Pre-hospital Clinicians Research Articles

Current Methods for the Prehospital Detection of Large Vessel Occlusion (LVO) Ischemic Stroke

This review describes the technologies and methods currently utilized to detect large vessel occlusion (LVO) ischemic stroke in the prehospital setting. A comparison of various LVO stroke scales, including their similarities and differences, is included. Emerging technology, novel stroke detection methods, and likely areas of future research are discussed. Many prehospital stroke detection scales have been described previously in the medical literature, characterized by varying degrees of efficacy. Despite their cost-effectiveness and ease of use, prehospital stroke scales do not reliably detect LVO. Current efforts in prehospital LVO stroke detection are aimed at improving upon the sensitivity and specificity of these scales, leveraging new screening technologies to streamline LVO triage and decrease time-to-intervention. The prehospital stroke scales that we reviewed differ greatly in many respects, including their definition of LVO and the type and number of items tested. Despite the tremendous global effort made to rapidly triage and deliver LVO stroke patients to definitive treatment centers, no single scale has emerged with both a high positive predictive value (PPV) and negative predictive value (NPV). This has led to a lack of consensus, preventing widespread adoption of a single scale for prehospital LVO detection. Despite the ever-increasing number of stroke scales available to the prehospital clinician, LVO detection remains a challenge. Future advances in prehospital LVO stroke detection are expected to involve new and improved in-field diagnostic testing.

Responding to the COVID-19 pandemic: The experiences of South Australia's Rescue, Retrieval and Aviation Services.

COVID-19 poses significant challenges to pre-hospital and retrieval medicine (PHRM) clinicians - and many are unique to this area of clinical practice. We share the experiences of the South Australian Ambulance Service (SAAS) MedSTAR Emergency Medical Retrieval Service in preparing for the COVID-19 pandemic in the pre-hospital and retrieval setting - including the role of a multidisciplinary leadership team; challenges and potential approaches to screening for COVID-19; personal protective equipment for pre-hospital and aeromedical taskings; issues arising with interstate retrievals; and the role of telehealth. Although novel solutions allowed SAAS MedSTAR to continue to deliver high-quality care, considering the resource implications involved in undertaking the transfer of patients with COVID-19, it is clear that significant community disease transmission threatens to overwhelm any PHRM service. Should Australia face a significant future outbreak, it is conceivable that some PHRM operations may need to be reduced or suspended entirely.

Protocol for Development of a Consensus-Based Reporting Guideline Extension for Pre-Hospital Case Reports (Prehospital-Care)

Introduction Case reports make important contributions to evidence-based practice. As with research of any methodological design, the quality and completeness in how the evidence is reported influences the strength of the evidence. Quality in reporting is best achieved through the use of a consensus-based reporting guideline. ‘Case Reports’ (CARE) is a 13-item reporting guideline for case reports. To make CARE more applicable, several discipline specific ‘extensions’ have been developed. Pre-hospital care is an emerging clinical discipline rich in its own specific context and character. Therefore, the aim of this project is to develop and disseminate a pre-hospital extension of the CARE reporting guideline (PREHOSPITAL-CARE). Methods This project will consist of four phases and will be undertaken in accordance with the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network's guidance for developers of health research reporting guidelines. Phase 1 will comprise a systematic review aimed at identifying features commonly reported in pre-hospital case reports. In phase 2, two consensus-based processes will be conducted, including a Delphi method and an interactive consensus meeting, to produce a list of items that will form the draft guideline items for PREHOSPITAL-CARE. Phase 3 will see this draft being piloted among a selected group of pre-hospital clinicians, academics and students. In the fourth and final phase, an extensive dissemination strategy will be executed, including publication of the PREHOSPITAL-CARE reporting guideline and an ‘elaboration and explanation’ (E&E) companion paper to advocate for the standardised, high-quality reporting of pre-hospital case reports. Outcomes The final outcome will be the publication of the PREHOSPITAL-CARE reporting guideline with an associated E&E paper. Discussion The reporting of health research, including pre-hospital case reports, has been criticised for a lack of completeness and consistency. The development of PREHOSPITAL-CARE will enable the improvement and standardised reporting of pre-hospital case reports.

Ketamine as a rescue treatment for severe acute behavioural disturbance: A prospective prehospital study.

