Christopher Stein

Burnout among advanced life support paramedics in Johannesburg, South Africa

Objectives To establish the prevalence of burnout among advanced life support (ALS) paramedics in Johannesburg, South Africa and assess the relationship between burnout and a number of demographic characteristics of the sampled ALS paramedics. Design Cross-sectional internet-based survey. Method Survey invitations were sent via email to 98 registered ALS paramedics in the Johannesburg area. The survey questionnaire was created by combining the Copenhagen Burnout Inventory (CBI) with numerous distractor questions. Burnout was defined as a CBI score >50. Descriptive analysis was performed and results subjected to Chi-square testing in order to establish dependencies between burnout scores and demographic factors. Results A 46% (n=45) response rate was obtained. Forty responses were eligible for analysis. 30% of these respondents had total burnout according to their CBI score, while 63% exhibited some degree of burnout in one of the CBI subcategories. The results of the subcategory analyses showed that 23% of respondents experienced burnout in the patient care-related category, 38% experienced burnout in the work-related category and 53% experienced burnout in the personal burnout category. There were no statistical differences in the burnout scores according to gender (p=0.292), position held (p=0.193), employment sector (p=0.414), years of experience (p=0.228) or qualification (p=0.846). Distractor questions showed that paramedics feel overworked, undervalued, poorly remunerated and unsupported by their superiors. Conclusion This sample of Johannesburg-based paramedics had a greater prevalence of burnout compared with their international counterparts. Further research is needed to identify the true extent of this problem.

Nonphysician Out-of-Hospital Rapid Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis

Study objective: Rapid sequence intubation performed by nonphysicians such as paramedics or nurses has become increasingly common in many countries; however, concerns have been stated in regard to the safe use and appropriateness of rapid sequence intubation when performed by these health care providers. The aim of our study is to compare rapid sequence intubation success and adverse events between nonphysician and physician in the out‐of‐hospital setting. Methods: A systematic literature search of key databases including MEDLINE, EMBASE, and the Cochrane Library was conducted. Eligibility, data extraction, and assessment of risk of bias were assessed independently by 2 reviewers. A bias‐adjusted meta‐analysis using a quality‐effects model was conducted for the primary outcomes of overall intubation success and first‐pass intubation success and for adverse events when possible. Results: Eighty‐three studies were included in the meta‐analysis. There was a 2% difference in successful intubation proportion for physicians versus nonphysicians, 99% (95% confidence interval [CI] 98% to 99%) versus 97% (95% CI 95% to 99%). A 10% difference in first‐pass rapid sequence intubation success was noted between physicians versus nonphysicians, 88% (95% CI 83% to 93%) versus 78% (95% CI 65% to 89%). For airway trauma, bradycardia, cardiac arrest, endobronchial intubation, hypertension, and hypotension, lower prevalences of adverse events were noted for physicians. However, nonphysicians had a lower prevalence of hypoxia and esophageal intubations. Similar proportions were noted for pulmonary aspiration and emesis. Nine adverse events estimates lacked precision, except for endobronchial intubation, and 4 adverse event analyses showed evidence of possible publication bias. Consequently, no reliable evidence exists for differences between physicians and nonphysicians for adverse events. Conclusion: This analysis shows that physicians have a higher rapid sequence intubation first‐pass and overall success, as well as mostly lower rates of adverse events for rapid sequence intubation in the out‐of‐hospital setting. Nevertheless, for all success and adverse events no firm conclusion for a difference could be drawn because of lack of precision of meta‐analytic estimates or selective reporting. First‐pass success could be an area in which to focus quality improvement strategies for nonphysicians.

Assessment of safe endotracheal tube cuff pressures in emergency care - time for change?

2 To avoid tracheal injury due to emergency intubation, it is important that ETT cuff over-inflation is avoided in the pre-hospital and ED phases of emergency care. Although ETT cuff pressure manometry is optimal in determining safe ETT cuff pressure, it is standard practice in the ED and in the pre-hospital emergency care environment to assess ETT cuff pressure using palpation of the cuff s pilot balloon - a qualitative technique prone to subjective interpretation. Aimsaims of the study were to describe the ability of a convenience sample of practising ALS paramedics and emergency doctors in Johannesburg to accurately estimate safe ETT cuff pressures using palpation of the cuff s pilot balloon alone, and to determine whether there was any dependence between correctness of ETT cuff estimation and the practitioners years of clinical experience and estimated monthly number of intubations.

