Advanced Life Support Paramedics Research Articles

The neonatal transfer process through the lens of neonatologists at public hospitals in South Africa.

BackgroundNeonatal care is provided by various levels of healthcare facilities in South Africa. Intensive care for neonates is only provided at the higher levels, hence the need for transfers from lower-level to higher-level facilities (e.g. primary hospitals to tertiary hospitals) or across levels of facilities, particularly when life-threatening situations arise (e.g. cardiac deterioration, respiratory deterioration and desaturation).AimThe aim of the study was to explore neonatologists’ views regarding the neonatal transfer process and to describe the preparedness of advanced life support (ALS) paramedics to undertake such transfers.SettingThe setting consisted of neonatologists from three provinces i.e. KwaZulu-Natal, Gauteng and Western cape.MethodA qualitative descriptive design was utilised in this study. Semistructured interviews were conducted on the public health hospitals in three provinces (N = 9; n = 3) with neonatologists (N = 7; n = 7) who were involved in the transfers of critically ill neonates. The process of thematic analysis was used.ResultsThe themes that emerged in this study were: an awareness of local contextual realities related to neonatal transfers, challenges evident within the context of neonatal transfers, decision-making around the transfer of ill neonates, ALS paramedic preparedness for transfers and good clinical governanceConclusionThe study found that there was a need to be aware of local contextual realities confronting neonatal transfers, a need for greater preparedness for paramedics to undertake these transfers, a need for a sound referral processes and a need for coordinated transfer effort between paramedics, hospital staff and transport team members for the successful transfer of critically ill neonates.ContributionThe findings highlight the challenges confronting the neonatal transfer process in South Africa through the lens of neonatologist at public hospitals. Hence, the study reinforces the preparedness and coordination of the transfer process, along with more efficient communication between paramedics, hospital staff and the transfer team.

An exploratory study on the preparedness of advanced life support paramedics for the neonatal transfer process

An exploratory study on the preparedness of advanced life support paramedics for the neonatal transfer process

The neonatal transfer process through the lens of neonatologists at public hospitals in South Africa

Background: Neonatal care is provided by various levels of healthcare facilities in South Africa. Intensive care for neonates is only provided at the higher levels, hence the need for transfers from lower-level to higher-level facilities (e.g. primary hospitals to tertiary hospitals) or across levels of facilities, particularly when life-threatening situations arise (e.g. cardiac deterioration, respiratory deterioration and desaturation). Aim: The aim of the study was to explore neonatologists’ views regarding the neonatal transfer process and to describe the preparedness of advanced life support (ALS) paramedics to undertake such transfers. Setting: The setting consisted of neonatologists from three provinces i.e. KwaZulu-Natal, Gauteng and Western cape. Method: A qualitative descriptive design was utilised in this study. Semistructured interviews were conducted on the public health hospitals in three provinces ( N = 9; n = 3) with neonatologists ( N = 7; n = 7) who were involved in the transfers of critically ill neonates. The process of thematic analysis was used. Results: The themes that emerged in this study were: an awareness of local contextual realities related to neonatal transfers, challenges evident within the context of neonatal transfers, decision-making around the transfer of ill neonates, ALS paramedic preparedness for transfers and good clinical governance Conclusion: The study found that there was a need to be aware of local contextual realities confronting neonatal transfers, a need for greater preparedness for paramedics to undertake these transfers, a need for a sound referral processes and a need for coordinated transfer effort between paramedics, hospital staff and transport team members for the successful transfer of critically ill neonates. Contribution: The findings highlight the challenges confronting the neonatal transfer process in South Africa through the lens of neonatologist at public hospitals. Hence, the study reinforces the preparedness and coordination of the transfer process, along with more efficient communication between paramedics, hospital staff and the transfer team.

An exploratory study of the experiences and challenges faced by advanced life support paramedics in the milieu of neonatal transfers.

