Ambulance Crews Research Articles

Prehospital thrombolysis for STEMI where PPCI delays are unavoidable

Background: Primary percutaneous coronary intervention (PPCI) is the gold standard for treating patients experiencing ST-elevation acute myocardial infarction (STEMI). More than 30 000 patients experience cardiac arrest out of a hospital setting in the UK every year and may be some distance from a PPCI facility. Aims: To analyse and consider if a better outcome could be achieved for patients if PPCI was an adjunct to thrombolytic therapy, where delays of ≥60 minutes are inevitable or unavoidable. Methods: The current review examined a range of articles, research materials and databases. Results: Some studies suggested the use of prehospital thrombolysis while others compared the effectiveness of drug-eluting stents. While the ‘gold standard’ for the treatment of patients experiencing a myocardial infarction is still PPCI, several factors can delay patients from receiving this treatment at an appropriate facility within the recommended time frame. Conclusion: Patients may not be able to access PPCI within 60, 90 or 120 minutes for reasons including increasing urbanisation, population growth and NHS hospital funding cuts. If the PPCI unit is some distance away, ambulance crews could start thrombolysis treatment and transmit clinical findings to a specialist cardiologist in the PPCI facility, or stop at a local hospital that could provide thrombolysis.

JoshSeim2020: Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Urban Suffering. Oakland, CA: University of California Press

JoshSeim2020: Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Urban Suffering. Oakland, CA: University of California Press

Respecting an autonomous decision to refuse life-saving treatment: a case study

Background: Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights. Case presentation: An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP. Conclusions: Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.

MEDICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF PROXIMAL FEMUR FRACTURES IN CITY OF KHARKIV AND KHARKIV REGION POPULATION

Regional clinical and epidemiological characteristics of the patients with the proximal femur fractures have been determined. To perform the research, the following tasks were solved: to establish the prevalence of fractures of the proximal femur depending on age and sex characteristics, place of residence, lesion, features of admission to the clinic, mechanisms of referral, timing of admission, concomitant pathology and comorbid burden, functional level, type of fracture and treatment tactics. The regional epidemiological characteristics of patients with these fractures were retrospectively studied using the date of seven medical institutions of the city of Kharkiv during 2011−2016. The predominance of women with a total average age of all the patients of 70.36±0.20 years and the one of the contingent of the patients aged 71−80 years and older 80 years and older were found. There was a significant prevalence of urban dwellers among the patients. The predominance of patients admitted to trauma departments by ambulance crews was determined. It was stated that the vast majority of respondents received medical care in the first 6 hours after injury. A significant proportion of comorbidly burdened patients with a predominance of the patients with one or two concomitant diseases was identified. Almost identical injuries of both the right and left extremities with a significant predominance of closed fractures and those of type 31A1 and 31B1 according to the classification of the Society for the Study of Osteosynthesis. A certain decrease in functional status was determined according to the classification of the American Society of Anesthesiologists. Conservative treatment was used more often than surgical treatment. Key words: proximal femur fractures, clinical and epidemiological characteristics, concomitant pathology, comorbid burden, age−sexual characteristics, functional status.

Treatment process differences with and without an ambulance offload zone

In this paper we compare the emergency department (ED) treatment processes which occur when an Ambulance Offload Zone (OZ) is functioning and when it is not. An OZ is a monitored waiting space for ambulance patients which is designed to allow ambulance crews to return to service more quickly. The implementation of OZ style concepts has been trialled around the world with mixed results. In this paper we use concurrent comparison data and show how treatment processes and the behaviour of ED actors change when the OZ is functioning. We discuss how these changes in behaviour impact the effectiveness of the OZ.

Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance

BackgroundUK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme.MethodsThis was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality.ResultsOlder individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14–5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58–3.65).ConclusionsDespite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care.

