Critical Care Paramedics Research Articles

Measured task load in directed observers versus active participants undergoing high-fidelity simulation education in a critical care setting.

The use of directed observers in high-fidelity simulation education is increasingly common. While evidence suggests similar educational outcomes for directed observers compared to active participants in technical skills, it remains uncertain if this benefit also exists for senior clinicians, especially in mental workload. We sought to compare the workload between active participants and directed observers using an objective measure. We performed a prospective, repeated-measures observational study during the New South Wales Ambulance Aeromedical Operations induction training from 2019 to 2020. Participants included senior critical care doctors, paramedics, and nurses undergoing high-fidelity simulation of prehospital and interhospital aeromedical missions. Task load was measured using the National Aeronautics and Space Administration task load index (NASA-TLX) administered following each simulation debrief. Prehospital and interhospital simulations were compared separately by building a multilevel model for complete case and all study data. Post hoc comparisons of NASA-TLX score for each group were performed using estimated marginal means (EMMs). We enrolled 70 participants, comprising 49 physicians (70%), 19 paramedics (27%), and two flight nurses (3%). From the complete case analysis, statistically significant differences were observed for total NASA-TLX scores between active participants and directed observers in both prehospital (participant EMM 78, observer EMM 65, estimated difference -13, 95% confidence interval [CI] -20 to -7) and interhospital simulations (participant EMM 69, observer EMM 59, estimated difference -10, 95% CI -16 to -3). When all available data were included, the pattern of results did not change. In our sample of senior clinicians, the task load experienced by both active participants and directed observers in high-fidelity simulation education was high for both prehospital and interhospital simulation exercises. The statistically significant differences we report are unlikely to be practically significant. Our results support the use of directed observers when resource limitations do not allow all course attendees to participate in every simulation.

Air Medical Support for a Peripheral Hospital in Southern Israel: An Evolving Role for the Air Ambulance and Emergency Department Clinicians

The early use of helicopters on the battlefields of Korea and Vietnam led to the introduction of “air ambulances” into civilian practice. Initially, these aircraft were tasked to retrieve casualties and provide conventional paramedic care at the scene and en route to the hospital. The introduction of advanced medical teams on helicopters led to the evolution of helicopter emergency medical service units. Yoseftal Hospital is a 65-bed hospital serving the town of Eilat in southern Israel. It does not offer full intensive care or specialist services but does provide general surgical, medical, pediatric, and psychiatric services. The hospital is 100 km from the nearest tertiary center in Be'er Sheva, an ambulance journey of 2 hours across desert. The hospital serves a population of 70,000 residents and up to 500,000 tourists. Recognizing the need to provide a facility to transfer critical or complex patients, in August 2021, the Israeli Ministry of Health provided a dedicated helicopter to Yoseftal Hospital. The first 100 missions are presented. Forty-four missions were for cardiac presentations. For patients with ST-segment elevation myocardial infarction, the median time from the initial medical contact at Yoseftal to reception at the tertiary center was 141 minutes. Other transfers were for ear, nose, and throat (2); neurosurgical (14); trauma (9); respiratory (6); obstetrics and gynecology (3); and pediatric services (14) and nontraumatic surgical emergencies (15). Our experience validates the need for this resource and highlights the importance of robust clinical, operational, and transfer protocols between Yoseftal and the receiving specialist units. The challenging and diverse clinical activity requires additional skills and competencies for the critical care paramedics on the aircraft. Integrating the flight crew into the emergency department team facilitated early activation of the aircraft and expedited patient preparation for flight. Our experience describes an evolving new role for the helicopter—support for a remote peripheral hospital.

Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis

BackgroundOpen limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients MethodsWe undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 – December 2019). ResultsOverall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22–59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62–144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval. ConclusionOpen limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts

Is there an association between 30-day mortality and adrenaline infusion rates in post-ROSC patients? A retrospective observational analysis.

Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase. Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared. Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37). Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient.