BackgroundThe safe transfer of critically ill neonates is important for their survival. This calls for greater preparedness on the part of paramedics to effect these transfers safely.AimTo understand the experiences and the challenges faced by advanced life support (ALS) paramedics during neonatal transfers.SettingThe study setting consisted of advanced life support paramedics from urban and rural areas in KwaZulu-Natal. It comprised of a network of district hospitals as well air and ground transfer facilities, both public and private.MethodUsing a qualitative research approach, the study sought the views of ALS paramedics who were involved in neonatal transfers in KwaZulu-Natal. A purposive sample of n = 8 ALS paramedics was selected. Data were collected using in-depth semi-structured interviews. The data were analysed through the process of thematic analysis.ResultsThe study found that paramedics faced multiple complex challenges related to neonatal transfers. Poor pre-transfer preparation of the neonate, equipment related challenges, lack of clinical support available during transfers and pressure to effect inappropriate transfers were some of the challenges they faced. These challenges coupled with insufficient education and the lack of sub-speciality programmes to capacitate, rendered them unprepared to deal with neonatal transfers effectively.ConclusionEmergency medicine needs to provide greater attention towards preparing all stakeholders for successful neonatal transfers.ContributionThe findings provide recommendations for a programme that will limit risks involved with, and support the inter-healthcare facility transfer of critically ill neonates in South Africa.

Higher resuscitation guideline adherence in paramedics with use of real-time ventilation feedback during simulated out-of-hospital cardiac arrest: A randomised controlled trial

ObjectivesTo investigate whether real-time ventilation feedback would improve provider adherence to ventilation guidelines. DesignNon-blinded randomised controlled simulation trial. SettingOne Emergency Medical Service trust in Copenhagen. Participants32 ambulance crews consisting of 64 on-duty basic or advanced life support paramedics from Copenhagen Emergency Medical Service. InterventionParticipant exposure to real-time ventilation feedback during simulated out-of-hospital cardiac arrest. Main outcome measuresThe primary outcome was ventilation quality, defined as ventilation guideline-adherence to ventilation rate (8–10 bpm) and tidal volume (500−600 ml) delivered simultaneously. ResultsThe intervention group performed ventilations in adherence with ventilation guideline recommendations for 75.3% (Interquartile range (IQR) 66.2%–82.9%) of delivered ventilations, compared to 22.1% (IQR 0%–44.0%) provided by the control group. When controlling for participant covariates, adherence to ventilation guidelines was 44.7% higher in participants receiving ventilation feedback. Analysed separately, the intervention group performed a ventilation guideline-compliant rate in 97.4% (IQR 97.1%–100%) of delivered ventilations, versus 66.7% (IQR 40.9%–77.9%) for the control group. For tidal volume compliance, the intervention group reached 77.5% (IQR 64.9%–83.8%) of ventilations within target compared to 53.4% (IQR 8.4%–66.7%) delivered by the control group. ConclusionsReal-time ventilation feedback increased guideline compliance for both ventilation rate and tidal volume (combined and as individual parameters) in a simulated OHCA setting. Real-time feedback has the potential to improve manual ventilation quality and may allow providers to avoid harmful hyperventilation.

Towards a Safer and More Efficient Neonatal Transfer System in South Africa: A Qualitative Inquiry with Advanced Life Support Paramedics

Introduction The inter-healthcare transfer of the critically ill neonate is a critical aspect of larger neonatal intensive care, as it influences the safe transport of neonates from the receiving to the referring hospital. It is crucial then that the transfer process be safe and efficient so as not to compromise the already fragile condition of the neonate. The aim of the study was to understand the challenges advanced life support (ALS) paramedics face during neonatal transfers and to understand how the process could be made safer and more efficient. The objectives related to understanding the transfer process, the challenges linked to the critically ill neonate and the difficulties associated with the ambulance vehicle and equipment. Methods Using a qualitative research approach we sought the views of ALS paramedics at the forefront of transfers nationally. In-depth interviews were held with eight paramedics in KwaZulu-Natal and four focus group discussions with ALS paramedics in KwaZulu-Natal, Gauteng, Free State and the Western Cape in South Africa. A total of 35 ALS paramedics were involved in these group discussions. Results The study uncovered several challenges that paramedics face related to poor organisational preparation for transfer of the critically ill neonate, and other crucial issues that compromise the transfer such as inadequate or defective equipment. Conclusion There is a need for greater scrutiny of the transfer process and a commitment from stakeholders to begin addressing the challenges confronting the safe transfer of critically ill neonates.