Accessible communication in the transport of non-urgent people with communication impairments

Abstract Introduction Paramedics may find innumerous circumstances that require careful consideration of the patient’s clinical condition. Because of that, communication between paramedics and patients in a critical condition must be as clear and effective as possible. Objectives This study aims to identify the communicative needs of ambulance’s crew members when transporting non-urgent people with communicative impairments and to create a tool that facilitates the communicative process. Methodology A brainstorming was held at Associação de São Jorge to gather information regarding the needs and difficulties experienced by the ambulance’s crew members. An audio record of this meeting was collected and a qualitative analysis was carried out. Additionally, a questionnaire was fulfilled. Based on these results, a first version of the communicative tool was developed. A pluridisciplinary focus group was held to discuss it, regarding content, form and utility. After this focus group, the second version of the communicative tool was elaborated to be tested by the crew members of this association. As so, a dynamic of three hours was implemented to empower these professionals to use this tool and other communicative strategies. Results The qualitative analysis of the first meeting collected data recognize as crew member’s needs: communicating basic and immediate needs at clinical level and at colloquial discourse. This data allowed to establish parameters for the construction of the first version of the communicative tool. The referred focus group identified the need to improve it, considering: format, content and also the need to complement this tool with other communicative facilitators (e.g. braille; gestures). Conclusion This study shows the need of facilitating the communication in non-urgent transportation. Despite the modifications that have to be done, the communicative tool that was developed already shows a positive impact in the ambulance crew and in the community.

BİR ÜNİVERSİTE HASTANESİ ACİL SERVİSİNE 112 İLE BAŞVURAN HASTALARIN ANALİZİ

INTRODUCTION: In Turkey, emergency diseases, natural disasters, accidents and injuries are frequently experienced and the number of patients per 112 emergency service station is increasing over years. Therefore, development and organization of the emergency healthcare services is a crucial issue. In this study, we aimed to examine the patients brought to emergency department by 112 Emergency Services, and to evaluate effect of demographic features of the presenting patients on the emergency service intensity of 112 ambulances when future planning of is made for emergency departments.MATERIAL & METHODS : This study is a cross-sectional study, and study population consisted of the persons brought to the emergency department (ED) of the XX University Hospital by 112 ambulance. Patients’ data were obtained from 112 emergency department ambulance form and hospital system. Sample of the study consisted of 1066 persons with complete data and who accepted to participate to the study. Data of the study were collected with a data collection form. Data were evaluated using SPSS statistical software. Descriptive statistics are expressed as median (min. – max.), mean ± standard deviation, frequency, and percentage. Analytic statistical analysis was performed using Kolmogorov Smirnov test, Chi-square test, Student’s t test, and Spearman correlation analysis. p< 0.05 values were considered statistically significant.RESULTS: 1066 persons included in the study, 52.3% were male and 47.7% were female. Median age was 52.0 (1.0–112.0). 44.3% of all patients were brought within working hours (09:01–16:00) The patients were most commonly brought on Saturday (15.4%). Of all patients, 0.4% were intubated and intravenous access was opened in 87.5% patients by 112 teams. Vital findings were examined in all patients. According to the preliminary diagnosis of 112 emergency ambulances, the most frequent patient group which brought by 112 ambulance was trauma patients (n=335,%31.44), second frequent group was cardiovascular system emergencies (n=169,% 15.9). There was a statistically significant, strong positive correlation between presumed diagnoses by 112, and definitive diagnoses decided after evaluation in the ED (r=0.621, p<0.001). 67.9% (n = 724) of the patients who were brought to the emergency department by 112 emergency ambulance were discharged after the first evaluation. CONCLUSION: The majority of the patients who brought by the 112 emergency ambulance were discharged. This suggests that 112 emergency ambulances are unnecessarily used. This problem can be solved by making the society aware of this issue. If it is considered that the most common diagnosis is trauma in patients who brought by 112 emergency ambulances, planning to increase the knowledge and experience of 112 emergency ambulance crew on prehospital trauma can be a good idea. While staffing the emergency services, appropriate planning can be made by considering the hours when 112 emergency ambulances are most frequently applied. The bed capacities of the departments where the most frequent service and intensive care hospitalizations are made should be observed.

COVID-19: long-term effects on the community response to cardiac arrest?

COVID-19: long-term effects on the community response to cardiac arrest?

Self assessment

A 2-year-old girl was brought to the Emergency Department (ED) by ambulance. The child had been found unconscious and covered in vomitus by the ambulance crew. She was reported to be well that morning. She is known to social services, and there is a history of maternal drug abuse and depression. On arrival to ED her heart rate was 80 beats per minute, respiratory rate 12 per minute, saturation was 96%, BP: 96/66 mmHg. Her GCS was 5/15 and pupils were equal and constricted.1.What is the most likely drug overdose responsible for her clinical condition?a)Fluoxetineb)Opioid intoxicationc)Tricyclic antidepressant intoxicationd)Paracetamol2.Given her clinical condition which TWO are the most important initial investigations?a)Chest X-rayb)Capillary blood gasc)Urine toxicologyd)ECGe)Blood culturef)Blood glucose

Viewpoint: What's the NEWS? Supporting the identification of the deteriorating patient.