Pre-hospital predictors of long-term survival from out-of-hospital cardiac arrest

ObjectiveTo identify predictors of longer-term outcomes from adult out-of-hospital cardiac arrest of presumed cardiac aetiology. MethodsIn this retrospective cohort study, three large routinely collected databases were linked: 1)QAS Out-of-Hospital Cardiac (OHCA) Registry; 2)Queensland Hospital Admitted Patient Data Collection; and 3)Queensland Registrar General Death Registry. Participants were adult (18years+) residents of Queensland, who suffered an OHCA of presumed cardiac aetiology and had resuscitation attempted by QAS paramedics between 2002 and 2014. Four mutually exclusive outcomes were analysed: 1) No pre-hospital return of spontaneous circulation (ROSC) sustained to the Emergency Department (ED) or ROSC in ED; 2) Survival< 30 days (Pre-hospital ROSC sustained to ED or ROSC in ED but death within 30 days; 3) survival between 30 and 364 days; and 4) survival to 365 + days. Multinomial logistic regression was used to calculate odds ratios and 95 % confidence intervals. ResultsVariables significantly predictive of survival to 365 + days after adjusting for all measured confounders are: an initial shockable rhythm; bystander witnessed events with bystander CPR; paramedic witnessed events; intubation placement; time of day (midday-2.59 pm); and attendance by Critical Care Paramedic (CCP). ConclusionFrom a service provision perspective, attendance of a CCP at an OHCA may be an important factor to achieve preferred long-term outcomes. Enhanced experience, exposure and expertise, together with extended clinical practice, may explain this finding.

Designing learning simulations for cognitive absorption

‘The future of learning is immersive. In the future, learning will take the shape of a story, a play, a game; involving multiple platforms and players; driven by dialogue and augmented with technology, an interplay of immersive experiences, data, and highly social virtual worlds’ [1]. Our simulation was designed to raise aspirations as to what is ‘possible’ for our wider faculty as we expand our simulation-based education (SBE). The ‘Godzilla’ multi-casualty exercise offered a fun and engaging theme to the serious focus on student development and assessment. Facilitated at a music venue enabling creative visual and audio backdrops, to a dynamic and immersive learning space. This exploited sensory boundaries in the form of challenging environments, whilst focusing expectations for our student cohorts to demonstrate clinical praxis. The directing staff (DS) included academics, Critical Care Practitioners, Nurses, and Paramedics who ensured a multidisciplinary overview of students’ safety and feedback discussions, appraising decision making, treatment, and management of multiple patient scenarios. Drawing upon the multimedia and interdisciplinary expertise from the faculty, a holistic set of skills brought together the creation of an authentic educational experience, with the evaluation of the students against clinical expectations of a modern healthcare response. The main points of contact were at ‘handover’ post patient extraction and assessment, to senior clinicians. This exercise modelled inclusive approaches, reflected in the seminal Delphi study that identified requirements and opportunities in Immersive Learning namely: Facilitating Authentic Learning Experiences and Developing the Capabilities of the Future Workforce [1]. This approach aligns with the NHS Simulation Strategy [2] but also with the psychological concept of flow and deep absorption in learning proposed by the Open University Innovating Pedagogy report [3]. Premised on the innovation of best learning moments, our student tasks were designed to engender deep involvement through memorable learning activities. 36 level 4 Paramedic students and 24 level 6 Paramedic students undertook the simulated challenges. Facilitators and learners reported high levels of satisfaction and attainment of praxis. Comparisons were recognised between cohorts that informed future adaptations and design, evaluating tasks for future ambitions, fusing interdisciplinary endeavours. This successful exercise met the key learning objectives and students identified this as a ‘memorable’ point in their learning. Inclusion of our allied health professions had handover scenarios filmed with 360° and conventional cameras, and videos were edited for future curricular inclusion. The learning from this inaugural event will inform the diversity and complexity of future tasks set for students. Further feedback capture methods will be used to quantify further investment into future simulation-based educational endeavours. 1. Lee MJ, Georgieva M, Alexander B, Craig E, Richter J. State of XR &amp; Immersive Learning Outlook Report 2021. Immersive Learning Research Network, Walnut, CA. 2021. 2. Health Education England (HEE) A national vision for the role of simulation and immersive technologies in health and care. NHS: 2020 3. Kukulska-Hulme A, Bossu C, Coughlan T, Ferguson R, FitzGerald E, Gaved M, Herodotou C, Rienties B, Sargent J, Scanlon E, Tang J, Wang Q, Whitelock D, Zhang S. Innovating Pedagogy 2021: Open University. Innovation Report 9: 2021

Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM)