An analysis of the descriptors of acute myocardial infarction used by South Africans when calling for an ambulance from a private emergency call centre.

IntroductionAcute myocardial infarction (AMI) is a time sensitive emergency. In resource limited settings, prompt identification and management of patients experiencing AMI in the pre-hospital setting may minimise the negative consequences associated with overburdened emergency medical and hospital services. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in call centres is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI.MethodsIn this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an advanced life support (ALS) paramedic-diagnosed AMI. Using the unique case reference number of randomly selected AMI cases, original voice recordings between the caller and emergency medical dispatcher at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified.ResultsOf the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors used by callers were found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n = 16; 23.2%), followed by the code describing pain in the chest (n = 15; 21.7%).ConclusionSouth African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non-pain descriptors related to the heart. These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the unnecessary dispatch of limitedly available ALS paramedics to inappropriate cases.

The effect of prehospital critical care on survival following out-of-hospital cardiac arrest: A prospective observational study

AimTo examine the effect of prehospital critical care on survival following OHCA, compared to routine advanced life support (ALS) care. MethodsWe undertook a prospective multi-centre cohort study including two ambulance services and six prehospital critical care services in the United Kingdom (UK), between September 2016 and October 2017. Inclusion criteria were adult patients with non-traumatic OHCA treated by either prehospital critical care teams or ALS paramedics. Patients who received prehospital critical care were matched to those receiving ALS using propensity score matching. Primary outcome was survival to hospital discharge; secondary outcome was survival to hospital admission. ResultsThe primary analysis included 658 patients with OHCA receiving prehospital critical care and 1847 patients receiving ALS care. Rates of survival to hospital discharge (primary outcome) were 11.9% in both groups; rates of survival to hospital admission (secondary outcome) were 34.4% and 27.7% in the prehospital critical care and ALS group, respectively. The corresponding odds ratios for survival to hospital discharge and survival to hospital admission with prehospital critical care were 1.06 (95% confidence interval 0.75–1.49) and 1.39 (95% confidence interval 1.10–1.75), respectively. Results were consistent across subgroups and sensitivity analyses. ConclusionsDespite a positive association with the secondary outcome of survival to hospital admission, prehospital critical care was not associated with increased rates of survival to hospital discharge following OHCA.

Perspectives of advanced life support paramedics on clinical simulation for summative assessment in South Africa: Is it time for change?

Background. The Professional Board for Emergency Care (PBEC), the statutory body regulating the quality of emergency care education programmes in South Africa, has mandated these programmes to use integrated clinical simulation as an instrument for authentic assessment. In support of the validity of this instrument, actions by students during simulation are assumed to replicate what they would do in similar circumstances in practice. Objectives. To present and discuss perspectives of advanced life support (ALS) paramedics on the use of integrated clinical simulation as a summative assessment instrument, offer a critique of assumptions regarding the use of this assessment instrument, and recommend improvements for its use. Methods. A qualitative, single, embedded case study design was used to address assessment criteria and case types for integrated clinical simulation as a summative assessment instrument. Qualitative data were collected by means of focus group interviews. Perspectives of ALS paramedics emerged from the results of this study. Results. Participants agreed that integrated clinical simulation was an appropriate assessment instrument if assessment principles were adhered to. Accurate replication of the contextual elements of emergency care practice was perceived as central for eliciting authentic responses associated with ALS paramedic practice. The conditions, context and range of life-threatening conditions across medical disciplines challenged the idea that a single, once-off assessment event could be a valid reflection of competence. Conclusion. To elicit authentic responses, the design of integrated clinical simulation events for summative assessment should include relevant clinical, environmental and social-professional elements of ALS paramedic practice. More than one assessment should be done, and should address the range and complexity of medical and trauma emergencies, thereby assessing the true competence of ALS paramedic students. Assessors should acquire the requisite skills to assess simulation effectively.

Paediatric weight estimation practices of advanced life support providers in Johannesburg, South Africa.

