Blurring of vision with malaise

We present the case of a 56-year-old female brought to the Emergency Department via routine ambulance transport with complaints of blurred vision and malaise. She was screened by ambulance crew using the facial arm speech time (FAST) tool and a basic top-to-toe assessment as per current routine. The examining practitioner performed a thorough assessment of the patient, revisiting the initial examination findings, and establishing new clinical features of visual field deficit and pan-systolic murmur. The likely diagnosis of septic emboli or stroke with infective endocarditis was identified through the power of rigorous history taking and examination. These were then supported by investigation with blood tests and imaging. This prompted discussion with a tertiary centre and subsequent transfer for further investigation and management. The patient’s journey shows that there may indeed be a role for a more comprehensive (but not exhaustive) initial screening from ambulance services in order to help appropriately stream specific patients to hospital in a timelier manner (to meet the thrombolysis window). This case supports the addition of V (visual fields) to the FAST screening tool.

Paramedic-delivered teleconsultations: A scoping review

Introduction Progression in the field of paramedicine has resulted in the development of novel roles within the profession, including the role of advanced paramedics providing teleconsultations for frontline paramedics. Little is known about the experience of paramedics providing or receiving teleconsultations. This scoping review aimed to investigate paramedic perceptions of physician and paramedic-delivered teleconsultations. Methods A scoping review of MEDLINE, CINAHL and EBM Reviews as well as paramedic-specific journals and the grey literature was conducted. Articles were included if they examined advanced paramedics, paramedics, emergency ambulance crew or emergency medical technicians receiving teleconsultations, or physicians and advanced paramedics providing teleconsultations. Results A total of 7461 unique citations were identified. Two citations were ultimately included in the review. One study examined the delivery of teleconsultations by advanced paramedics and one by physicians, both from the perspective of paramedics. Paramedics delivering teleconsultations generally considered the experience to be positive, while those receiving paramedic-delivered teleconsultations felt the level of advice was appropriate and assisted in expanding their own knowledge base. Paramedics receiving physician-delivered teleconsultations reported variable understanding of the unique challenges of out-of-hospital care and tension in the relationship between paramedics and physicians. Conclusion Little literature was identified examining the perceptions of paramedics delivering or receiving physician-delivered or paramedic-delivered teleconsultations. Given the continuing expansion of teleconsultation programs for out-of-hospital staff, this represents a significantly understudied area.

Respecting an autonomous decision to refuse life-saving treatment: a case study

Background: Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights. Case presentation: An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP. Conclusions: Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.

Accessible communication in the transport of non-urgent people with communication impairments

Introduction Paramedics may find innumerous circumstances that require careful consideration of the patient’s clinical condition. Because of that, communication between paramedics and patients in a critical condition must be as clear and effective as possible. Objectives This study aims to identify the communicative needs of ambulance’s crew members when transporting non-urgent people with communicative impairments and to create a tool that facilitates the communicative process. Methodology A brainstorming was held at Associação de São Jorge to gather information regarding the needs and difficulties experienced by the ambulance’s crew members. An audio record of this meeting was collected and a qualitative analysis was carried out. Additionally, a questionnaire was fulfilled. Based on these results, a first version of the communicative tool was developed. A pluridisciplinary focus group was held to discuss it, regarding content, form and utility. After this focus group, the second version of the communicative tool was elaborated to be tested by the crew members of this association. As so, a dynamic of three hours was implemented to empower these professionals to use this tool and other communicative strategies. Results The qualitative analysis of the first meeting collected data recognize as crew member’s needs: communicating basic and immediate needs at clinical level and at colloquial discourse. This data allowed to establish parameters for the construction of the first version of the communicative tool. The referred focus group identified the need to improve it, considering: format, content and also the need to complement this tool with other communicative facilitators (e.g. braille; gestures). Conclusion This study shows the need of facilitating the communication in non-urgent transportation. Despite the modifications that have to be done, the communicative tool that was developed already shows a positive impact in the ambulance crew and in the community.

Do patients suffering an out-of-hospital cardiac arrest present to the ambulance service with symptoms in the preceding 48 h?

Aims In-hospital cardiac arrests are often preceded by a period of physiological deterioration that has often gone unnoticed. We proposed that the same might be true for out-of-hospital cardiac arrests (OHCAs) where ambulance crews leave patients at home who then subsequently go on to suffer a cardiac arrest. Methods and results We identified all OHCA over a 12-month period that had been seen and assessed by an ambulance crew within the 48 h preceding their cardiac arrest. We retrospectively calculated the patient’s NEWS2 score at the time of their initial assessment as a marker of their physiological status and need for hospital admission. Of 1960 OHCA patients, 184 (9.4%) had been assessed by ambulance crews within the preceding 48 h. Excluding those who had been taken to hospital (and then discharged), declined hospital conveyance or were on end-of-life care pathways, 79 (56% of total) were left at home through crew discretion. Thirty-four out of 79 (43%) patients not conveyed had either a NEWS score of 3 in a single parameter or a score of ≥5, which in hospital would mandate an urgent medical review. The most overlooked observation was respiratory rate. Conclusions In total, 1.7% of all OHCA had been assessed in the previous 48 h and inappropriately left at home by ambulance crews. This represents a missed opportunity to avert cardiac arrest. NEWS scoring has the potential to improve pre-hospital triage of these patients and avoid missing the deteriorating patient.

Triage Problem Among the Ambulance Crew (Paramedic) in Japan

Introduction:At various accidents or disaster sites, rescue, first aid, and transport to hospitals has been provided by ambulance crews (paramedics). In the case of mass casualties, they also need to operate triage for injured people.Aim:To consider and reveal challenges in triage by ambulance crews (paramedics) on-site.Methods:Interviews of seven ambulance crews (paramedics) and their instructors were conducted and their answers were analyzed.Results:(1.) Triage black tags: declaring “deceased: not able to survive” might give a heavy mental burden and psychological responsibility. Legal protection and an interstitial rule will be necessary in the future. (2.) Missed triage: the ambulance crew cannot perform a triage that may develop a legal problem. It is always important to prevent ambulance crews from being charged. (3.) Triage education and training: there are few triage trainings at fire departments although the number of emergency medical responses is increasing compared to fire response. It will be necessary to increase time of the triage education and training in near future. (4.) Command system (characteristic rank system in the fire department): There is a problem with the rank system in fire departments since confusion occurs when a commander of the First Aid Station is not a licensed paramedic. The ambulance crew (paramedic) usually consists of the three different ranked people. Individual operations are difficult during operation. Education for the paramedic executive is necessary for the fire organization.Discussion:For the triage by ambulance crew (paramedic), legal protection by medical control operation is required, and it may lead to a reduction of heavy mental burden. Triage training is needed to improve the training of triage. The ambulance crew (paramedic) operates under the fire department command system. However, at the time of disaster, the ambulance crew (paramedic) should also work under the medical command system.