BackgroundPre hospital emergency anaesthesia (PHEA) is a complex procedure with significant risks. First-pass intubation success (FPS) is recommended as a quality indicator in pre hospital advanced airway management. Previous data demonstrating significantly lower FPS by non-physicians does not distinguish between non-physicians operating in isolation or within physician teams. In several UK HEMS, the role of the intubating provider is interchangeable between the physician and critical care paramedic—termed the Inter-Changeable Operator Model (ICOM). The objectives of this study were to compare first-pass intubation success rate between physicians and critical care paramedics (CCP) in a large regional, multi-organisational dataset of trauma PHEA patients, and to report the application of the ICOM.MethodsA retrospective observational study of consecutive trauma patients ≥ 16 years old who underwent PHEA at two different ICOM Helicopter Emergency Medical Services in the East of England, 2015–2020. Data are presented as number (percentage) and median [inter-quartile range]. Fisher’s exact test was used to compare proportions, reported as odds ratio (OR (95% confidence interval, 95% CI)), p value. The study design complied with the STROBE (Strengthening The Reporting of Observational studies in Epidemiology) reporting guidelines.ResultsIn the study period, 13,654 patients were attended. 674 (4.9%) trauma patients ≥ 16 years old who underwent PHEA were included in the final analysis: the median age was 44 [28–63] years old, and 502 (74.5%) were male. There was no significant difference in the FPS rate between physicians and CCPs—90.2% and 87.4% respectively, OR 1.3 (95% CI 0.7–2.5), p = 0.38. The cumulative first, second, third, and fourth-pass intubation success rates were 89.6%, 98.7%, 99.7%, and 100%. Patients who had a physician-operated initial intubation attempt weighed more and had a higher heart rate, compared to those who had a CCP-operated initial attempt.ConclusionIn an ICOM setting, we demonstrated 100% intubation success in adult trauma patients undergoing PHEA. There was no significant difference in first-pass intubation success between physicians and CCPs.

Critical care paramedics' experiences of performing an emergency scalpel cricothyroidotomy: a qualitative study.

A scalpel cricothyroidotomy or front of neck access (FONA) is a rarely performed part of airway management for when other steps have failed and the patient cannot be intubated or ventilated. Increasingly advanced and specialist paramedics are being trained to perform this procedure within the pre-hospital environment. Advanced and specialist paramedics within a UK ambulance service that had performed a FONA were invited to participate in this qualitative research. Semi-structured interviews were used to gather information on the participants' experiences. This information underwent thematic analysis to develop codes which were then grouped into themes. Seven participants were interviewed between December 2020 and January 2021. Three main themes were identified: the procedure, isolation and training. The main complications described were bleeding in excess of expectations, moving structures, surgical emphysema and a false track. Complications appeared common; training to perform a FONA should include complications and an approach to their management similar to other airway management procedures. Isolation was a common theme within this study, however remote support from a peer appeared beneficial.

Peripheral intravenous catheter and intraosseous device insertions reported from the 1st July 2016 to 30th June 2017 in an Australian state ambulance service: An observational study

ObjectiveTo overcome the lack of larger, population-based studies reporting the prevalence of insertion of PIVCs and IO devices, and to describe the patient-related and service-related characteristics of these devices, inserted by paramedics, in an Australian state ambulance service. MethodsA retrospective analysis of the electronic Ambulance Report Form (medical record) and Computer Aided Dispatch system from the 1st July 2016 until 30th June 2017. Results709,217 events were analysed. Of these, 20.4% involved at least one successful PIVC insertion and 0.07% involved at least one successful IO device insertion; most of the time on first attempt (89% and 86.4% respectively). Most PIVCs were inserted into the right antecubital fossa or dorsum of the right hand while IO devices were inserted into the proximal tibia. Of male patients, 21.4% received PIVCs while 19.5% of female patients received PIVCs. Very low numbers of both male and female patients received IOs (0.1%). Medical, non-traumatic presentations were the most common presentation and received the most insertions of both devices, followed by trauma presentations. Advanced Care Paramedics inserted 84.0% of PIVCs while Critical Care Paramedics inserted 94.4% of IO devices. Time treating and transporting patients generally increased with number of attempts at vascular access undertaken. ConclusionsQueensland paramedic practices relating to insertion of PIVCs, and IO devices appears consistent with documented practice internationally. Further study is required to determine whether the antecubital fossa and dorsum of the hand insertions are clinically necessary in this population as areas of flexion and distal extremities are generally to be avoided for PIVC insertion.