IntroductionThe choice of weight estimation method to use during prehospital paediatric emergency care is important because it needs to be both accurate and easy to use. Accuracy is important to ensure optimum drug dosing while ease-of-use is important to minimise user errors and the cognitive load experienced by healthcare providers. Little is known about which weight estimation systems are used in the prehospital environment anywhere in the world. This knowledge is important because if the use of inappropriate weight estimation practices is identified, it could be remedied through education and institutional policies.MethodsThis was a prospective questionnaire study conducted in Johannesburg, South Africa, which obtained information on the knowledge, attitude and practice of weight estimation amongst advanced life support (ALS) paramedics.ResultsForty participants were enrolled, from both the public and private sectors. The participants’ preferred method of weight estimation was visual estimation (7/40; 18%), age-based formulas (16/40; 40%), parental estimation (3/40; 8%), the Broselow tape (2/40; 5%) and the PAWPER tape (11/40; 28%). No participant was familiar with or used the Mercy method. All participants were very confident in the accuracy of their selected system.DiscussionThe knowledge and understanding of weight estimation systems by many advanced life support paramedics was poor and the use of inappropriate weight estimation systems was common. Further education and intervention is needed in order to change the sub-optimal weight estimation practices of ALS paramedics in Johannesburg.

Impact of Expanding the Prehospital Stroke Bypass Time Window in a Large Geographic Region.

The Ontario Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) was revised to allow paramedics to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact and safety of implementing the Revised ASMRPP. We conducted a 12-month implementation study involving prehospital patients presenting with possible stroke symptoms. A total of 1317 basic and advanced life support paramedics, of 9 land services in 10 rural counties and 5 cities, used the Revised ASMRPP to take appropriate patients directly to 6 designated stroke centers. We enrolled 1277 patients with 98.8% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.1 (range 16-101), male 51.1%, mean time scene to hospital 16.7 minutes (range 0-92). Paramedics demonstrated excellent interobserver agreement (κ, 0.94; 95% confidence interval, 0.91-0.96) and 97.9% accuracy in interpretation of the Revised ASMRPP. Prehospital adverse events occurred in 14.7% of patients, but few were life-threatening. Overall, 71.4% of 755 cases had a stroke code activated at the hospital and 23.2% received thrombolysis. For the 189 potential stroke patients picked up in 1 city, the ASMRPP classified thrombolysis administration with sensitivity 100% and specificity 37.3% and a final diagnosis of stroke, with sensitivity 86.1% and specificity 41.9%. In a large urban-rural area with 9 paramedic services, we demonstrated accurate, safe, and effective implementation of the Revised ASMRPP. These revisions will allow more patients with stroke to benefit from early treatment.

ECMO retrieval: A case for Critical Care Paramedic integration into the team

ECMO retrieval: A case for Critical Care Paramedic integration into the team

A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town.

IntroductionEmergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.MethodsA retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.ResultsA total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66–74) cases, nitrates in 197 (37%, 95% CI 33–41) and ketamine in 9 (1.7%, 95% CI 1–3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70–79) cases, with the median dose being 4 mg (IQR 3–6). Single doses were administered to 268 (72.2%, 95% CI 67–77) morphine administrations, five (56%, 95% CI 21–86) ketamine administrations and 161 (82%, 95% CI 76–87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2–4).DiscussionPre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.

New Zealand Paramedics are Ready for An Autonomous Pre-Hospital Thrombolysis Protocol

Introduction Internationally, autonomous paramedic-delivered pre-hospital thrombolysis (PHT) administration for ST-elevation myocardial infarction patients has proven to be a highly effective strategy in facilitating expedited delivery of this treatment modality. However, current New Zealand models rely on physician authorised telemetry-based systems which have proved problematic, particularly due to technological failings. The aim of this study is to establish whether current paramedic education in New Zealand is sufficient for the introduction of an autonomous paramedic clinical decision-making model of PHT. Methods A one-hour workshop introduced a new PHT protocol to 81 self-selected paramedic participants – both rural and metropolitan based – from New Zealand. Paramedics were then tested in protocol application through completion of a scenario-based standardised written test. Four written scenarios constructed from actual field cases assessed 12-lead electrocardiogram interpretation, understanding of protocol inclusion/exclusion criteria, and treatment rationale. Ten multiple-choice questions further tested cardiac and pharmacology knowledge as well as protocol application. Results Overall clinical decision-making showed a sensitivity of 92.0% (95% CI: 84.8–96.5), and a specificity of 95.6% (95% CI: 89.1–98.8). Electrocardiogram misinterpretation was the most common error. University educated paramedics (n=44) were significantly better at clinical decision-making than in-house industry trained paramedics (n=37) (p=0.001), as were advanced life support paramedics (n=36) compared to paramedics of lesser practice levels (n=45) (p=0.006). Conclusion Our New Zealand paramedic sample demonstrated an overall clinical decision-making capacity sufficient to support the introduction of a new autonomous paramedic PHT protocol. Recent changes in paramedic education toward university degree programs are supported.

Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries.

Traumatic arrests have historically had poor survival rates. Identifying salvageable patients and ideal management is challenging. We aimed to (1) describe the management and outcomes of prehospital traumatic arrests; (2) determine regional variation in survival; and (3) identify Advanced Life Support (ALS) procedures associated with survival. This was a secondary analysis of cases from the Resuscitation Outcomes Consortium Epistry-Trauma and Prospective Observational Prehospital and Hospital Registry for Trauma (PROPHET) registries. Patients were included if they had a blunt or penetrating injury and received cardiopulmonary resuscitation. Logistic regression analyses were used to determine the association between ALS procedures and survival. We included 2,300 patients who were predominately young (Epistry mean [SD], 39 [20] years; PROPHET mean [SD], 40 [19] years), males (79%), injured by blunt trauma (Epistry, 68%; PROPHET, 67%), and treated by ALS paramedics (Epistry, 93%; PROPHET, 98%). A total of 145 patients (6.3%) survived to hospital discharge. More patients with blunt (Epistry, 8.3%; PROPHET, 6.5%) vs. penetrating injuries (Epistry, 4.6%; PROPHET, 2.7%) survived. Most survivors (81%) had vitals on emergency medical services arrival. Rates of survival varied significantly between the 12 study sites (p = 0.048) in the Epistry but not PROPHET (p = 0.14) registries.Patients in the PROPHET registry who received a supraglottic airway insertion or intubation experienced decreased odds of survival (adjusted OR, 0.27; 95% confidence interval, 0.08-0.93; and 0.37; 95% confidence interval, 0.17-0.78, respectively) compared to those receiving bag-mask ventilation. No other procedures were associated with survival. Survival from traumatic arrest may be higher than expected, particularly in blunt trauma and patients with vitals on emergency medical services arrival. Although limited by confounding and statistical power, no ALS procedures were associated with increased odds of survival. Prognostic study, level IV.

The impact of a pre-hospital critical care team on survival from out-of-hospital cardiac arrest.

To assess the impact of a pre-hospital critical care team (CCT) on survival from out-of-hospital cardiac arrest (OHCA). We undertook a retrospective observational study, comparing OHCA patients attended by advanced life support (ALS) paramedics with OHCA patients attended by ALS paramedics and a CCT between April 2011 and April 2013 in a single ambulance service in Southwest England. We used multiple logistic regression to control for an anticipated imbalance of prognostic factors between the groups. The primary outcome was survival to hospital discharge. All data were collected independently of the research. 1851 cases of OHCA were included in the analysis, of which 1686 received ALS paramedic treatment and 165 were attended by both ALS paramedics and a CCT. Unadjusted rates of survival to hospital discharge were significantly higher in the CCT group, compared to the ALS paramedic group (15.8% and 6.5%, respectively, p<0.001). After adjustment using multiple logistic regression, the effect of CCT treatment was no longer statistically significant (OR 1.54, 95% CI 0.89-2.67, p=0.13). Subgroup analysis of OHCA with first monitored rhythm of ventricular fibrillation or pulseless ventricular tachycardia showed similar results. Pre-hospital critical care for OHCA was not associated with significantly improved rates of survival to hospital discharge. These results are in keeping with previously published studies. Further research with a larger sample size is required to determine whether CCTs can improve outcome in OHCA.

