Craig Vincent-Lambert

Use of Morphine Sulphate by South African Paramedics for Prehospital Pain Management

Pain management in the prehospital setting (ie, in patients being transported to the emergency department) has been described as inadequate in the literature, similar to pain management in the emergency department. Morphine is one of the most commonly used analgesics administered by paramedics who are treating patients being transported to hospital. This study included 60 paramedics practicing in South Africa, who responded to a survey querying their use of morphine in the prehospital environment. The results reveal the ways in which actual morphine administration differs from recommendations on administration, and suggests reasons for this as well as potential resolutions.

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.

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.

Hypothermia in trauma patients arriving at an emergency department by ambulance in Johannesburg, South Africa: a prospective study

Introduction Normal body temperature is considered to be between 36 and 38°C. Temperatures that are too low may negatively affect physiological functions. In trauma cases, factors that promote the development of hypothermia include concomitant hypoxia, hypotension, decreased levels of consciousness, contact with cold surfaces, exposure to low ambient temperatures and the administration of cold fluids. Studies on emergency department related hypothermia in Africa are sparse. This study investigated instances of hypothermia in a sample of trauma cases arriving by ambulance to an emergency department in Johannesburg, South Africa. Methods Core body temperatures of 140 trauma cases were measured upon arrival and 30 minutes later. Ambient temperatures outside the hospital, inside the ED and in the resuscitation areas were also recorded. Additional information was gathered describing the equipment available to the ambulance crews for temperature, control and rewarming. Results Seventy-two (51%) of the cases were found to have core body temperatures less than 36°C upon arrival. Twenty-nine (21%) the cases were considered clinically hypothermic (core temperatures of less than <35°C). After 30 minutes, 79 (56%) of the participants had core body temperatures of less than 36°C and 39 (28%) remained lower than 35°C. Patients were not warming up in the ED as expected. Rather, some had become colder. The study also found that the ambient temperature in the triage area fluctuated and was recorded as less than the recommended 21°C in 95 (68%) of the cases. In addition, the majority of ambulances that transported these cases lacked appropriate equipment on board to properly facilitate temperature control and rewarming. Conclusion Fifty-one percent of the trauma cases arriving by ambulance had core temperature <36°C. Many became even colder in the ED. Attention needs to be given to the early identification of hypothermia, the regulation of ambient temperatures inside the ED including the provision of appropriate heating and rewarming devices on ambulances.

A Randomized Controlled Trial to Assess the Impact of Upfront Point-of-Care Testing on Emergency Department Treatment Time

Objectives To compare standard emergency department (ED) workflow to a protocolized pathway using upfront point-of-care (POC) tests performed prior to doctor evaluation to determine if this could produce a significant reduction in treatment time. Methods We performed a prospective, randomized, controlled trial. Patients were randomized to receive the standard of care or one of the enhanced workflow pathways with POC tests. Results There were 1,044 patients enrolled. All workflows, except electrocardiogram and low-dose x-ray (LODOX), exceeded the outcome measure (20% reduction in treatment time). It was significantly shorter compared with the control workflow if the patient received any (i-STAT + CBC)-containing workflows (P = .0001, P = .020, P = .0009, P = .011), as well as the i-STAT + LODOX workflows (P = .0001, P = .034). Conclusions The full benefit of POC testing can be realized if it is implemented prior to doctor evaluation, as part of a standardized procedure in the ED. This allows for a more rapid availability of investigation results subsequently leading to decreased treatment times.

Challenges relating to the inter-facility transport of high acuity paediatric cases

Introduction The motivation for this study came from anecdotal reports and observations that there was a potential need for improvement to the systems that support inter-facility transfers of high acuity paediatric cases between referring and receiving facilities in Johannesburg, South Africa. In this exploratory study, we formally document and describe challenges being experienced by members of the healthcare team in facilitating the inter-facility transport of high acuity paediatric cases. Methods A qualitative, explorative design was applied, making use of interviews with purposefully-identified role players involved in paediatric transportation and care. Verbatim transcripts from audio recorded interviews underwent content analysis to allow for the identification of common categories. Results Participants described a number of challenges, which included time delays, lack of qualified ambulance personnel, poor communication between role players, and lack of appropriate equipment. Discussion There are significant challenges experienced by members of the healthcare team with regard to inter-facility transport of high acuity paediatric and neonatal cases in Johannesburg, South Africa. Whilst we acknowledge the African context and resource constrained setting, health systems managers need to explore the feasibility of establishing dedicated and suitably resourced retrieval teams who specialise in the transfer of high acuity paediatric and neonatal patients in order to improve quality of care and overall patient outcomes in this population.