Rapidly and safely managing severe acute behavioural disturbance (ABD) in the prehospital setting is important for the welfare of both patient and prehospital clinician alike. We investigated the safety and effectiveness of ketamine as rescue sedation in patients with severe ABD. This prospective observational study investigated ketamine use by a state ambulance service as rescue sedation for patients with severe ABD who remained agitated following droperidol administration. The primary outcome was the proportion of adverse events (vomiting, hypersalivation, emergence, over-sedation, airway obstruction, laryngospasm, hypoxia, bradypnoea and intubation). Secondary outcomes included time to sedation, requirement for additional sedation and rate of successful sedation. There were 105 presentations (males 69/102 [69%]; median age 31 years (16-83 years). The commonest causes of ABD were illicit drug (39%) and alcohol (33%) intoxication. The median total dose of intramuscular ketamine was 200 mg (interquartile range [IQR] 150-200 mg). There were 64 adverse events in 40 (38%) patients. Four had vomiting, two had hypersalivation, two had emergence, 15 were oversedated, four had hypoxia, three had bradypnoea and 16 were intubated. Sedation was achieved in 103 (98%) patients at a median time post-ketamine of 8min (IQR 5-13 min). Additional sedation was administered to 41 patients (nine prehospital and 37 within 1 h of arriving to hospital). In 44 (42%) patients, ketamine successfully sedated the patient with no adverse effects and no ongoing sedation requirement. The use of ketamine as rescue sedation in prehospital patients with severe ABD is effective. Adverse events are common but can be managed supportively.

How accurate is the prehospital diagnosis of hyperventilation syndrome?

Background: The literature suggests that hyperventilation syndrome (HVS) should be diagnosed and treated prehospitally. Aim: To determine diagnostic accuracy of HVS by paramedics and emergency medical technicians using hospital doctors' diagnosis as the reference standard. Methods: A retrospective audit was carried out of routine data using linked prehospital and in-hospital patient records of adult patients (≥18 years) transported via emergency ambulance to two emergency departments in the UK from 1 January 2012–31 December 2013. Accuracy was measured using sensitivity, specificity, positive and negative predictive values (NPV/PPVs) and likelihood ratios (LRs) with 95% confidence intervals. Results: A total of 19 386 records were included in the analysis. Prehospital clinicians had a sensitivity of 88% (95% CI [82–92%]) and a specificity of 99% (95% CI [99–99%]) for diagnosing HVS, with PPV 0.42 (0.37, 0.47), NPV 1.00 (1.00, 1.00), LR+ 75.2 (65.3, 86.5) and LR− 0.12 (0.08, 0.18). Conclusions: Paramedics and emergency medical technicians are able to diagnose HVS prehospitally with almost perfect specificity and good sensitivity.

Residential aged care homes: Why do they call '000'? A study of the emergency prehospital care of older people living in residential aged care homes.

To describe the clinical characteristics, medical interventions and patterns of ambulance service use related to the emergency, prehospital care of older people living in residential aged care (RAC) homes. Retrospective cohort study using secondary analyses of routinely collected clinical and administrative data from Ambulance Victoria and population data from the Australian Bureau of Statistics for the state of Victoria, Australia. Participants included people aged 65 years and over, attended by emergency ambulances from 2008 to 2013, with data captured in the Ambulance Victoria electronic record. The mean (standard deviation) age of RAC residents attended by emergency ambulance was 85 (7.3) years and 63% were women. Common comorbidities included dementia (32.7%), ischaemic heart disease (27.7%) and osteoarthritis (24.6%). Polypharmacy was prevalent with 70% currently prescribed antibiotics, over 20% prescribed sedatives and a further 14.9% antipsychotics. Fifteen percent of attendances were for falls, which were more frequent among women than men. Other common reasons for ambulance call-out included uncontrolled pain, respiratory tract infection, non-specific febrile illness and altered conscious state. Almost 90% of people were transported to hospital from the RAC, with just over half of call-outs occurring out-of-hours. This is the first study to describe emergency prehospital care, case-mix and intervention of frail, older people living in RAC. These results demonstrate a clinically complex group of people with high rates of comorbidity, cognitive impairment and polypharmacy. These valuable data will inform education and training of prehospital clinicians, assist in targeting preventative medicine and primary care programmes and further development of alternate, acute and emergency care pathways for this unique patient group.