Three Insulation Methods to Minimize Intravenous Fluid Administration Set Heat Loss

Abstract Objective. To assess the effect of three methods for insulating an intravenous (IV) fluid administration set on the temperature of warmed fluid delivered rapidly in a cold environment. Methods. The three chosen techniques for insulation of the IV fluid administration set involved enclosing the tubing of the set in 1) a cotton conforming bandage, 2) a reflective emergency blanket, and 3) a combination of technique 2 followed by technique 1. Intravenous fluid warmed to 44°C was infused through a 20-drop/mL 180-cm-long fluid administration set in a controlled environmental temperature of 5°C. Temperatures in the IV fluid bag, the distal end of the fluid administration set, and the environment were continuously measured with resistance thermosensors. Twenty repetitions were performed in four conditions, namely, a control condition (with no insulation) and the three different insulation methods described above. One-way analysis of variance was used to assess the mean difference in temperature between the IV fluid bag and the distal fluid administration set under the four conditions. Results. In the control condition, a mean of 5.28°C was lost between the IV fluid bag and the distal end of the fluid administration set. There was a significant difference found between the four conditions (p < 0.001). A mean of 3.53°C was lost between the IV fluid bag and the distal end of the fluid administration set for both the bandage and reflective emergency blanket, and a mean of 3.06°C was lost when the two methods were combined. Conclusion. Using inexpensive and readily available materials to insulate a fluid administration set can result in a reduction of heat loss in rapidly infused, warmed IV fluid in a cold environment.

Meeting national response time targets for priority 1 incidents in an urban emergency medical services system in South Africa: More ambulances won't help

BACKGROUND Response time is viewed as a key performance indicator in most emergency medical services (EMS) systems. OBJECTIVE To determine the effect of increased emergency vehicle numbers on response time performance for priority 1 incidents in an urban EMS system in Cape Town, South Africa, using discrete-event computer simulation. METHOD A simulation model was created, based on input data from part of the EMS operations. Two different versions of the model were used, one with primary response vehicles and ambulances and one with only ambulances. In both cases the models were run in seven different scenarios. The first scenario used the actual number of emergency vehicles in the real system, and in each subsequent scenario vehicle numbers were increased by adding the baseline number to the cumulative total. RESULTS The model using only ambulances had shorter response times and a greater number of responses meeting national response time targets than models using primary response vehicles and ambulances. In both cases an improvement in response times and the number of responses meeting national response time targets was observed with the first incremental addition of vehicles. After this the improvements rapidly diminished and eventually became negligible with each successive increase in vehicle numbers. The national response time target for urban areas was never met, even with a seven-fold increase in vehicle numbers. CONCLUSION The addition of emergency vehicles to an urban EMS system improves response times in priority 1 incidents, but alone is not capable of the magnitude of response time improvement needed to meet the national response time targets.

THE EFFECT OF THE EMERGENCY MEDICAL SERVICES VEHICLE LOCATION AND RESPONSE STRATEGY ON RESPONSE TIMES

Response time is currently considered to be an important performance indicator in Emergency Medical Services (EMS) systems. A number of factors may affect response times, including the location of emergency vehicles and the type of response system design used. This study aimed to assess the effects of emergency vehicle location and response system design on response time performance in a model of a large South African urban EMS system, using discrete-event simulation. Results indicated that both the emergency vehicle location and response system design factors had a significant effect on r

The Effect of Physical Exertion in Chemical and Biological Personal Protective Equipment on Physiological Function and Reaction Time

