Graham Munro

Achy breaky makey wakey heart? A randomised crossover trial of musical prompts

Objective Compared with no music (NM), does listening to ‘Achy breaky heart’ (ABH) or ‘Disco science’ (DS) increase the proportion of prehospital professionals delivering chest compressions at 2010 guideline-compliant rates of 100–120 bpm and 50–60 mm depths? Methods A randomised crossover trial recruiting at an Australian ambulance conference. Volunteers performed three 1-min sequences of continuous chest compressions on a manikin accompanied by NM, repeated choruses of ABH and DS, prerandomised for order. Results 37 of 74 participants were men; median age 37 years; 61% were paramedics, 20% students and 19% other health professionals. 54% had taken cardiopulmonary resuscitation training within 1 year. Differences in compression rate (mode, IQR) were significant for NM (105, 99–116) versus ABH (120, 107–120) and DS (104, 103–107) versus ABH (p<0.001) but not NM versus DS (p=0.478). Differences in proportions of participants compressing at 100–120 bpm were significant for DS (61/74, 82%) versus NM (48/74, 65%, p=0.007) and DS versus ABH (47/74, 64%, p=0.007) but not NM versus ABH (p=1). Differences in compression depth were significant for NM (48 mm, 46–59 mm) versus DS (54 mm, 44–58 mm, p=0.042) but not NM versus ABH (54 mm, 43–59 mm, p=0.065) and DS versus ABH (p=0.879). Differences in proportions of subjects compressing at 50–60 mm were not significant (NM 31/74 (42%); ABH 32/74 (43%); DS 29/74 (39%); all p>0.5). Conclusions Listening to DS significantly increased the proportion of prehospital professionals compressing at 2010 guideline-compliant rates. Regardless of intervention more than half gave compressions that were too shallow. Alternative audible feedback mechanisms may be more effective.

Paramedic empathy levels: results from seven Australian universities

Purpose Evidence suggests that improved empathy behaviours among healthcare professionals directly impacts on healthcare outcomes. However, the ‘nebulous’ properties of empathic behaviour often means that healthcare profession educators fail to incorporate the explicit teaching and assessment of empathy within the curriculum. This represents a potential mismatch between what is taught by universities and what is actually needed in the healthcare industry. The objective of this study was to assess the extent of empathy in paramedic students across seven Australian universities. Methods A cross-sectional study using a paper-based questionnaire employing a convenience sample of first, second, and third year undergraduate paramedic students. Student empathy levels were measured using a standardised self-reporting instrument: Jefferson Scale of Physician Empathy – Health Profession Students (JSPE-HPS). Findings A total of 783 students participated in the study of which 57% were females. The overall JSPE-HPS mean score was 106.74 (SD=14.8). Females had greater mean empathy scores than males 108.69 v 103.58 (p=0.042). First year undergraduate paramedic mean empathy levels were the lowest, 106.29 (SD=15.40) with second years the highest at 107.17 (SD=14.90). Value The overall findings provide a framework for educators to begin constructing guidelines focusing on the need to incorporate, promote and instil empathy into paramedic students in order to better prepare them for future out-of-hospital healthcare practice.

Use of mechanical ventilation protocols in intensive care units: A survey of current practice

INTRODUCTION Mechanical ventilation protocols for treating intensive care unit (ICU) patients are often recommended to improve process of care and outcomes, but their composition may be variable and penetration into clinical practice may be incomplete. We sought to ascertain ICU and hospital characteristics associated with adoption of mechanical ventilation (MV) protocols in Ontario, Canada. METHODS We surveyed respiratory therapy leaders in all 97 Ontario hospitals capable of providing MV in an ICU. RESULTS We received responses from 70 hospitals (72.2%). Two-thirds (46/67; 68.7%) of hospitals reported having a respiratory therapist on duty 24 hours/7 days per week. Mechanical ventilation protocols were present in most hospitals (47/67; 70.2%), but low tidal volume ventilation was incorporated into only half of these protocols (24/44; 54.5%). Factors associated with reported use of MV protocols were intensivist-staffing model (89.3% vs 56.4%; odds ratio [OR], 6.44; [95% confidence interval {CI}, 1.66-25.0; P = .007]), presence of daily multidisciplinary rounds (84.4% vs 42.9%; OR, 7.24 [95% CI, 2.22-23.6; P = .001]), and presence of 24 hour/7 days per week respiratory therapist coverage (87.0% vs 36.4%; OR, 11.7 [95% CI, 3.44-39.6; P < .001]). The likelihood of having an MV protocol also increased with increasing patient-to-physician ratio (OR for each increase of 1 patient, 1.17 [95% CI, 1.01-1.35; P = .034] and increasing ICU size (OR for each additional ICU bed, 1.05 [95% CI, 1.00-1.10; P = .04]). CONCLUSION Most surveyed hospitals reported the presence of a protocol for MV, but only half of these incorporated low tidal volume ventilation. Several organizational factors were associated with adoption of protocols, and therefore, these should also be considered when evaluating the impact of protocols on clinical outcomes.