Surgery to stabilise my spine sorted the pain and power was restored to my leg. I was re-admitted feeling vaguely unwell and with a CRP of 600, but that had returned to normal and I arrived home, admittedly with a PICC line in place, but relishing the peace and the contrast to a busy Nightingale Ward. A few hours later I was deeply asleep, but suddenly woke with a profound feeling of doom. My husband called 999 saying something had happened but I was not making sense. Within minutes an ambulance crew were running into our house and, blue lights flashing, I was transferred to hospital. I remember doors swinging as the F1 ran onto the ward, but this was followed by a very disjointed conversation when I kept saying ‘I feel really, really ill’ and …

The paramedic profession: disruptive innovation and barriers to further progress

The paramedic profession in the UK evolved from a small number of pilot programmes in the early 1970s that focused on training selected NHS ambulance crews in advanced resuscitation techniques. Similar initiatives occurred almost simultaneously in the United States, Australia, New Zealand and Canada. This case study focuses primarily on the UK, and England in particular. The purpose of the initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity and became fully professionally recognised and regulated as allied health professionals, becoming an example of the phenomenon termed ‘disruptive Innovation’; this is something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in NHS ambulance services which, in comparison, have lagged behind and also failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, and hampered these practitioners' ability to make full use of their skills. The consequence of this has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover. Parallel developments in medical personnel deployment have increased the quantity of medical labour available to patients with serious or life-threatening injuries, with medical staff added to helicopter emergency medical crews. While many patients with urgent conditions would have benefited from general practitioners being available out of hours, proportionally fewer doctors are available to fulfil this role today and those that are attracted to working with the ambulance service often prefer to respond to cases involving major injury. For these reasons and given the reality that the ambulance service is morphing into primarily an urgent care organisation, de-emphasising the transport aspect of the service, changes are needed to its model of operation and to staff management and support.

MAIN ASPECTS OF BRUGADA SYNDROME

To date, there is a sufficient amount of data on the nature of diseases associated with the risk of sudden death. It is shown that many of them are genetically determined, and this is particularly dangerous, since not only the patient who has been diagnosed with the disease, but also his children and close relatives are at risk. Such diseases are rarely detected in normal clinical practice, and patients die, as a rule, not in specialized hospitals, but at home or on the street, and the doctor of the polyclinic or the ambulance crew remains to state the death. Cardiologists often pay attention only to the first symptoms of the disease, primarily syncope and palpitations, but also often the first and last manifestation of the disease is sudden death. Modern clinical medicine identifies a number of diseases and syndromes that are closely associated with a high risk of sudden death at a young age. These include one of the most «mysterious» diseases — Brugada syndrome (SB).

Robust ambulance base allocation strategy with social media and traffic congestion information

At present, traffic congestion has become a major problem in many metropolitan areas globally, affecting the economy and social conditions in these areas. Of special concern, the response time of ambulances has increased, causing the death or disability of patients during emergencies. Various ambulance allocation strategies have been developed to locate a base that can achieve coverage of the demand point within a prescribed time or distance frame. However, real-time ambulance deployment is required to determine the number of ambulance and their bases. In particular, the dynamic relocation of an ambulance base is complicated, and each relocation does not guarantee that the next period will change again, thus increasing the workloads of the ambulance crew and potentially reducing their capability of responding to an emergency call. Furthermore, these models only considered covering all demand points but lacked the ability to consider uncertain factors, such as traffic congestion, patient conditions, public events, and population movement. Therefore, this study focused on formulating a covering model based on traffic congestion from web-based services and social media analysis, using the Markov-chain traffic speed assignment to allocate ambulance bases and trade-off the number of ambulance facilities between the current period and next period while considering the number of ambulance vehicles. Moreover, the proposed model was demonstrated using a case study of Bangkok emergency medical services. According to the results, obtained through collecting data on social media and traffic speed, the average traveling time of an ambulance can be improved by more than 70% with the trade-off between different periods if several emergency calls are received.