Training trial of critical care paramedics for non-medical authorisation of blood

The use of pre-hospital blood transfusion by air ambulance crews is increasing. Blood transfusion is traditionally ‘authorised’ by doctors, not prescribed. However, there is an increasing interest in extending the capability of authorisation to other practitioners – that is, non-medical authorisation (NMA). A UK framework for nurses and midwives has existed since 2007, but training for critical care paramedics (CCPs) has been limited.The Resuscitation with Pre-Hospital Blood Products (RePHILL) trial was launched in 2016, requiring pre-hospital administration of red cells and LyoPlas. Authorisation was initially restricted to doctors, leading to missed recruitment by paramedic-only crews. The trial protocol was amended in 2019 to permit NMA following suitable training and stakeholder consultation. We present a targeted training programme designed to support paramedic-led transfusion within the framework of the pre-hospital trial.We considered the knowledge and skills required for NMA and compared this with baseline knowledge from paramedic training to identify the training gap. We examined examples of existing military and civilian NMA training to develop a targeted programme for a single air ambulance. The four elements of our training programme were pre-course online training, previous trial participation, face-to-face training and competency assessment.Training was delivered to three CCPs, who cascaded the training to 14 colleagues. The training time was one morning, including a face-to-face session and assessment. Novel topics included physiological triggers for transfusion and transfusion risks in the pre-hospital environment. Paramedics were encouraged to recognise and report new patterns of adverse events. Reflective feedback suggests the programme provided CCPs the knowledge to autonomously recruit trial patients and authorise transfusion.

At the front of the front-line: Ontario paramedics' experiences of occupational safety, risk and communication during the 2020 COVID-19 pandemic

PurposeThe study aimed to (1) determine on what bases paramedics in this context have defined themselves as feeling safe or at risk while serving on the front lines and (2) develop recommendations to support paramedics in their critical public health emergency response role.Design/methodology/approachThis qualitative study consisted of 21 semi-structured interviews with primary care paramedics (PCPs), advanced care paramedics (ACPs) and critical care paramedics (CCPs) with first-hand experience responding to the COVID-19 pandemic in Ontario. Qualitative research is best suited to the research objectives of gaining detailed and nuanced understandings of paramedics' experiences during this public health emergency, and identifying in paramedics' accounts what changes to policy and practice might strengthen their sense of safety in future infectious disease outbreaks (Bowling, 2002; Chafe, 2017). Data collection occurred over the course of 3.5 months, from June 2020 until September 2020.FindingsParticipants described several factors that heightened their feeling exposed to risk particular to working on the front lines of the COVID-19 public health response. These factors include stress connected to personal protective equipment (PPE) and equipment access, risks of infection to self and family, communications and feelings of being systematically under-considered. Recommendations from this research include, but are not limited to, ensuring a more equitable distribution of protective equipment to paramedics across unevenly funded services, and recognizing paramedics face unique and additional stressors in public health emergencies.Research limitations/implicationsA key limitation of this study was the relatively small sample, with 50% of potential participants deciding not to engage in an interview. The authors suspect this is likely a result of timing, as this was conducting during significant periods of the COVID-19 pandemic in Ontario. The study identifies and begins to shed light on the way in which feelings of compromised safety and specific stressors in a public health emergency context connect to one another and potentially increase risks of burnout for this healthcare provider group. This study's documentation of paramedics feeling uncertainty about their own and their family's safety, combined with feeling occupational pressure, decisional pressure within constrained frameworks of care delivery, a lack of autonomy and a lack of consideration within their healthcare system in general and within its pandemic response in particular, is important in and of itself. These stressors can have serious implications for the ability of paramedics to sustain their integral role in public health emergency response.Practical implicationsA series of pandemic-specific and generalizable recommendations emerged from this research and in collaboration with community-based medical leadership. (1) Consult paramedics on effectiveness of screening questions and equipment. Be sure to illicit and respond to paramedic feedback in a timely manner. (2) Implement operational changes during pandemics in the form of donning and doffing stations, disposable gowns, decontamination teams at hospitals, infectious disease paramedic (IDP) truck, anti-fog sprays for goggles, and safe and controlled areas for eating and taking breaks. (3) Develop an emergency pandemic plan that is resourced and maintained as part of EMS strategic planning. Involve EMS in decisions related to health system emergency planning and sustainability of EMS practice. (4) Establish equitable distribution of resources, such as ensuring PPE is distributed equitably and applying pandemic pay equally to all essential workers. (5) Validate and respect EMS, as they are essential workers. Recognize the expertise of paramedics and community healthcare providers. Finally, an overarching recommendation at the core of this research is the consideration for paramedic knowledge as expertise given their role as critical front line healthcare specialists and the protection of this crucial human resource as it relates to their resilience and mental wellbeing.Social implicationsEvidence-based awareness and improved understanding of paramedic stress during the pandemic is a first step to developing strategies to reduce that stress. This is essential in ensuring access to this essential service during emergencies and the safety of the communities they serve.Originality/valueFindings from this study can inform development of supports to sustain paramedic wellbeing during public health emergencies, during the ongoing pandemic, in Ontario and beyond.