Undergraduate paramedic students' attitudes to e-learning: findings from five university programs

Computers and computer-assisted instruction are being used with increasing frequency in the area of undergraduate paramedic education. Paramedic students’ attitudes towards the use of e-learning technology and computer-assisted instruction have received limited attention in the empirical literature to date. The objective of this study was to determine paramedic students’ attitudes towards e-learning. A cross-sectional methodology was used in the form of a paperbased survey to elicit students’ attitudes to e-learning using three standardised scales. Convenience sampling was used to sample a cross-section of paramedic students at five universities during semester 1 of 2009. The scales used were: the Computer Attitude Survey (CAS), the Online Learning Environment Survey (OLES), and the Attitude Toward CAI Semantic Differential Scale (ATCAISDS). There were 339 students who participated. Approximately onehalf (57.7%) were female and most (76.0%) were under 24 years of age. Moderate results were noted for the CAS general and education subscales. The CAS results were broadly corroborated by the OLES, although a statistically significant difference between participants preferred and actual results on the OLES Computer Usage subscale identified that participants would prefer to use computers less than they actually do. Similarly, the ATCAISDS found participants were largely ambivalent towards computers. As paramedic degree programs continue to emerge and develop, careful consideration should be given to the usability and utility of various e-learning approaches.

Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single‐use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single‐use bougie, 16/60 (27%) using a Frova single‐use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

What price 90 seconds: is ‘Call Connect’ a disservice to 999 callers?

In 2005 the UK Department of Health published ‘ Taking healthcare to the patient: transforming NHS ambulance services ’.1 This insightful and imaginative report was intended to deliver ambulance services fit for the 21st century. It made 70 recommendations, most of which gave particular focus to addressing the (currently unmet) needs of the majority of users of the 999 service, up to 80% of which have a non-life threatening or even a non-urgent clinical condition. One of the reports recommendations, which was unrelated to patients with non-urgent unscheduled care needs, has since however dominated the attention of ambulance service managers to such an extent that it has had a negative impact on progress in most other areas. In accordance with this recommendation, in 2008 a new definition for the key Department of Health performance measure of ambulance response times was introduced. Previously the ‘clock-start’ for measuring response times occurred when a patients chief complaint had been confirmed: this was now moved back to the point at which the telephone call was received in the ambulance dispatch centre—hence the title ‘ Call Connect ’ for this policy revision.2 Consequently, responding emergency vehicles now have, on average, a 90 s reduction in the time available for them to drive to a patient within the otherwise unchanged 7 min and 59 s target. The premise of ‘ Call Connect ’ is based on the view that achieving this revised 8 min target will make ‘ … a real difference to patients and the way we deliver patient care ’, and has been publicised as a great advance in ambulance service delivery.2 It builds on previous technical analyses of how to measure call times accurately and to present …

Malleable stylet vs re-useable and disposable bougies in a model of difficult intubation: a randomised cross-over trial