Determinants of prehospital lactate in trauma patients: a retrospective cohort study

BackgroundPoint of care serum lactate measurement is emerging as an adjunct to prehospital clinical assessment and has the potential to guide triage and advanced treatment decision-making. In this study we aimed to assess which factors potentially affect prehospital lactate levels.MethodsWe performed a retrospective cohort study of all trauma patients attended by the Air Ambulance, Kent, Surrey & Sussex (AAKSS) between July 2017 and April 2018 in whom a pre-hospital lactate was measured. Lactate was measured before AAKSS treatments were commenced, but generally after prehospital treatment by ground ambulance crews was initiated. Primary endpoint of interest was the association of various patient- and treatment characteristics with prehospital lactate levels.ResultsDuring the study period, lactate was measured in 156 trauma patients. Median lactate was 3.0 [2.0–4.1] mmol/l. Patients with an elevated lactate more often had deranged indices of end organ perfusion- and oxygenation (shock index 0.80 [0.58–1.03] vs 0.61 [0.40–0.82], p < 0.001, SpO2 96 [89–100%] vs 98 [96–100%], p = 0.025). They more often suffered from head injuries (62% vs 41%, p = 0.008), and received less analgesia prior to arrival of the AAKSS team (51.6% vs 67.2%, p = 0.03). In multivariate analysis, indices of end organ perfusion- and oxygenation only explained 15% of the variation in lactate levels.ConclusionsPrehospital lactate levels are not solely associated with indices of end organ perfusion- and oxygenation. Injury type, treatments given on scene and many other (unmeasured) factors likely play an important role as well. This should be taken into account when lactate is used in clinical algorithms to guide prehospital triage or treatment.

Spotlight on Research

Early cooling of resuscitated patients improves neurological outcome, yet out-of-hospital initiation of cooling is uncommon for mainly practical reasons. This pilot study hypothesized that the use of burn cooling dressings in the out-ofhospital environment could initiate brain cooling at an earlier stage and potentially be of value. Burn dressings are readily available in most ambulance services so the method is easily adaptable for ambulance crews.

EFFICIENCY OF PRE-HOSPITAL DIAGNOSIS OF THE STROKE

Purpose of the study. To assess the quality of diagnosis cerebrovascular accident (CA) at the pre-hospital stage in patients brought to the regional vascular center. Material and methods. 2708 case histories of the emergency department and accompanying sheets of first aid in patients with a guiding diagnosis of CA and 973 medical records of impatient in the regional vascular center were analyzed. Results and conclusion. Of the 2708 patients admitted with a diagnosis of CA, 973 people were hospitalized. Among hospitalized patients, the diagnosis of stroke was confirmed in 96.5% of cases. The most frequent diseases that were mistakenly diagnosed as a stroke turned out to be: diabetes, traumatic brain injury and brain neoplasms, etc. Confirmation of the guiding diagnosis during self-circulation was 36.6%, when delivered by ambulance crews — 39.8%, air ambulance — 86.7% and by sanitary transport — 16.5% of cases.

Exceptional case of surgical treatment of huge inguinal hernia at the woman

Despite significant progress in a health care system the started cases of huge inguinal hernias still meet. For successful treatment of such patients objective diagnostics, preoperative preparation, the choice of suitable tactics of surgery and treatment in the postoperative period is important. The clinical case of treatment by not reducible huge inguinal hernia at the patient of 73 years is presented in article. The patient showed complaints to presence of the big sizes of the hernia in the bottom of a stomach limiting movement of the patient and self-service reducing quality of life. For the first time hernial protrusion in inguinal area has appeared in 2008 which gradually increased in sizes. Since 2015 I have noted the intensive growth of hernia. I didn’t ask for medical care. To clinic it is brought by an ambulance crew with the diagnosis of The Restrained Inguinal Hernia direction. At the time of survey data for infringement weren’t. After comprehensive examination to the patient surgery in volume has been executed: a gryzhesecheniye on the right, plasticity across Liechtenstein. The postoperative period proceeded without complications. The patient is written out for the 13th days after operation. Extremely exceptional clinical case, the choice of adequate stage-by-stage preoperative inspection and treatment, optimum surgical tactics and postoperative kuration is shown. The chosen approach led to prevention of development of a cascade of the complications including a compartment syndrome, to elimination of cosmetic defect and restoration of quality of life.

Ambulance crews allowed access to patient plans

Ambulance crews allowed access to patient plans

Ambulance crews allowed access to mental health crisis plans

Ambulance crews allowed access to mental health crisis plans