The association between manual mode defibrillation, pre-shock pause duration and appropriate shock delivery when employed by basic life support paramedics during out-of-hospital cardiac arrest

BackgroundPre-shock pause duration of <20s is associated with improved survival after cardiac arrest. Manual mode defibrillation has been associated with the shortest duration of pre-shock pause but is largely practiced by advanced life support paramedics (ALS) whereas defibrillator only paramedics (basic life support or BLS) routinely use the defibrillator in automatic mode. ObjectiveWe sought to explore the relationship between manual mode defibrillation, pre-shock pause duration and rate of inappropriate shocks when defibrillation is provided by ALS vs. BLS trained in manual mode defibrillation. MethodsWe performed a retrospective review of all treated non-traumatic adult out-of-hospital cardiac arrest (OHCA) presenting in a shockable rhythm over a one year period beginning January 1, 2012. Our primary outcome measure was the proportion of manual mode shocks delivered by BLS with pre-shock pause duration of <20s when compared to ALS. Our secondary outcome measures were the duration of pre-, post- and peri-shock pause and the proportion of appropriate shocks (defined as correct identification and shock delivery to patients in a shockable rhythm) delivered by either level of paramedic. This study had a power of 90% to detect an absolute difference of 15% between paramedic levels in proportion of shocks delivered with pre-shock pause duration <20s. ResultsAmong 2019 treated OHCA, 335 (20%) presented in a shockable rhythm. Manual defibrillation was performed in 155 (46%) of these cases (196 shocks by ALS, 143 shocks by BLS). There were no differences in the proportion of shocks delivered with pre-shock pause duration <20s (ALS 82.8% vs. BLS 84.8%, p=.65) nor pre-shock pause duration (s) (median, Q1, Q3); ALS: 12.0 (7.0,17.0) vs. BLS: 11.0 (5.0,17.0), p=.13 while BLS had a significantly shorter peri-shock pause duration (s) (median, Q1, Q3); ALS: 17.0 (12.0, 23.0) vs. BLS: 15.0 (9.0, 22.0), p=.05. There were no differences in the rate of inappropriate shocks (ALS 1.0% vs. BLS 0.7%), p=1.0 between levels of paramedics. ConclusionsManual mode defibrillation by BLS paramedics produced similar measures of pre-shock pause duration when compared to ALS paramedics without increasing the incidence of inappropriate shocks. Further study is required to determine the potential impact of BLS manual mode defibrillation on clinical outcomes.

Feasibility of LMA Supreme for airway management in unconscious patients by ALS paramedics

BackgroundAirway management to ensure sufficient gas exchange is of major importance in emergency care. The accepted basic technique is to maintain an open airway and perform artificial ventilation in emergency situations is bag-valve mask (BVM) ventilation with manual airway management without airway adjuncts or with an oropharyngeal tube (OPA) only. Endotracheal intubation (ETI) is often referred to as the golden standard of airway management, but is associated with low success rates and significant insertion-related complications when performed by non-anaesthetists. Supraglottic devices (SADs) are one alternative to ETI in these situations, but there is limited evidence regarding the use of SAD in non-cardiac arrest situations. LMA Supreme (LMA-S) is a new SAD which theoretically has an advantage concerning the risk of aspiration due to an oesophageal inlet gastric tube port.MethodsForty paramedics were recruited to participate in the study. Adult (>18 years) patients, unconscious due to medical or traumatic cause with a GCS score corresponding to 3–5 and needed airway management were included in the study. Our aim was to study the feasibility of LMA-S as a primary airway method in unconscious patients by advanced life support (ALS) trained paramedics in prehospital care.ResultsThree regional Emergency Medical Service (EMS) services participated and 21 patients were treated during the survey. The LMA-S was placed correctly on the first attempt in all instances 21/21 (100%), with a median time to first ventilation of 9.8 s. Paramedics evaluated the insertion to be easy in every case 21/21 (100%). Because of air leak later in the patient care, the LMA-S was exchanged to an LT-D in two cases and to ETI in three cases (23.81%) by the paramedics. Regurgitation occurred after insertion two times out of 21 (9.52%) and in one of these cases (4.76%), paramedics reported regurgitation inside the LMA-S.ConclusionWe conclude that the LMA-S seems to be relatively easy and quick to insert in unconscious patients by paramedics. However, we found out that there were ventilation related problems with the LMA-S. Further studies are warranted.