Introduction Paramedics’ intubation success rates with Cormack and Lehane grade III/IV views have been reported to be 0%. Misplaced tracheal tubes occur in 5.8 to 25% of all pre-hospital intubations: 67 to 75% of these are in the oesophagus. This trial evaluated four adjuncts in a simulated pre-hospital difficult intubation. Methods Pre-hospital laryngoscopists attending the Australian College of Ambulance Professionals (ACAP) conference (September 2007) attempted to intubate a manikin model of a grade III/IV view using each of three different tracheal tube introducers (bougies) and a malleable stylet in accordance with a prospectively randomised sequence (one attempt per device). Successful intubation was defined as correct placement within 30 seconds. Results 19/65 (29%) of the participants claimed previous experience with a bougie and 46/65 (71%) with a stylet. Intubation success rates were 37/65 (57%) with the stylet and with the bougies 22/65 (34%, Portex (Sims Portex Ltd, Hythe, UK) single-use), 17/65 (26%, Frova, William Cook Europe, Bjaeverskov, Denmark) and 6/65 (9%, Portex re-usable), p,0.0001. There was no correlation between intubation success and prior experience. Oesophageal intubation rates were 19/65 (29%, stylet); 29/65 (45%, Portex single-use); 21/65 (32%, Fova); and 27/65 (42%, Portex re-usable), p = 0.026. Median times to intubation (with ranges) were 20 s (6 to 60 s, stylet); 30 s (15 to 60 s, Portex single-use); 42 s (12 to 60 s, Fova); and 49 s (16 to 60 s, Portex re-usable), p,0.001. Median difficulty-of-use scores (with 100 representing ‘‘very difficult’’) were 30, 28, 40, and 80 for the stylet, Portex single-use, Frova, and Portex re-usable respectively, p,0.001. Limitations The results of manikin studies should not be assumed to accurately predict outcomes in human patients. Conclusion In pre-hospital laryngoscopists attending the ACAP 2007 conference, a malleable stylet facilitated the highest intubation success rate within the shortest interval in a manikin model of a grade III/IV view. There were significant between-device differences in oesophageal intubation rates and user-rated difficulty-of-use scores. Abstract 011 Table

Looking after Yourself

The development of a career as an academic can be a very rewarding experience, but many entering this career are unprepared for what the role actually entails. This lack of preparedness can bring unnecessary stress to new academics, delaying their achievement of career goals. In this chapter we aim to help reduce this unpreparedness by highlighting some common difficulties experienced by new academics. We provide context for the competing demands and outline key lessons to be learned from the experiences of those who have journeyed before you.

A11 Achy Breaky Makey Wakey Heart

Background Music has been recommended as an aid to improving chest compression quality, but research indicates the popular European tune “Nellie the Elephant” reduces the proportion of lay-persons compressing at the correct depth. Objectives Compared to no music (NM), does listening to “Achy Breaky Heart” (ABH) or “Disco Science” (DS) increase the proportion of CPR-trained health professionals delivering compressions at the 100 bpm recommended rate and 4–5 cm depth? Methods Randomised cross-over trial recruiting at the 2009 ACAP conference. Findings Of 74 participants 50% were male; median age was 37; 61% were paramedics, 20% students, and 19% other health professionals. 54% had taken CPR training within 1 year. Mode and IQR for compression rate were NM 105 (99–116); ABH 120 (107–120); DS 104 (103–107). Differences between-interventions were significant for NM vs ABH and DS vs ABH (p<0.001) but not NM vs DS (p=0.478). Compression rates of 95-105 were achieved with NM, ABH, and DS for 26/74 (35%), 8/74 (11%) and 34/74 (46%) of participants respectively. Differences were significant for NM vs ABH (p=0.0005) and DS vs ABH (p<0.0001) but not NM vs DS (p=0.256). RR for a compression rate of 95-105 for ABH vs NM=0.31, for DS vs NM=1.31 (not significant) and for DS vs ABH=4.25. The number needed to harm was 5 for listening to ABH vs NM and 3 for ABH vs DS. A high proportion of compressions were too deep (NM 86%; ABH 79%; DS 77%, differences not significant). Conclusions Listening to Disco Science while performing CPR did not increase the proportion of prehospital professionals delivering compressions correctly. Perhaps unsurprisingly, listening to Achy Breaky Heart had a negative effect. Disconcertingly, regardless of the nature or absence of musical accompaniment, the majority of participants did not compress at the recommended rate or depth.