Cardiovascular and liver disease among pre-hospital trauma deaths: A review of autopsy findings

Introduction Pre-existing disease is a common contributor to mortality and morbidity after injury and resuscitation of injured patients are often altered in hospital based on comorbidities. However, this is uncommon in the pre-hospital phase of care where patients are managed according to clinical practice guidelines. This study aimed to quantify the prevalence of cardiovascular disease (CVD) and liver disease among trauma patients attended by pre-hospital clinicians but who died prior to reaching hospital and assess associations with age. Methods This was a retrospective review of pre-hospital trauma deaths in the state of Victoria, Australia between 01 Jan 2008 and 31 Dec 2014. The inclusion criteria were (a) patients attended by pre-hospital clinicians, (b) deceased before arrival to hospital, (c) evidence of recent trauma and (d) underwent a full autopsy. Cardiovascular and liver disease status were extracted from autopsy reports. Results There were 1043 patients included in this study. Most patients were male (77.1%). Intentional self-harm was significantly more common in patients aged ≥65 years (17.4%). CVD was prevalent in 495 (47.5%; 95%CI: 44.4–50.5) cases with myocardial fibrosis the most common abnormality detected. All sub-groups of CVD demonstrated a significant association with increasing age, except right ventricular hypertrophy. Liver disease was present in 235 (22.5%; 95%CI: 20.1-25.2) patients and most common among patients aged 35–64 years. Discussion CVD was prevalent in almost half of all injured patients included in this study while liver disease was present in about a fifth. The prevalence of CVD was associated with increasing age, while liver disease was more common among middle-aged patients. This high prevalence in our population indicates that pre-existing cardiovascular and liver disease be considered when tailoring pre-hospital life-saving interventions for injured patients.

P008: Care of palliative patients by paramedics in the 911 system

Introduction: Palliative Care aims to relieve suffering and improve the quality of living and dying in patients with life-limiting, progressive conditions. Many patients and families prefer to stay at home at end of life. Despite this, many access 911 in times of apparent crisis. It has been noted in the literature that a well functioning palliative care system includes considering Emergency Medical Services as part of the patients’ circle of care. Training in palliative care is traditionally limited or absent for prehospital clinicians, including Paramedics and Emergency Medical Services Physicians. Furthermore, in our region, there are currently no medical directives available to Paramedics within the 911 system specifically addressing the needs of palliative care patients. Methods: A feasibility study (Expanding Care by Paramedics for Palliative Patients – EC3P) was designed to evaluate implementation of a new palliative care medical directive with trained teams of Paramedics available to respond to 911 calls. As part of this study, a pre-implementation retrospective chart review was performed. Patient care records were screened for “palliative” within the past medical history and text fields. Information about dispatch and scene times, patient demographics, details of patient encounter, and disposition of the patient were recorded. Descriptive statics were used. Results: Data was reviewed for all calls in 2018. Call data was reviewed to exclude those that were pediatric (<18yo) and those whose palliative status was unknown or unclear. There was a total of 318 calls. The majority of the calls (83%) were between 7am and 8pm, with peaks at 10 am and 6pm. The majority were transported to hospital (74%), 16% were transferred to hospital initiated by their palliative care physician, 20% “refused” transport, and 6% were declared dead and not transported. The most common reasons for calling 911 were new symptoms or a sudden worsening of chronic symptoms, followed by needs exceeding caregiver capacity; the third most common was lift assist without apparent injury. Conclusion: Much is unknown about the palliative patient population as it intersects with prehospital emergency care. This study will help provide information needed to guide further research and implementation.

Transport Blood Pressures and Outcomes in Stroke Patients Requiring Thrombectomy

ObjectiveMechanical thrombectomy is the treatment of choice for acute ischemic strokes from large vessel occlusions. Absolute blood pressure and blood pressure variability (BPV) may affect patients’ outcome. We hypothesized that patients’ outcomes were not associated with BPV during transport between hospitals in the era of effective thrombectomy. MethodsWe performed a retrospective observational review of adult patients admitted to our comprehensive stroke center who underwent mechanical thrombectomy between January 1, 2015, and December 31, 2018. Data were collected from our stroke registry and transportation records. Outcomes were defined as 90-day modified Rankin Scale (mRS) ≤2 and any acute kidney injury (AKI) during hospitalization. ResultsWe analyzed 134 eligible patients. The mean age was 66 years (standard deviation = 14 years). Forty percent achieved mRS ≤2, and 16% had an AKI. BPV and maximum systolic blood pressures during transport were examined as variables to determine outcome. We found BPV was similar between patients with good and bad functional independence. Furthermore, the maximum systolic blood pressure during transport (odds ratio = 0.98; 95% confidence interval, 0.96-0.99; P = .038), not BPV, was associated with a lower likelihood of mRS ≤2. No similar correlation of analyzed blood pressure variables could be found for AKI as an outcome. ConclusionThe maximum systolic blood pressure was associated with worse functional outcomes in stroke patients transported for thrombectomy. Prehospital clinicians should be cognizant of high blood pressure among patients with acute ischemic stroke from large vessel occlusion during transport and treat accordingly.

