Malcolm Woollard

Levels of mental health problems among UK emergency ambulance workers

This study examined the prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety in a sample of emergency ambulance personnel. Of 1029 personnel in one ambulance service mailed a questionnaire, 617 were returned. Among respondents, the overall rate of PTSD was 22%. Levels of PTSD did not differ according to grade, but men had a higher prevalence rate than women (23% compared with 15%). Nearly one in ten reported probable clinical levels of depression, 22% reported probable clinical levels of anxiety based on Hospital Anxiety and Depression Scale scores.

Associations between organizational and incident factors and emotional distress in emergency ambulance personnel

OBJECTIVESnThis study examined the prevalence and correlates of post-traumatic stress disorder (PTSD), anxiety and depression among emergency ambulance personnel.nnnDESIGN AND METHODnA questionnaire and reminder were sent anonymously to 1029 emergency ambulance personnel in a large ambulance service.nnnRESULTSnAmong the 617 respondents, levels of PTSD symptoms did not differ according to grade, but men had a higher prevalence rate than women. Key predictors of the severity of symptoms were organizational stress, the frequency of experiencing potentially traumatic incidents, length of service, and dissociation in response to an index incident. The degree of organizational, but not incident-related, stress discriminated between cases and non-cases. Nine and 23% of recorded scores indicated clinical levels of depression and anxiety respectively. Several work factors were associated with these emotions, explaining 38% of anxiety and 31% of depression scores.nnnCONCLUSIONnBoth organizational and individually based interventions may be necessary to minimize PTSD and other emotional disorders among ambulance personnel.

Reliability of the Cardiff Test of basic life support and automated external defibrillation version 3.1

The introduction of the European Resuscitation Guidelines (2000) for cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED) prompted the development of an up-to-date and reliable method of assessing the quality of performance of CPR in combination with the use of an AED. The Cardiff Test of basic life support (BLS) and AED version 3.1 was developed to meet this need and uses standardised checklists to retrospectively evaluate performance from analyses of video recordings and data drawn from a laptop computer attached to a training manikin. This paper reports the inter- and intra-observer reliability of this test. Data used to assess reliability were obtained from an investigation of CPR and AED skill acquisition in a lay responder AED training programme. Six observers were recruited to evaluate performance in 33 data sets, repeating their evaluation after a minimum interval of 3 weeks. More than 70% of the 42 variables considered in this study had a kappa score of 0.70 or above for inter-observer reliability or were drawn from computer data and therefore not subject to evaluator variability. 85% of the 42 variables had kappa scores for intra-observer reliability of 0.70 or above or were drawn from computer data. The standard deviations for inter- and intra-observer measures of time to first shock were 11.6 and 7.7 s, respectively. The inter- and intra-observer reliability for the majority of the variables in the Cardiff Test of BLS and AED version 3.1 is satisfactory. However, reliability is less acceptable with respect to shaking when checking for responsiveness, initial check/clearing of the airway, checks for signs of circulation, time to first shock and performance of interventions in the correct sequence. Further research is required to determine if modifications to the method of assessing these variables can increase reliability.

To blow or not to blow: a randomised controlled trial of compression-only and standard telephone CPR instructions in simulated cardiac arrest