Coping strategies adopted by Hamad Medical Corporation Paramedics before and during the COVID-19 Pandemic

Background: Paramedics are subjected to high levels of stress, which increase their risk of depression, burnout, quitting the profession, or even committing suicide.1 Some recent studies have focused on the coping strategies used by nurses in response to the COVID-19 pandemic2, but little is known regarding paramedics. This study explored the potential coping strategies used by Hamad Medical Corporation Ambulance Service (HMCAS) paramedics and critical care paramedics (referred to as “Paramedics”) in Qatar to manage the stress associated with their work before and during the COVID-19 pandemic. Methods: An online survey combining a validated tool (an adapted tool from the COPE [Coping Orientation to Problems Experienced] Inventory3) with additional questions were sent to all HMCAS emergency Paramedics (n = 1,100) in early 2021 with text message reminders, with the aim of recruiting 285 participants based on a sample size calculation with a 95% Confidence Interval. Results: Only the responses from staff who had started to work in Qatar before December 2019 were considered for inclusion in the study. As such, 274 valid responses were analyzed. The results show that the staff has used a variety of coping strategies that differed slightly before and during the pandemic (Figure 1). The percentage of paramedics using coping strategies due to work-related stress was 75.9% before COVID-19 and only 54.4% during the pandemic. This reduction is presented in Figure 2. Moreover, the results showed that the observed differences in coping strategies adopted before and during the pandemic were not always statistically significant. Conclusion: The use of coping strategies among HMCAS Paramedics generally decreased during the COVID-19 pandemic, especially those related to going out, meeting up with friends and relatives, and practicing a sport. This can probably be explained by their increased working hours during the pandemic and the precautionary measures limiting group activities and interactions, but regrettably, this can only exacerbate their level of stress.

Blind bougie first pass success endotracheal intubation process: An out-of-hospital case report

The blind bougie technique is performed when the epiglottis is visible to the intubator, but the vocal cords cannot be seen (Grade III Cormack-Lehane view). The blind bougie technique for endotracheal intubation is not routinely performed by Critical Care Paramedics for a failed intubation in the prehospital setting. However, at Hamad Medical Corporation Ambulance Service in the State of Qatar, the blind bougie technique is included in their failed airway clinical practice guidelines. This case report aims to describe the rapid sequence induction for intubation process and endotracheal tube placement in an adult trauma patient, presenting with a difficult airway, using the blind bougie technique in the out-of-hospital setting. A 35-year-old male patient was ejected from an all-terrain vehicle following a high-speed accident in the desert. The patient sustained an isolated head injury. Based on the patient’s clinical presentation, he required immediate endotracheal intubation for maintenance and protection of his airway prior to rapid transport to definitive care. Predictors of difficult airway were calculated. Using the blind bougie technique, endotracheal intubation was performed with first pass success. It is recommended that emergency medical services include the blind bougie technique of endotracheal intubation among their difficult airway procedures.

