First of all, thanks to Maurice for his explanation of the system within the
London Ambulance Service and to Anton for his explanation of Staffs. And
apologies to Rowley for the bit that tags on the end of my posts. Don't know
how to get rid of it.
> " at scene " times and " left scene " times often refer to
> the ambulance
> as a vehicle not "clinician to patient" and "leaving where the patient
> was assessed"
>
> This queers the pitch to some extent in looking at timings -
>
> Scene time is a intangible , without going and walking the route again
> the same " with patient " scene time can be vastly different
Certainly. Individual long scene time isn't a problem. However it is
reasonable to assume that all A and E crews working the same area will have
a broadly similar workload over a period of time unless there is a skewing
factor. So if one crew consistently deviates a lot from the mean, it's worth
looking at the reasons for this. As Maurice says, trying to look at all the
individual components in each case would mean a lot of data collection and
would be unreliable; and there will be consistent differences between
different parts of the country.
>> Relating to trauma I believe, which is quite specific, and included a
>>number of explanations such as selection bias - a paramedic WOULD have
>>been called to assist any of the complex entrapment rta's for example
>>wherever possible
Also relating to critically ill medical patients in general. Distinct
shortage of RCTs. However, observational studies do exist. If you look
through the studies, selection bias is an inadequate explanation (would
explain some of them, and some of the difference in some of the others, but
it's a bit of a stretch to say it's the only factor). However, one possible
explanation is that paramedics (as compared to technicians or- in one study-
taxi drivers) are delaying transfer to hospital by performing procedures
that on an effectiveness basis are of no benefit and may be harmful.
>>Roll on the 1960's...your taxi has arrived sir? 50-75% of cases are
>>typically transported to hospital disappointed you haven't noticed our
>>efforts to divert traffic away from A&E :).
Agreed. I think this is one possible vision of the future- where it is clear
from the call that a patient is sick and needs to go to hospital, a
technician crew or (if you have paramedics with different levels of
training, a basic level paramedic) in a fast vehicle is responded to
transport; where the patient appears to be stable and may be able to stay at
home, a paramedic or Emergency Care Practitioner can be responded to make
that decision or to perform a useful prehospital procedure in a patient who
will be coming in anyway- analgesia comes to mind.
(Concerning looking at numbers of procedures carried out etc.)
> Matt, does the emergency SHO, SpR or Consultant's annual
> appraisal routinely
> look at this kind of info in your trust?
Yes.
>
> > as do the studies showing at best no
> > benefit from use of paramedics as opposed to technician
> crews for critically
> > ill patients; and at worst (statistically) significantly
> worse outcomes.
>
> Think the major benefit of paras is ETT and adrenaline in
> cardiac arrest
> (there is some data out there to support this) and of course
> thrombolysis.
Pre hospital thrombolyis by paramedics has had some efficacy studies showing
it reduces call to needle time. I haven't come across any studies showing it
reduces mortality on an effectiveness basis- and bear in mind that some
studies suggest that a minute's reduction in call to door time reduces
mortality by as much as a 5 minute reduction in call to needle time. Even
the GREAT study had limitations- data were not presented on an intention to
treat basis. It is however a well written paper and it is easy to reanalyse
the data on intention to treat. Shows a worse outcome in the prehospital
thrombolysis group, though. Arguably the improvement in outcomes suggested
was due to a higher incidence of inferior MI in the thrombolysis group.
We recently introduced pre- hospital thrombolysis since when our call to
needle times (which had been steadily improving up to then) have worsened.
Could be a coincidence; could be a regression to the mean; could be cause
and effect.
I'm not aware that prehospital ETT by paramedics (as opposed to opening the
airway without use of ETT) or prehospital adrenaline have been shown to
improve outcome in cardiac arrest (in terms of leaving hospital walking and
talking as opposed to ROSC).
Re: Effectiveness of pre- hospital ETT:
> J Emerg Med. 1993 May-Jun;11(3):245-52.
> Prehospital cardiac arrest survival and neurologic recovery.
> Hillis M, Sinclair D, Butler G, Cain E...
> Survival in the
> experimental group by
> airway management technique was basic airway support (3/76 3.9%), EOA
> (3/67 4.5%), and ETT (6/48 12.5%). The improved effect on
> survival by ETT
> management was statistically significant.
I don't make it significant on these data, even treating it as a 2 way test
comparing ETT to basic support. Can anyone explain the stats, please?
>
> Absolutely agree no difference between techs and paras with trauma -
> though suspect has more to do with giving lfuids and
> subsequent on-scene
> times than anything else.
Some studies show no difference, some show worse outcomes with paramedics.
Agree that this may be due to on scene times. It may also be due to pre- op
fluids worsening outcomes in trauma as some RCTs have shown and some people
believe. It may be due to delay in opening the airway by thinking of ETT
instead of simple airway manoeuvres. Whole lot of things it might be due to.
> > Does a paramedic's annual appraisal include looking
> > at how many of each procedure they have done in the last
> year and whether
> > this deviates significantly from the average for their trust?
>
> Yes. Main prob we have is paucity of evidence for most procedures to
> indicate what min no. should be performed per year. Also not
> convinced
> that is the same for all paras.
I wasn't thinking just of the number needed to maintain competence (and
agree that this will not be the same for everyone), but as a suggestion as
to whether some paramedics are looking at different indications. To take the
case under discussion- use of adrenaline for anaphylaxis. Suppose you were
to find that most paramedics were doing it about 5 times a year. If you
picked up that someone was going 3 years without doing a single one or that
someone was doing one a week, you might want to consider whether these
individuals were using different indications. Not clear who is right or
wrong or whether it's just chance; but might be worth looking at. Only works
if your IT system collects the data properly of course, so really more
something to consider when specifying your system for most of us.
Matt Dunn
This email has been scanned for viruses by NAI AVD however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicitly stated.
If you have received this email in error please notify the sender.
The information contained in this email may be subject to public disclosure
under the NHS Code of Openness or the Freedom of Information Act 2000.
Unless the information is legally exempt from disclosure, the
confidentiality of this e-mail and your reply cannot be guaranteed.
|