This randomised controlled trial used a manikin model of cardiac arrest to compare skill performance in untrained lay persons randomised to receive either compression-only telephone CPR (Compression-only tel., n=29) or standard telephone CPR instructions (Standard tel., n=30). Performance was evaluated during standardised 10 min cardiac arrest simulations using a video recording and data from a laptop computer connected to the training manikin. A number of subjects in both groups did not open the airway. More than 75% in the Standard tel. group failed to deliver two effective initial rescue breaths, and only 17% provided an adequate inflation volume for subsequent breaths, delivering a median of only five inflations during the entire scenario. Most subjects in both groups gave chest compressions that were too shallow and at an inappropriately rapid rate. Hand position was also poor, but was worse in the group given simplified instructions. There was a significant delay to first compression in both groups, although this interval was shortened by over a minute when ventilations were eliminated from the telephone instruction algorithm (245 vs. 184 s, P<0.001). Over two-and-a-half times as many chest compressions were delivered during an average ambulance response time with compression-only telephone directions compared with standard CPR (461 vs. 186, P<0.001). These variables may be critical in predicting survival from out-of-hospital cardiac arrest. Further research is necessary to establish if modifications to scripted telephone instructions can remedy the identified performance deficiencies. Eliminating instructions for rescue breaths from scripted telephone directions will have little impact on the ventilation of most patients. Research is required to determine if the consequent reduction in the delay to starting chest compressions and the significant increase in the number of compressions delivered can increase survival from out-of-hospital cardiac arrest.

E MERGENCY C ALLS N OT R EQUIRING AN U RGENT A MBULANCE R ESPONSE : E XPERT C ONSENSUS

Objectives. This study sought expert consensus about which categories of patients from 248 Medical Priority (MPDS) ambulance dispatch codes might be appropriate for a nonemergency response or for whom dispatch of an ambulance might be appropriately denied if the patient were referred to a more suitable health care provider. Methods. A Delphi technique was used. Ten physicians, from the specialities of emergency medicine, general practice, and pre-hospital care formed the expert panel but were blinded to each others identity. Participants received a written description of the operation of the MPDS and the Delphi technique and voted independently by mail. Results. Using majority voting, 54 dispatch codes (22%) were recommended for a nonemergency response/referral. This equates to 12.44% of annual emergency calls in a typical UK ambulance service (n = 9,021; 95% confidence interval, 12.21 to 12.69%). The kappa statistic (chance-corrected proportional agreement) between members of the expert panel was 0.62 (substantial). Conclusions. The recommended dispatch codes for non-emergency response or referral represent a significant proportion of emergency ambulance calls. Theoretically, the implementation of nonemergency responses could have the benefit of reducing accidents involving emergency ambulances and could lead to improved response times for critically ill patients by freeing up resources. It could also support the targeting of patients to appropriate health care providers on first contact with the health service. However, given the poor reliability of expert opinion, further research using clinical outcome data is required to validate the recommendations made in this article before changing existing ambulance response systems.

Hitting them where it hurts? Low dose nalbuphine therapy

Objective: To determine if low dose nalbuphine provides an adequate reduction in pain with minimal side effects. Methods: Prospective cohort of 115 patients given nalbuphine by paramedics in Wales and the English borders. Outcome measures: (1) Mean total dose of nalbuphine administered, change in pain score, time to adequate pain relief (score below four), and change in respiratory rate and systolic blood pressure; (2) proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (3) incidence of adverse events. Results: Full data were obtained for all patients. The mean total dose of nalbuphine administered was 6.09 mg (range 2.5 to 12.5 mg). This was significantly higher in trauma than ischaemic chest pain patients (7.03 versus 5.13 mg). The mean reduction in pain score was −3.97 (95% CI −4.38 to −3.57, p<0.001). The mean time to adequate pain relief (where this was achieved) was 15.7 minutes (95% CI 13.4 to 17.9 minutes). On arrival at hospital 60% of patients (n=69, 95% CI 50.9 to 68.5%) still met ambulance criteria for analgesia (70.7% of trauma patients and 49.1% with ischaemic chest pain). Systolic blood pressure fell by a mean of −3.67 (95% CI −6.76 to −0.58, p=0.02) and respiratory rate increased by a mean of 1.63 (95% CI 1.08 to 2.17, p<0.001). Two patients complained of nausea (1.74%, 95% CI 0.5 to 6.0%). No other adverse events were reported. Conclusion: Low dose nalbuphine results in few adverse events, but offers poor pain control for a high proportion of patients.