Paediatric weight estimation practices of advanced life support providers in Johannesburg, South Africa

Introduction The choice of weight estimation method to use during prehospital paediatric emergency care is important because it needs to be both accurate and easy to use. Accuracy is important to ensure optimum drug dosing while ease-of-use is important to minimise user errors and the cognitive load experienced by healthcare providers. Little is known about which weight estimation systems are used in the prehospital environment anywhere in the world. This knowledge is important because if the use of inappropriate weight estimation practices is identified, it could be remedied through education and institutional policies. Methods This was a prospective questionnaire study conducted in Johannesburg, South Africa, which obtained information on the knowledge, attitude and practice of weight estimation amongst advanced life support (ALS) paramedics. Results Forty participants were enrolled, from both the public and private sectors. The participants’ preferred method of weight estimation was visual estimation (7/40; 18%), age-based formulas (16/40; 40%), parental estimation (3/40; 8%), the Broselow tape (2/40; 5%) and the PAWPER tape (11/40; 28%). No participant was familiar with or used the Mercy method. All participants were very confident in the accuracy of their selected system. Discussion The knowledge and understanding of weight estimation systems by many advanced life support paramedics was poor and the use of inappropriate weight estimation systems was common. Further education and intervention is needed in order to change the sub-optimal weight estimation practices of ALS paramedics in Johannesburg.

Views of emergency care providers about factors that extend on-scene time intervals

Introduction Rapid response, patient care and transportation remain recognised goals of the Emergency Medical Services (EMS). Spending more time on-scene may delay the initiation of definitive care interventions. This study focused on describing the perceptions of a sample of emergency care providers regarding the impact of environmental, clinical and systemic factors with respect to their on-scene time intervals. Method The study was descriptive and prospective in nature making use of a self-designed questionnaire. Basic descriptive methods were used during the analysis of the participants’ responses to 16 close-ended questions. A further review of the limited narrative elicited by two open-ended questions allowed for the reporting of additional views and opinions. Results Thirty-three (92%) participants agreed that extended time on-scene may negatively affect patient outcome. Twenty-three (64%) agreed that spending longer than 20 min on-scene may be considered excessive for medical emergencies and 28 (77%) felt the same for trauma cases. Respondents felt that many of the environmental, clinical and systemic factors mentioned in the questionnaire do have the potential to extend on-scene time intervals. The factors that were seen to have the greatest effect included waiting for fire, rescue and police services, patient acuity, the use of an air ambulance, patient extrication and multi-casualty incidents. Discussion There are a number of environmental, clinical and systemic factors that emergency care providers indicate have the potential to extend on-scene time intervals. Acknowledging and attempting to address these factors is important for EMS as limiting the time spent on-scene is not only clinically desirable but may also lead to improved efficiency and availability of resources.

International Perspectives: South African Ambulance Services in 2020

Prior to 1980, ambulance services in South Africa were almost solely rendered by public sector emergency services. Levels of care and associated training differed between regions and provinces. There was little or no recognition for emergency care providers as independent healthcare professionals. Consequently, working on an ambulance was often seen as an “unwanted” add-on or adjunct to a more formally recognised primary role of municipal traffic officer, firefighter or civil defence volunteer. The lack of professional recognition and standing was in part as a result of an absence of formal higher education qualifications in emergency medical care at that time. Emergency care training which did occur was in-service and largely “skills based,” taking the form of short courses which ranged from only a few weeks to months. Post 1994, service delivery failures of an under-resourced public sector resulted in the emergence and rapid expansion of private ambulance services. Since the mid-nineties we have seen the South African emergency care profession begin to professionalise. The professionalization of ambulance services has been characterised by a gradual movement away from the historical “doctor-driven” technician system of the 1980s toward a separate self-regulated autonomous stand-alone profession. Emergency care practitioners now able to register and function as independent clinicians / practitioners and the historical short-course training system is in the process of being phased out in favour of formal 1-, 2- and 4-year higher education qualifications. Consequently, in South Africa the responsibility for clinical decision-making, interrogation, critique and development of prehospital medical protocol and direction is now largely driven and owned by South African paramedics themselves.

Factors Affecting the Frequency of Vascular Access via Intraosseous Cannulation performed by Paramedics in Johannesburg

Purpose In an emergency, the administration of fluids and medications remains a vital component of patient care. Although this is usually achieved via an intravenous line, intraosseous (IO) cannulation is accepted as a useful alternative for the administration of fluids and medications in situations where intravenous cannulation is difficult or impossible. Despite this, IO cannulation appeared to be infrequently performed by paramedics in Johannesburg (JHB). This study investigated factors that may be affecting the frequency with which IO cannulation is performed by paramedics in JHB. Methods A qualitative design was utilized making use of one-on-one interviews with 12 purposefully selected operational paramedics from emergency medical services in JHB. The interviews were recorded and transcribed. Introspective analysis and interpretive phenomenological analysis were conducted to identify emerging themes and patterns. Results IO cannulation is infrequently performed by paramedics in JHB. Factors identified that reduce the likelihood of the procedure being performed included “Negative Perceptions Relating to the Procedure”; “Practitioner Success at Intravenous Cannulation”; “Close Proximity of Hospitals”; “Patient Profile, Presentation and Case Load”; “Lack of Appropriate Equipment”; and “Lack of Appropriate Training.” Conclusion Procedures are more inclined to move from the in-hospital to the prehospital environment if they are seen to be commonly performed, safe and effective. It would appear that paramedics infrequently witness IO cannulation being performed in emergency departments. This together with a lack of appropriate equipment, training and retraining including the perceived invasiveness and pain associated with the procedure appears to be dissuading paramedics from regularly performing IO cannulation.