Advanced Life Support Paramedics Research Articles

Burnout among advanced life support paramedics in Johannesburg, South Africa

ObjectivesTo establish the prevalence of burnout among advanced life support (ALS) paramedics in Johannesburg, South Africa and assess the relationship between burnout and a number of demographic characteristics of the...

The pending loss of advanced life support paramedics in South Africa

Background In 2008 South Africa (SA) had 1631 registered advanced life support (ALS) paramedics to provide pre-hospital advanced life support care to a population of approximately 50 million. Compared to globally accepted ratios, the number of ALS paramedics in South Africa can be considered as grossly inadequate. This current shortage may be ascribed to migration. However, the extent and nature of this migration, the factors that have contributed to them leaving the country and the existence or effectiveness of implemented strategies that attempt to manage migration of SA ALS paramedic is not known for sure. Methods The study consisted of a two-phase mixed method descriptive survey. A subset of SA ALS paramedics made up the study population. Quantitative data (Phase One) was obtained from a web-based survey distributed to the accessible population (N=97). Thereafter, qualitative data (Phase Two) was gathered through in-depth interviews with selected information rich participants (n=10) also from within the accessible population. Through methodological triangulation, data from Phase One and Phase Two were integrated to obtain an in-depth understanding of South African ALS paramedic migration. In addition, the study investigated whether strategies that attempted to manage migration of SA ALS paramedics existed, and if they did, how effective have they been. Result Fifty-one of 97 (53%) ALS paramedics responded to the questionnaire in Phase One. Of those, 24 (47.1%) were found to be working inside South Africa, while 27 (52.9%) were working outside South Africa. Working conditions, physical security, and economic considerations were ranked as the top three major factors contributing to the decision or intended decision to migrate. Initiatives to manage the shortage of ALS paramedics in the public sector EMS do exist; however, it appears to be inadequate at its current rate of progress. Conclusion This study suggests that ALS paramedics in SA are leaving to find work outside the country because of working conditions, physical security, and economic considerations. The current measures to manage migration appear to be ineffective, indicating that new or additional strategies to manage migration of ALS paramedics in SA may be required.

Factors influencing the departure of South African advanced life support paramedics from pre-hospital operational practice

Abstract Objectives South Africa has a lack of advanced life support (ALS) paramedics in full-time operational practice within the pre-hospital and inter-hospital fields. This is due at least in part to the departure of experienced ALS paramedics from operational practice. It is therefore important to identify and understand the factors that cause this departure in order to positively alter them. Methods This study was a cross-sectional on-line survey conducted over 28 days. South African ALS paramedics were invited by e-mail to complete an on-line questionnaire consisting of 64 questions, including sections on demographics, reasons for leaving operational practice, current satisfaction levels and willingness to return to operations. Results Of 318 registered ALS paramedics with valid e-mail addresses, a response rate of 52% (166) was observed. Top respondent groups were whites, critical care assistants and those operational in Gauteng. The top five reasons for leaving operational practice were related to remuneration, a lack of control of workplace dynamics, inadequate opportunities for promotion, poor organisational communication and poor benefits. The paramedics' current, or post-operational, satisfaction levels (in earning, time, stress and career development) were higher than when operational. Sixty-five percent of respondents were willing to consider returning to operational practice if the above issues were addressed. Conclusion Whilst the job of an ALS paramedic is difficult and demanding, it was not operational factors that appeared to cause the majority of ALS paramedics to leave operational practice, but rather organisational and career-based factors. These factors should be addressed in order to improve job satisfaction, with the objective of retaining more operational paramedics for longer.

262: The Augmentation of Ambulance Crews With a Second Advanced Life Support Paramedic Enhances the Effectiveness of Out-of-Hospital Care for Patients With Potential Acute Coronary Syndromes

In the United States there is great variability as to whether emergency medical services staff one paramedic or 2 paramedics capable of advanced life support as part of ambulance crews. The objective of the study was to determine whether the augmentation of ambulance crews with a second paramedic capable of advanced life support care would reduce the times to accomplish critical out-of-hospital interventions in patients with acute chest pain presumed to be the result of acute coronary syndrome.

Derivation and evaluation of a termination of resuscitation clinical prediction rule for advanced life support providers

The primary aim was to derive a new termination of resuscitation (TOR) clinical prediction rule for advanced life support paramedics (ALS) and to measure both its pronouncement rate and diagnostic test characteristics. Secondary aims included measuring the test characteristics of a previously derived and published basic life support termination of resuscitation (BLS TOR) clinical prediction rule [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006;355(5):478-87] on the same cohort of patients for comparison purposes. Secondary data analysis of adult cardiac arrests treated by ALS in rural and urban EMS systems participating in the OPALS study (data extracted from Phase III). A previous study for a basic life support termination of resuscitation (BLS TOR) clinical prediction rule proposed Termination of Resuscitation if the patient had no return of spontaneous circulation (ROSC) before transport; no shock administered; EMS personnel did not witness the arrest [Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006;355(5):478-87]. Multivariable logistic regression was used to examine the relationship between these variables, additional Utstein variables, and the primary outcome of survival to hospital discharge. Diagnostic test characteristics were measured for both the ALS TOR and BLS TOR models on this derivation cohort. Four thousand six hundred and seventy-three cardiac arrest patients were included; 3098 (66%) were male, mean (S.D.) age 69 (15); 239 (5.1%; 95% CI 4.5-5.8) survived to hospital discharge; 3841 patients had no ROSC (82%) and of these only three survived (0.08%; 95% CI 0.02, 0.23). The final ALS TOR model associated with survival, included: ROSC (OR 260.9; 95% CI 96.3, 706.7), bystander witnessed (OR 2.0; 95% CI 1.3, 3.1), bystander CPR (OR 2.8; 95% CI 1.9, 4.1), EMS witnessed (OR 12.3; 95% CI 7.1, 21.3) and shock prior to transport (OR 6.4; 95% CI 4.1, 10.1). A new ALS TOR clinical prediction rule based on these variables was 100% sensitive (95% CI 99.9-100) for survival and had 100% negative predictive value (95% CI 99.9-100) for death. Under the ALS TOR clinical prediction rule, 30% of patients would be pronounced in the field. The BLS TOR clinical prediction rule, was 100% sensitive (95% CI 99.9, 100), had 100% negative predictive value (95% CI 99.9-100) and the field pronouncement rate was 48%. Cardiac arrest patients may be considered for prehospital ALS TOR when there is no ROSC prior to transport, no shock delivered, no bystander CPR and the arrest was not witnessed by bystanders or EMS. A single EMS termination clinical prediction rule for all levels of providers would be optimal for EMS systems to implement. Prospective evaluation of the ALS TOR clinical prediction rule in the hands of ALS providers will be required before implementation.