Care of the patient with invasive meningococcal disease by prehospital emergency medical service clinicians: a scoping review

ObjectiveThe objective of this scoping review is to systematically map the literature to identify the scope, depth, key concepts and gaps in the evidence regarding care of the patient with...

Prehospital analgesia for femur fractures: An improvement study

Background: Management of pain in the prehospital setting is an important priority for prehospital clinicians, yet is often underestimated, either due to poor pain assessment, under dosing and inadequate provision of analgesia1,2. A femur fracture is considered a painful injury and as such, should be managed with effective analgesia. Pain is associated with multiple negative physiological effects which may potentially worsen a patient's clinical condition1, further highlighting the importance of providing effective analgesia. Vassiliadis et al., highlighted that patients with a femur fracture receive only moderate analgesia in the prehospital setting and this requires a focused strategy to improve the care received by these patients3. A retrospective audit of the Hamad Medical Corporation Ambulance Service (HMCAS) electronic patient care records (ePCR) highlighted the low frequency of prehospital analgesia for the management of femur fractures (October 2016 – December 2016). The provision of three pharmacological agents (Methoxyflurane, Fentanyl and Ketamine) which are the primary analgesics used by the HMCAS for the management of pain associated with femur fractures was reviewed. These drugs are often used together in a multimodal strategy to manage pain effectively. A multimodal approach to managing trauma pain has the benefit of improving efficacy with multiple mechanisms of action, limiting the number of doses required of a single drug, as well as reducing the risk of side effects4. The aim of this study was to improve prehospital analgesia for femur fractures, by means of introducing a purpose-designed trauma CPD training course. Focused training through the means of high fidelity simulations and simple skills training leads to improved performance and an increase in knowledge gained by the practitioner5, resulting in improved and safer care delivered to patients. Methods: An intervention consisting of a theoretical, individual skills and simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a three-month period (January 2017 – March 2017). The eight-hour trauma CPD training session focused on managing major trauma with specific focus on femur fracture identification and optimization of analgesia (Figure 1). Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the frequency of prehospital analgesia for patients with femur fractures (April 2017 – June 2017). Results: The mean provision of prehospital analgesia for a femur fracture in the pre-intervention stage was found to be suboptimal (Methoxyflurane 61%; Fentanyl 21%; Ketamine 12%). Whereas, following the intervention period, the mean provision of prehospital analgesia for femur fractures increased significantly (Methoxyflurane 100%; Fentanyl 30%; Ketamine 52%). See Figure 2. Conclusion: This study found that focused trauma training is an effective means to improve prehospital analgesia for femur fractures as well as overall patient care. Introduction of the trauma CPD training session resulted in an improvement in the management of pain associated with a femur fracture. Significant room for improvement still exists and prehospital analgesia should continue to be developed. Further research is still required.

Effect of placental transfusion on neonatal resuscitation attempts

Objective: Overall, neonatal mortality has been shown to be reduced by: placental transfusion (the transfer of blood from the placenta to the neonatal circulation after birth); delayed cord clamping (DCM) (waiting for the umbilical cord to stop pulsating before clamping and cutting the cord); and umbilical cord milking (UCM) (clamping and cutting the cord immediately before milking the cord towards the neonate to expel remaining volume). This systematic review aimed to determine whether placental transfusion negatively impacts resuscitation by delaying it or has any effect on infant mortality, and to identify any barriers to performing it. Methods: CINAHL, MEDLINE, AMED and the British Nursing Index were searched using key terms to identify relevant English language publications between 2017 and 2019. Results: Five papers were selected for critical analysis—three randomised control trials and two cohort studies. Conclusion: Placental transfusion was not found to have a negative impact on neonatal resuscitation but, equally, had no significant effect on Apgar at 5 minutes; however, Apgar is a crude measure of infant mortality. The question remains around the proven multifaceted benefit of placental transfusion in the prehospital environment, which requires further research. There is evidence to suggest prehospital clinicians should be looking to change practice. Further research, considerations and consultations are required to ascertain the best way to implement the procedure with a balanced and proportionate approach considering neonatal thermoregulation and maternal management. The main reported barrier to placental transfusion was a lack of appropriate equipment.