Antipyretic prehospital therapy for febrile convulsions: Does the treatment fit? A literature review

Objective The objective of this literature search was to find evidence to support (or refute) the prehospital emergency use of antipyretic therapies, such as tepid sponging and paracetamol, to prevent the recurrence of febrile convulsions. Methods An on-line literature search was made of Medline. The key text words utilised were febrile convulsion(s); febrile seizure(s); infantile convulsion(s); paracetamol; acetaminophen; rectal administration; treatment; prevention; pathophysiology, (a)etiology; recurrence; tepid; sponging; bathing; antipyretic; temperature reduction; fever. References from retrieved papers were also sought and reviewed where available. Each paper was critically appraised for relevance and content. Results Forty-eight papers were identified. Twenty-nine were irrelevant. Conclusions The available evidence suggests that neither antipyretic medication (including paracetamol) nor tepid sponging prevent the recurrence of febrile convulsions following a simple initial fit, and both are associated with risk to the patient. We recommend that neither intervention be used in the prehospital phase of treatment.

Bringing order from chaos: The challenge of training lay responders to use automated external defibrillators and provide cardiopulmonary resuscitation

Each minutes delay to treatment for out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) reduces the likelihood of survival by ten per cent. Automated external defibrillators (AEDs) were developed to make rapid definitive treatment more widely available.AEDs use a computer algorithm to diagnose the collapsed patients heart rhythm and determine the need for a defibrillatory electric shock. This requires no intellectual input from the operator, whose actions are directed by simple written and recorded vocal prompts. Increasing the number of members of the public with the ability to access and use AEDs and provide cardiopulmonary resuscitation (CPR) is a cost-effective strategy for reducing deaths from OHCA. However, conventional training often results in inadequate skill acquisition and fails to ensure skill retention beyond three to six months. Classes without instructors and which use computer-assisted learning or automated voice-advisory manikins have resulted in competence similar to that achieved with traditional training, and may be more cost-effective and convenient. Simplified staged CPR classes offer improved skill acquisition and have a moderate benefit for skill retention. Short self-instructional video training classes or frequently repeated brief practice sessions with feedback from a voice-advisory manikin (both in the absence of an instructor) offer the greatest benefit for CPR skill acquisition and retention, but have not been used for AED instruction. Further research is required to determine the optimal method for training lay members of the public to use AEDs. It seems, however, that the ideal teaching strategy is unlikely to utilise a conventional instructor-led model.

OUTCOME OFASYMPTOMATICELECTRICSHOCKVICTIMSREQUESTING ANEMERGENCYAMBULANCE

Objective. To determine whether patients suffering from electric shock without significant symptoms at the point of an emergency call could be appropriately assigned a non-emergency ambulance response using the Medical Priority Dispatch System (MPDS). Methods. Welsh Ambulance Service dispatch records were searched to identify patients allocated the MPDS code of 15C01 (electric shock without priority symptoms) over a 30-month period. Ambulance and hospital records were also reviewed. Results. Records were unavailable for seven of the 52 patients identified (13%). Nine refused transport (17%, 95% CI 8.2% to 30.3%), and 36 were taken to emergency departments (69%, 95% CI 55% to 81%). Of the 52 patients, 23 were discharged shortly after arrival (44%, 95% CI 31% to 59%), 11 receiving no treatment (21%, 95% CI 11% to 35%). Thirteen patients were admitted as inpatients or were transferred to another hospital (25% of the total sample, 95% CI 14% to 39%). Fourteen had burns (27% of the total sample, 95% CI 16% to 41%). Five of these were admitted or transferred to another hospital, five were discharged after treatment, and two left without treatment (one self-discharged). Records were unavailable for two burns patients. Conclusions. The findings of this study do not justify allocating a low-priority response to victims of electric shock without significant symptoms at the point of the emergency call, since 25% require hospital admission. Further research is required to determine whether the addition of questions to the MPDS about burns and pregnancy might allow safe allocation of a nonemergency response to other asymptomatic electric shock patients.