Managing “Real” Anesthesia Emergencies on Human Simulators

Managing “Real” Anesthesia Emergencies on Human Simulators

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Clinical Variables Associated with Mortality in Out‐of‐hospital Patients with Hemodynamically Significant Bradycardia

To estimate mortality rates and identify clinical variables associated with mortality among patients with hemodynamically unstable bradycardia in an urban emergency medical services (EMS) system. This was a retrospective study conducted in a large, urban EMS system. Adult non-cardiac arrest patients transported by advanced life support paramedics from March 1996 to February 1997 with a heart rate < or =60 beats/min and systolic blood pressure < or =90 mm Hg were included. Transcutaneous pacing was not available. Patients under age 18 years, pregnant, or presenting with vital signs absent were excluded from the study population. Multivariate analysis of the association of patient characteristics with 30-day mortality was conducted by using a Cox proportional hazards model. Of the 247 patients studied, 133 (53.9%) received a fluid bolus, 37 (15.0%) were treated with atropine, and 17 (6.9%) received dopamine. Fifty-one (20.7%) died in the 19-month follow-up period (15.6 per 100 person-years); 10.5% died on the same day, 15.8% within 30 days, and 17.8% within one year. Variables associated with 30-day mortality included wide QRS complex (adjusted risk ratio [RR] 2.6 [95% confidence interval (95% CI) = 1.3 to 5.2]), use of heart rate-lowering calcium channel blockers (adjusted RR 2.1 [95% CI = 1.0 to 4.7]), and paramedic assessment of lack of patient improvement over the course of the call (adjusted RR 0.2 [95% CI = 0.1 to 0.6]). Out-of-hospital patients with hemodynamically unstable bradycardia have a high mortality rate. A wide QRS complex and use of heart rate-lowering calcium channel blockers were associated with 30-day mortality.

Inter-observer agreement using the Canadian Emergency Department Triage and Acuity Scale

To determine the inter-observer agreement on triage assignment by first-time users with diverse training and background using the Canadian Emergency Department Triage and Acuity Scale (CTAS). Twenty emergency care providers (5 physicians, 5 nurses, 5 Basic Life Support paramedics and 5 Advanced Life Support paramedics) at a large urban teaching hospital participated in the study. Observers used the 5-level CTAS to independently assign triage levels for 42 case scenarios abstracted from actual emergency department patient presentations. Case scenarios consisted of vital signs, mode of arrival, presenting complaint and verbatim triage nursing notes. Participants were not given any specific training on the scale, although a detailed one-page summary was included with each questionnaire. Kappa values with quadratic weights were used to measure agreement for the study group as a whole and for each profession. For the 41 case scenarios analyzed, the overall agreement was significant (quadratic-weighted K = 0.77, 95% confidence interval, 0.76-0.78). For all observers, modal agreement within one triage level was 94.9%. Exact modal agreement was 63.4%. Agreement varied by triage level and was highest for Level I (most urgent). A reasonably high level of intra- and inter-professional agreement was also seen. Despite minimal experience with the CTAS, inter-observer agreement among emergency care providers with different backgrounds was significant.

Surgical cricothyroidotomy in trauma patients: analysis of its use by paramedics in the field.

To analyze the indications for and the success rate, complications, and neurologic outcomes of surgical cricothyroidotomy when performed in the field by ambulance paramedics. The ambulance and hospital records of all trauma patients on whom a surgical cricothyroidotomy was attempted in the field by ambulance paramedics over a 5-year period were reviewed. A telephone survey of survivors was used to assess long-term complications and neurologic outcome. Surgical cricothyroidotomy was attempted on 50 patients, or 9.8% of those requiring definitive airway control. The most common indications were clenched teeth, blood or vomit obscuring visualization of the upper airway, severe maxillofacial injuries, and inaccessibility because the patient was trapped. Airway establishment was successful in 47 patients (94%). Major complications occurred in 2 patients (4%), where inadvertent dislodgement of the tube developed, requiring replacement. No patient developed significant subglottic stenosis. Nineteen patients (38%) survived and no patient died because of an inadequate airway. Evaluation of neurologic outcome revealed 12 patients (63%) with no significant deficits, 3 (16%) with moderate disability, 2 (10%) with severe disability, and only 2 in a persistent vegetative state. Surgical cricothyroidotomy can be performed on the critically injured patient in the field by ambulance paramedics with a high success rate and a low complication rate. The use of surgical cricothyroidotomy should be included in airway protocols for well-trained, ambulance Advanced Life Support paramedics.