Developing retention and return strategies for South African advanced life support paramedics: A qualitative study

There is a growing and dire shortage of advanced life support (ALS) paramedics in South Africa (SA). To further understand this phenomenon, a novel and comprehensive mixed method study was conducted. The study was undertaken in two Phases. In Phase One, the aim was to identify factors that influenced the migration and intended migration of ALS paramedics from SA. The aim of Phase Two was to provide, through consensus agreement, an expanded description of those factors, within the context of organisational policies and profession-guided beliefs. The findings of Phase One, published already, and Phase Two, presented in this study, were integrated to obtain an in-depth understanding of SA ALS paramedic migration. This understanding resulted in the development of steering principles, for a framework of strategies on how to retain or encourage the return of SA ALS paramedics. This article presents these steering principles, as well as the findings from Phase Two of the study. ALS paramedics who qualified between 2001 and 2006 made up the study population. In Phase Two, purposive sampling was used to choose a subsample of the study population. In-depth interviews were conducted with this subsample; data were recorded, transcribed verbatim, and analysed thematically using qualitative research techniques. Findings suggest that the success of retention and return strategies depends on the degree of collaborative stewardship that must exist between the SA National and Provincial Department of Health, the Emergency Medical Service/s (EMS) statutory governing body, training institutions, and private and public EMS providers. In addition, the constructs of return and retention strategies have to extend as far as revising both acceptance criteria and candidate recruitment policies. Furthermore, while particular attention must be placed on improving working conditions, security, and remuneration of ALS paramedics, return and retention strategies have to be continuously monitored, and updated. On observe une pénurie croissante et catastrophique de personnel paramédical spécialisé en soins avancés de réanimation en Afrique du Sud (AS). Pour mieux comprendre ce phénomène, une nouvelle étude approfondie faisant intervenir plusieurs méthodes a été conduite. Cette étude a été réalisée en deux phases. Au cours de la Phase un, l’objectif était d’identifier les facteurs influençant l’émigration et l’intention d’émigration du personnel paramédical spécialisé en soins avancés de réanimation en Afrique du Sud. L’objectif de la Phase deux était de proposer une description détaillée de ces facteurs, dans le contexte des politiques organisationnelles et des convictions propres à la profession. Les conclusions de la Phase un, déjà publiées, et de la Phase deux, présentées dans cette étude, ont été intégrées afin de mieux comprendre l’émigration du personnel paramédical sud-africain spécialisé en soins avancés de réanimation. Ceci a permis de développer des principes directeurs destinés à un cadre de stratégies de maintien en poste et de retour du personnel paramédical sud-africain spécialisé en soins avancés. Cet article présente ces principes directeurs, ainsi que les conclusions de la Phase deux de l’étude. Le personnel paramédical spécialisé en soins avancé de réanimation diplômé entre 2001 et 2006 constituait la population de l’étude. Des entretiens approfondis ont été menés auprès de ce sous-échantillon; les données ont été enregistrées, transcrites textuellement et analysées thématiquement à l’aide de techniques de recherche qualitatives. Selon les conclusions, la réussite des stratégies de maintien en poste et de retour dépend du degré de bonne gestion qui devrait exister entre le ministère de la Santé national et provincial en Afrique du Sud, l’organe directeur statutaire du ou des services de médecine d’urgence, les institutions de formation et les prestataires de services de médecine d’urgence privés et publics. En outre, les éléments des stratégies de maintien en poste et de retour doivent aller jusqu’à réviser les critères d’acceptation et les politiques de recrutement des candidats. De plus, s’il est nécessaire d’accorder une attention particulière à l’amélioration des conditions de travail, de la sécurité et de la rémunération du personnel paramédical spécialisé en soins avancé de réanimation, les stratégies de maintien en poste et de retour doivent être constamment contrôlées et mises à jour.

The impact of intense airway management training on paramedic knowledge and confidence measured before, immediately after and at 6 and 12 months after training

IntroductionAirway management is a core component in the practice of advanced life support (ALS) paramedics.ObjectiveTo determine if an intense airway management course would improve ALS paramedic knowledge and confidence and...