Abstract Objectives. The primary objective of this study was to describe and compare changes in heart rate, venous pH, venous partial pressure of carbon dioxide (pCO2), venous bicarbonate level, lactate level, oxygen saturation (SpO2), and tympanic membrane (TM) temperature occurring in a group of healthy volunteers during 20 minutes of physical exertion, both with and without chemical and biological personal protective equipment (PPE). A further aim was to establish whether any significant prolongation of reaction time occurred after physical exertion in chemical and biological PPE, compared to baseline values without the protective equipment. Methods. Nineteen highly fit volunteers were subjected to a baseline reaction time test and measurement of physiological variables. They were then subjected to physical exertion on a treadmill: once while wearing a short-sleeved t-shirt, shorts, and running shoes and once while wearing chemical and biological PPE. Repeat measurements of the physiological variables were made after 10 and 20 minutes of physical exertion in both groups, after which repeat reaction time tests were conducted. Results. Results showed that physical exertion of 20 minutes undertaken by highly fit volunteers wearing PPE resulted in a higher heart rate response and TM temperature compared with control measurements. Decreased venous pH and increased venous pCO2 were also observed during exertion in the PPE group. Although differences in these variables between the control and PPE groups were statistically significant, they were not of clinical relevance in the sample of volunteers studied. No significant difference in reaction time before and after exertion in PPE was identified. Conclusions. This study did not identify any effect of 20 minutes of heavy exercise in highly fit volunteers wearing level C chemical and biological PPE on reaction time. Heart rate response and TM temperature were higher during exertion in PPE. These differences, along with other physiological alterations observed, were not of clinical relevance. Further studies using arterial blood gas analysis and a more accurate measure of core body temperature are needed to better assess the physiological effect of this level and duration of exercise on subjects wearing similar PPE. Other aspects of cognition also require investigation under these conditions, in order to assess their effect on patient and rescuer safety.

Access to out-of-hospital emergency care in Africa: Consensus conference recommendations

Out-of-hospital emergency care (OHEC) should be accessible to all who require it. However, available data suggests that there are a number of barriers to such access in Africa, mainly centred around challenges in public knowledge, perception and appropriate utilisation of OHEC. Having reached consensus in 2013 on a two-tier system of African OHEC, the African Federation for Emergency Medicine (AFEM) OHEC Group sought to gain further consensus on the narrower subject of access to OHEC in Africa. The objective of this paper is to report the outputs and statements arising from the AFEM OHEC access consensus meeting held in Cape Town, South Africa in April 2015. The discussion was structured around six dimensions of access to care (i.e. awareness, availability, accessibility, accommodation, affordability and acceptability) and tackled both Tier-1 (community first responder) and Tier-2 (formal prehospital services and Emergency Medical Services) OHEC systems. In Tier-1 systems, the role of community involvement and support was emphasised, along with the importance of a first responder system acceptable to the community in which it is embedded in order to optimise access. In Tier-2 systems, the consensus group highlighted the primacy of a single toll-free emergency number, matching of Emergency Medical Services resource demand and availability through appropriate planning and the cost-free nature of Tier-2 emergency care, amongst other factors that impact accessibility. Much work is still needed in prioritising the steps and clarifying the tools and metrics that would enable the ideal of optimal access to OHEC in Africa.

Position statement. Pre-hospital rapid sequence intubation.

The Professional Board for Emergency Care at the Health Professions Council of South Africa (HPCSA) has approved pre-hospital rapid sequence intubation (RSI) as part of the scope of practice for registered emergency care practitioners (ECPs). RSI is an advanced airway management process that facilitates endotracheal intubation in adults and children. Features of this technique include pre-oxygenation, rapid pharmacological induction of unconsciousness, and neuromuscular blockade to enable the placement of an endotracheal tube. RSI has become widespread as the procedure of choice for definitive airway management by pre- and in-hospital emergency care personnel worldwide. In the emergency department setting, RSI is superior to intubation with deep sedation, a technique not incorporating pharmacological paralysis as part of the intubation sequence. For this reason, the implementation of RSI in the pre-hospital environment is supported, provided that it is practised within an appropriate framework of clinical governance.

Student Paramedic Experience with Prehospital Cardiac Arrest Cases in Johannesburg, South Africa

Objective. To describe the exposure of paramedic students studying at university level to prehospital cardiac arrest cases encountered during clinical learning. Method. Prehospital cardiac arrest cases included in an electronic clinical learning database between 2001 and 2007 were extracted and subjected to descriptive analysis in terms of student exposure and resuscitation-related procedures carried out by students. Results. On average, approximately 50% of first-and second-year students had any exposure to adult cardiac arrest cases, whereas approximately 75% of third-year students did. Very few students had any exposure to pediatric cases. Students who were exposed to cardiac arrest cases averaged two cases in the first and second years and three cases in the third year. The average maximum exposure for first-and second-year students was four cases and the average for third-year students was six cases. Less than half of the students exposed to cardiac arrest cases in any academic year of study were able to practice basic adult or pediatric resuscitation-related procedures. Relatively few students had any experience of adult or pediatric venous cannulation or management of patients with return of spontaneous circulation. Conclusion. In general, the exposure of paramedic students to prehospital cardiac arrest cases was low, as was their opportunity to practice resuscitation procedures in this context.