Prehospital Blood Glucose Testing as a Predictor of Impending Hypotension in Adult Trauma Patients

ObjectiveStress-induced hyperglycemia has been found to increase hemorrhagic shock, morbidity, and mortality in the trauma patient. The purpose of this study is to evaluate whether prehospital point-of-care glucose is an independent predictor of hypotension in the adult trauma patient transported by air ambulance to the receiving trauma center. MethodsThis retrospective chart review evaluated adult, nondiabetic trauma patients transported by air ambulance at 3 programs in the Midwest for the calendar year 2018. A total of 107 patients met the inclusion criteria. The primary analysis was the determination of an optimal cutoff for the blood glucose diagnostic for predicting a hypotensive outcome followed by chi-square incidence comparison. ResultsThe optimal diagnostic cutoff point using Youden's index (J) was determined to be a blood glucose value of 220 mg/dL or greater. Initial glucose values were associated with an increased relative risk of a hypotension outcome (P = .040). Glucose dichotomy was also associated with a mean decrease in systolic blood pressure during transport (P = .016). ConclusionThe findings in this study indicate a point-of-care glucose measurement greater than 220 mg/dL should prompt prehospital clinicians to initiate aggressive balanced resuscitation before arrival at the receiving trauma center in order to prevent worsening hypotension and hemorrhagic shock.

Prehospital tranexamic acid shortens the interval to administration by half in Major Trauma Networks: a service evaluation

IntroductionTranexamic acid (TXA) reduces bleeding and mortality. Recent trials have demonstrated improved survival with shorter intervals to TXA administration. The aims of this service evaluation were to assess the interval...

Pre-hospital stroke recognition in a UK centralised stroke system: a qualitative evaluation of current practice.

Background:A significant number of patients conveyed via ambulance to hyper acute stroke units (HASU) with suspected stroke have other diagnoses. This may delay treatment for non-stroke patients and cause burden to stroke teams. The Greater Manchester (GM) Connected Health Cities (CHC) stroke project links historical North West Ambulance Service NHS Trust (NWAS) data with Salford Royal Hospital electronic data to study stroke pathway compliance and accuracy of paramedic diagnosis and aims to use these data to improve pre-hospital clinicians’ accurate recognition of stroke through development of service improvement innovations. We report on supplementary qualitative work required to understand stroke recognition from the pre-hospital clinician’s perspective.Methods:Focus groups and semi-structured interviews were conducted with pre-hospital clinicians of various grades, working in the GM area of NWAS. Focus groups and interviews were audio recorded and transcribed verbatim. We used thematic analysis informed by normalisation process theory (NPT) to analyse the data. This theory helps us to understand how innovations are developed, implemented and sustained into healthcare practice.Results:Sixteen pre-hospital clinicians took part in two focus groups, one dyad interview and five one-to-one interviews. Analysis identified that respondents were unaware of false positive stroke rates entering onto the stroke pathway. Pre-hospital clinicians receive limited feedback from jobs and this impedes their ability to learn from their experiences. Respondents reported difficulty in ruling out stroke in certain patient cohorts and difficulty in recognising differential diagnoses. They expressed a lack of confidence to rule out stroke in the pre-hospital setting. They also expressed greater concern for ‘missed strokes’.Conclusion:The qualitative findings support the development of innovations to improve accurate recognition of stroke in the pre-hospital setting.An enhanced FAST tool, better relations with HASU clinicians, feedback and education on the stroke pathway and differential diagnoses were all considered useful to improve accurate stroke recognition.

A Surprise Mass Casualty Incident Simulation: Does It Improve Knowledge or Is It Just a Bit of Fun?

Introduction:We opened a national conference in Australia with a surprise mass casualty simulation scenario of a van versus multiple persons outside the conference venue. The purpose of this exercise was to increase awareness of, and preparation for, mass casualty incident (MCI) events for the conference delegates who were paramedics, emergency department nurses, and doctors.Aim:The aim of the research is to understand whether a surprise MCI simulation is a useful way to increase knowledge and motivate preparedness.Methods:A survey hosted on Qualtrics was circulated to delegates via email. The survey was designed by the research team and had 38 questions about demographics and respondents’ experience with MCIs, as well as their perceptions of the simulation exercise. The questions were a mixture of 5-point Likert scales, multiple choice, and short answers.Results:The majority of respondents were clinicians (n = 66, 76%) and those who worked in emergency departments or the prehospital setting (n = 75, 86%). While the majority had not responded to an MCI in the past 5 years (n = 67, 77%), more than half (n = 50, 57%) had undertaken MCI training during this time. Overall, a vast majority of respondents found the simulation to be a worthwhile exercise that increased knowledge and preparedness. An overwhelming majority also reported that the simulation was relevant to practice, of high quality, and a useful way to teach about major incidents.Discussion:Our surprise major incident simulation was a fun and effective way to raise awareness and increase knowledge in prehospital and emergency department clinicians about MCI response. This approach to simulation can be easily replicated at relatively low cost and is, therefore, a useful solution to training a group of multidisciplinary health professionals outside of the workplace.