Safety of healthcare workers undertaking transport and retrieval of patients on extracorporeal membrane oxygenation during the peak of COVID-19 pandemic in the State of Qatar

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous to patients and healthcare workers (HCWs). COVID-19 is highly contagious and can be transmitted by contact, droplet, or airborne route. Transport of COVID-19 patients exposes HCWs and the public to infection risks, hence strict measures must be in place to ensure everyone's safety. ECMO cannulation and transportation is considered an aerosol generating procedure and can pose significant risks to HCWs. In addition, close contact with the patient in the confined space of the ambulance may put HCWs at increased risk of exposure and infection. Methods: Between March 1st and September 30th 2020, a total of 32 episodes of COVID-19 ECMO transport were undertaken by the Medical Intensive Care Unit (MICU) and Ambulance Service. We reviewed the incidence of COVID-19 infection among HCWs involved in these missions. The transport clinical team is composed of ECMO consultant, two ECMO nurses, a perfusionist and a Critical Care Paramedic (CCP). Due to staff shortage and clinical needs, a respiratory therapist did not attend to the majority of cases. A crew of two paramedics supports the clinical team with their intensive care ambulance. Results: The number of clinical staff involved in the COVID-19 ECMO transport during that period is shown in . The duration of clinical staff’s exposure to the infected patient in the back of the ambulance is demonstrated in. MICU staff underwent COVID-19 serology tests every 2 weeks as per local policy. None of the clinical staff involved in these transfers and retrievals of COVID-19 positive patients tested positive after 2 weeks of transport. Conclusion: Strict infection prevention and personal protective measures are mandatory to avoid cross-infection and were carefully adhered to during all the missions. They translated into the well-being of the clinical staff involved in the transfer and retrievals of COVID-19 positive patients.

A Service Evaluation of Prehospital Blood Transfusion by Critical Care Paramedics in British Columbia, Canada

Early administration of blood products is emerging as best practice in selected trauma and medical patients. Blood products carried by critical care transport (CCT) teams are sometimes the first available to critically ill and injured patients. The purpose of this research was to evaluate the introduction of prehospital transfusion into a paramedic-led CCT program in Canada. A retrospective review of electronic patient care records for all patients who received a prehospital transfusion of uncrossmatched group O packed red blood cells between February 10, 2019, and September 30, 2020, was conducted. Forty-eight patients received a prehospital transfusion. The median age of the patients was 44 years, 81.3% were male, and most patients were victims of blunt trauma. Packed red blood cells were associated with a significant increase in systolic blood pressure (P < .001) and mean arterial pressure (P < .001), a decrease in shock index (P < .001), and a reduction in the time to first transfusion, with minimal waste, no patient-related adverse events, and complete traceability. The results of this service evaluation demonstrate the successful introduction of prehospital transfusion into a paramedic-led CCT program. Further prospective research is needed to assess the impact of such a protocol in this patient population.

Scoping the Demand for Night Operation of Essex & Herts Air Ambulance: A Prospective Observational Study

ObjectiveHelicopter emergency medical services play an important role in the prehospital care of critically ill and injured patients, providing enhanced interventions and direct transfer to specialist centers. Essex & Herts Air Ambulance (EHAAT) delivers prehospital critical care to patients in Essex, Hertfordshire, and the surrounding areas. Historically, EHAAT's resources have not operated during the night. This study aimed to ascertain demand for prehospital critical care in Essex and Hertfordshire during night hours. MethodsA prospective observational design was used. Data were collected by 11 critical care paramedics during night shifts on a critical care desk using an online survey. Details were recorded for incidents in Essex and Hertfordshire between 21:00 and 07:00 deemed appropriate for a prehospital critical care response. ResultsA total of 108 incidents were recorded across 52 nights, equating to an average of 2.08 incidents per night. For 52 incidents, there was no critical care resource available to attend. The majority of incidents fell in closer proximity to EHAAT's North Weald base than its Earls Colne base. ConclusionThe findings suggest a potential need for prehospital critical care during night hours in Essex and Hertfordshire and support the operation of a resource from EHAAT's North Weald base.

Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model.

The Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session. The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. This study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.

Quality of abdominal ultrasound image acquisition by novice practitioners following a minimal training session on healthy volunteers.

