inclusion criteria were age was > 17 years, initial pain severity score was > 3/10 and Glasgow Coma Score >13. Data were descriptively analysed for analgesia administration and type of analgesic by predictor variables: age, sex, pain score and case nature. Pearson’s chi-square test was used to test for associations between the outcome of interest and predictor variables. Adjusted logged odds of patients receiving analgesia was tested with binomial logistic regression.Findings3173 patient records met the inclusion criteria. ICP treated 86% of the sample population. Of those treated by an AP, 76.2% (n=340) received analgesia, whereas 71.6% (n=1952) of patients treated by an ICP received analgesia (p=0.042). Methoxyflurane was the most frequently administered analgesic, with 39.9% of the patients (n=1,264) receiving this agent; 31.1% of patients (n=988) received morphine, and 14.2% (n=452) received fentanyl. The unadjusted regression model found that AP have higher odds of administering analgesia than ICP paramedics (OR 1.264, p <0.05). However, once other covariates are included in the logistic regression, the significance no longer exists.ConclusionParamedic qualification is not associated with the administration of analgesia in this setting. This study contributes to the gap in knowledge regarding disparities in analgesia for adults experiencing pain and may inform future research that aims to identify and reduce barriers to appropriate pain management in the paramedic practice setting
Paramedic students working in snow resort medical clinics: a non-traditional interprofessional clinical placement model
Full text linkThis study investigates the experiences of undergraduate paramedic students completing interprofessional clinical placements in snow sport injury clinics. Qualitative methods were used to investigate the experiences of participants (n=6) undertaking non-traditional ambulance clinical placements as part of a multidisciplinary healthcare team. Ethical approval was obtained through Queensland University of Technology, Brisbane Australia. Data were collected via individual face-to-face interviews and analysed using holistic and focused coding. The analysed results indicated the presence of three main categories, namely Pre-Placement, Intra-Placement and Post-Placement phases. As it was a new placement, student capabilities were not initially known by clinic staff. Nevertheless the workplace culture was inclusive and supportive, and paramedic skills were applicable in the clinic environment. Despite the placement costs being excessive, participants viewed it as an investment in their future careers. Benefits of the placement included perceived improvement in maturity levels, the acquisition of professional networks, an understanding of interprofessional practice and an exposure to clinical skills not normally practiced during traditional ambulance placements. The interprofessional clinical placement appears to be a valid alternative to traditional ambulance placements. However, using this model to replace mainstream placements is problematic due to the costs involved, the limited number of spots available and the seasonal occurrence of snow sports.
Wellbeing Series: The patient is ready for you…but are you ready for the patient? The health status of paramedics and its effect on job performance.
Full text linkIn this wellbeing series we present practical advice for prehospital care providers, responders, and other shift workers. These articles are produced by experts in their field. Many of these topics were presented at the Irish College of Paramedics Wellbeing Symposium in University College Cork in May 2019