M. W. G. Gordon

An evaluation of paramedic activities in prehospital trauma care

The object of the study was to identify the effect paramedics have on prehospital trauma care and evaluate their influence on outcome compared to that of ambulance technicians. A prospective review of ambulance and hospital records was conducted over 2 years from 1 August 1993 to 31 July 1995. The setting for the study was the Royal Infirmary of Edinburgh and its primary response catchment area served by the South-East Region of the Scottish Ambulance Service central control room. The study involved 1090 patients brought to hospital by ambulance who met the entry criteria for the Scottish Trauma Audit Group study. The results show that paramedics spend significantly longer at scene than the ambulance technicians; however, there was no difference in total prehospital times between the groups. Paramedics direct a significantly higher proportion of patients to the resuscitation room and significantly more of these patients go to theatre, intensive care or the mortuary. There is no reduction in mortality or length of stay in intensive care in the paramedic group. The authors conclude that paramedics deliver an improved process of care but their activities do not significantly reduce mortality or length of stay in intensive care.

Prehospital trauma management: a national study of paramedic activities

Objectives: The benefits of prehospital trauma management remain controversial. This study aimed to compare the processes of care and outcomes of trauma patients treated by paramedics, who are trained in advanced prehospital trauma care, with those treated by ambulance technicians. Methods: A six year prospective study was conducted of adult trauma patients attended to by the Scottish Ambulance Service and subsequently admitted to hospital. Prehospital times, interventions, triage, and outcomes were compared between patients treated by paramedics and those treated by technicians. Results: Paramedics attended more severely injured patients (16.5% versus 13.9%, p<0.001); they attended a higher proportion of patients with penetrating trauma (6.6% versus 5.7%, p = 0.014) and had longer prehospital times. Patients managed by paramedics were more likely to be taken to the intensive care unit, operating theatre or mortuary, (11.2% versus 7.8%, p<0.001) and had higher crude mortality rates (5.3% versus 4.5%, p = 0.07). However, no difference in mortality between the two groups was noted when corrected for age, Glasgow coma score and injury severity score. Conclusions: This large scale national study shows that paramedics show good triage skills and clinical judgement when managing trauma patients. However, the value of the individual interventions they perform could not be ascertained. Further controlled trials are necessary to determine the true benefits of advanced prehospital trauma life support.

Appointment of a Resuscitation Training Officer is associated with improved survival from in-hospital ventricular fibrillation/ventricular tachycardia cardiac arrest

OBJECTIVE To determine if the appointment of a Resuscitation Training Officer improves survival to discharge from in-hospital ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. DESIGN A 22-month prospective study. SETTING A 1100-bed teaching hospital. SUBJECTS All inpatients suffering ventricular fibrillation or ventricular tachycardia cardiorespiratory arrests. INTERVENTIONS Appointment of a Resuscitation Training Officer at start of study, who introduced coordinated resuscitation training for all staff. MAIN OUTCOME Survival to discharge. RESULT Improvement in survival to discharge of 20-75% (P<0.03, Spearman Rank Correlation test). CONCLUSION Appointment of a Resuscitation Training Officer is associated with improved survival to discharge in ventricular fibrillation and ventricular tachycardia in-hospital cardiac arrest.

Status epilepticus in accident and emergency: a difficult case.

Status epilepticus is an acute medical emergency requiring effective immediate treatment to avoid excess morbidity and mortality.1 It is generally regarded as seizure activity lasting continuously for more than 20 minutes or multiple seizures with incomplete recovery between seizures lasting a total of 20 minutes or more, as this is the period necessary to cause injury to neurones.2 It is a relatively common presentation in accident and emergency (A&E) practice and it can present considerable difficulties in management. We present a case of status epilepticus that raised several therapeutic issues. A 20 year old man was brought to the A&E department by emergency ambulance. He had a past medical history of post-traumatic epilepsy after sustaining a depressed skull fracture eight years earlier. He had been found by his father at home 80 minutes earlier having continuous tonic-clonic seizures. The ambulance crew had administered high flow oxygen via a nasopharyngeal airway and administered 10 mg intravenous (IV) diazepam (Diazemuls) en route to hospital. On arrival, rapid examination confirmed continuing tonic-clonic status epilepticus. Vital signs were as follows: pulse rate 140 beats per minute, sinus rhythm; respiratory rate 25 per minute; non-invasive blood pressure 130/80 mm Hg; oxygen saturation 98% (on high flow oxygen). He had trismus complicated by copious secretions, but basic airway manoevres, a nasopharyngeal airway and suction proved sufficient to maintain a patent airway. There was no evidence of recent, new head injury and his blood glucose was 7.0 mmol/l on bedside testing. He was given IV lorazepam 4 mg with no effect; this was repeated after five minutes, again with no effect. Background information was available from the patients father. He had been admitted two …