Point of care ultrasound (POCUS) is an essential tool for physicians to guide treatment decisions in both hospital and prehospital settings. Despite the potential patient care and system utilization benefits of prehospital ultrasound, the financial burden of a "hands-on" training program for large numbers of paramedics remains a barrier to implementation. In this study, we conducted a prospective, observational, double-blinded study comparing paramedics to emergency physicians in their ability to generate usable abdominal ultrasound images after a 1-hour didactic training session. Canadian aeromedical critical care paramedics were compared against emergency medicine physicians in their ability to generate adequate abdominal ultrasound images on five healthy volunteers. Quality of each scan was evaluated by a trained expert in POCUS who was blinded to the identity of the participant using a 5-point Likert scale and using the standardized QUICk Focused Assessment with Sonography in Trauma (FAST) assessment tool. Fourteen Critical care paramedics and four emergency department (ED) physicians were voluntarily recruited. Of paramedics, 57% had never used ultrasound before, 36% has used ultrasound without formal training, and 7% had previous training. Physicians had a higher proportion of usable scans compared with paramedics (100% v. 61.4%, Δ38.6%; 95% confidence interval, 19.3-50.28). Paramedics were not able to produce images of interpretable quality at the same frequency when compared with emergency medicine physicians. However, a 61.4% usable image rate for paramedics following a short 1-hour didactic training session is promising for future studies, which could incorporate a short hands-on tutorial while remaining cost-effective.

Ability of Critical Care Medics to Confirm Endotracheal Tube Placement by Ultrasound.

The Advanced Cardiac Life Support (ACLS) guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement. While this method is employed in the emergency department under the guidance of the most recent American College of Emergency Physicians (ACEP; Irving, Texas USA) guidelines, it has yet to gain wide acceptance in the prehospital setting where it has the potential for greater impact. The objective of this study to is determine if training critical care medics using simulation was a feasible and reliable method to learn this skill. Twenty critical care paramedics with no previous experience with point-of-care ultrasound volunteered for advanced training in prehospital ultrasound. Four ultrasound fellowship trained emergency physicians proctored two three-hour training sessions. Each session included a brief introduction to ultrasound "knobology," normal sonographic neck and lung anatomy, and how to identify ETT placement within the trachea or esophagus. Immediately following this, the paramedics were tested with five simulated case scenarios using pre-obtained images that demonstrated a correctly placed ETT, an esophageal intubation, a bronchial intubation, and an improperly functioning ETT. Their accuracy, length of time to respond, and comfort with using ultrasound were all assessed. All 20 critical care medics completed the training and testing session. During the five scenarios, 37/40 (92.5%) identified the correct endotracheal placements, 18/20 (90.0%) identified the esophageal intubations, 18/20 (90.0%) identified the bronchial intubation, and 20/20 (100.0%) identified the ETT malfunctions correctly. The average time to diagnosis was 10.6 seconds for proper placement, 15.5 seconds for esophageal, 15.6 seconds for bronchial intubation, and 11.8 seconds for ETT malfunction. The use of ultrasound to confirm ETT placement can be effectively taught to critical care medics using a short, simulation-based training session. Further studies on implementation into patient care scenarios are needed.

Paramedic Board Certification: The International Board of Specialty Certification Turns 20

The International Board of Specialty Certification (IBSC) has been offering specialty certification for 20 years. Originally formed as the Board for Critical Care Transport Paramedic Certification (BCCTPC), the first official examination at the Air Medical Transport Conference (AMTC) in October of 2000. Paramedic specialty certification flourished because of the vision and tireless commitment of a small group of paramedic champions. Some of that group from 20 years ago included David O. Bump, John R. Clark, Dr. John Cole, Dr. Robert Donovan, Chris Giller, Lisa Gilmore, Jonathan Gryniuk; Bob Hesse, TJ Kennedy, Brian Schaeffer, and Jackie Stocking. Without their tenacity, paramedic specialty certification would not be celebrating this milestone.The IBSC is a functional specialty board with a mission to support paramedicine specialties anywhere in the world. The Certified Flight Paramedic (FP-C®), Certified Critical Care Paramedic (CCP-C®) Certified Tactical Paramedic (TP-C®), Certified Tactical Responder (TR-C®) and Certified Community Paramedic (CP-C®) examinations are well established and have become a recognized standard for clinical competency by medical providers in the United States, Europe, South Africa and the Middle East. Founded in 2000, the IBSC is a not-for-profit professional certification organization responsible for the administration and development of specialty certification exams for critical care professionals. The mission of the IBSC is to improve quality of care in all aspects of specialty EMS care across a wide variety of settings by providing a portfolio of certification exams that are an objective, fair, and honest validation of specialty knowledge to paramedics and other allied health providers are called upon to perform critical care transport. Exams are developed that are responsive to the needs of the paramedic community. Currently, there are nearly 10,000 board certified providers in one of the five specialty designations.