Stroke Prehospital Informed Decision-Making Using EEG Recordings (SPIDER)

Introduction:The acute care of stroke involves the administration of a clot-dissolving drug (thrombolysis) and/or its removal using endovascular clot retrieval. Earlier intervention results in significantly improved patient outcomes. Clinical assessment scores have limitations, and studies have shown that even the most robust scores have a reported false-negative rate of >20% for large vessel occlusive strokes that may be eligible for clot retrieval, while inappropriate bypass may delay delivery of thrombolysis.1 Quantitative Electroencephalography (QEEG) has been shown to have a very high sensitivity and specificity in the identification of acute stroke versus matched controls in an in-hospital setting.(2,3)Aim:The SPIDER study commenced in Brisbane, Queensland on September 3, 2018, and is investigating the use of an EEG recorder to gather data on acute stroke patients presenting to a metropolitan ambulance service.Discussion:The data collected will guide the development of a simple numerical output reference to guide decision making. The data may aid in identifying large vessel occlusive stroke and patients eligible for endovascular intervention. The QEEG will provide a more accurate and cost-effective tool for the prehospital clinician over other imaging technologies and can guide early destination decisions. This presentation discusses the implementation of a pre-hospital research platform, integration with the clinical dispatch matrix, staff engagement, patient recruitment, and the success of the project so far.

Pre-hospital pain assessment in paediatric patients.

The aim of this article is to review the literature on pre-hospital assessment of pain in paediatric patients. Many articles highlight the under-treatment of pain in paediatrics by pre-hospital clinicians, showing that this is an area falling short of best practice. This article evaluates the effectiveness of two established pain assessment tools authorised for the pain assessment of children in pre-hospital environments.

Emergency Medical Services Provider Perspectives on Pediatric Calls: A Qualitative Study

Objective: Previous research indicates that 9-1-1 response to incidents involving children is particularly distressing for emergency medical services (EMS) clinicians. This qualitative study was conducted to increase understanding about the difficulties of responding to pediatric calls and to obtain information about how organizations can better support EMS providers in managing potentially difficult calls. Methods: Paramedics and emergency medical technicians from a single U.S. ambulance service were invited to participate in focus groups about responding to 9-1-1 calls involving pediatric patients. A total of 17 providers from both rural and metro service regions participated in six focus groups held in community meeting spaces. A semi-structured focus group guide was used to explore (1) elements that make pediatric calls difficult, (2) pre-arrival preparation practices, (3) experiences with coping after difficult pediatric calls, and (4) perspectives about offered and desired resources or support. Focus groups were audio recorded and transcripts were analyzed using standard coding, memoing, and content analysis methods in qualitative analysis software (NVivo). Results: Responses about elements that make pediatric calls difficult were organized into the following themes: (1) special social value of children, (2) clinical difficulties with pediatric patients, (3) added acuity to already challenging calls, (4) caregivers as secondary patient, and (5) identifying with patient or patient’s family. Pre-arrival preparation methods included mental or verbal review of hypothetical scenarios and refocusing nerves or emotions back to the technical aspect of the job. Participants described using available resources that largely took the form of social support. Suggestions for additional resources included: increased opportunities for external feedback; more frequent pediatric clinical training; institutionalization of recovery time after difficult calls; and improved storage and labeling of pediatric equipment. Conclusions: This study provides qualitative data about the difficulties of responding to pediatric calls and resources needed to support clinicians. Findings from this study can be used to guide EMS leaders in designing and implementing institutional initiatives to enhance training and support for prehospital clinicians providing care to children.

Human factors, cognitive bias and the paramedic

The consequences of human factors and cognitive bias can be catastrophic if unrecognised. Errors can lead to loss of life because of the flawed nature of human cognition and the way we interact with our environment. Seemingly small mistakes or miscommunications can lead to negative outcomes for patients and clinicians alike. It is easy to see therefore why the College of Paramedics now recommends the teaching of human factors at higher education institutions. Using a problem-based approach, this article aims to inform prehospital clinicians about how human factors and cognitive bias can affect them and their practice, and how these can be mitigated.