Use, Outcomes and Policy on the Placement of Automated External Defibrillators on Commercial Aircraft for the Management of In-flight Cardiac Arrest; A Scoping Review

<p><strong>ABSTRACT</strong></p><p><strong>Introduction </strong></p><p>Automated external defibrillators (AEDs) are increasingly available in public places for the treatment of cardiac arrest. Some commercial aircraft carry an AED, but little is known about international policies and requirements. The aim is to review policy regarding AED placement on commercial aircraft, summarising reported incidence and outcomes of AED utilisation for individuals experiencing an in-flight cardiac arrest (IFCA).</p><p><strong>Methods</strong></p><p>A scoping review was undertaken. Online databases (Medline and CINAHL) were searched using prespecified terms to identify reports evidencing use, outcome and policy of AEDS for IFCA on commercial aircraft. Reports were screened and data extracted following scoping review extraction methods. Data were analysed to describe incidence of AED use and outcomes following IFCA, and policies regarding AED placement on commercial aircraft.</p><p><strong>Results</strong> </p><p>9 observational studies were identified. 8 reported instances of successful shock delivery using AED. No published reports of safety incidents involving in-flight AED use were found. 7 studies reported survival following AED use: of these, 6 reported administration of a shock for IFCA survivors, whilst 1 study reported deployment of an AED without shock delivery. Overall, survival following in-flight AED use was 9%, with 37% survival reported where patients presented with shockable rhythm. Only one policy mandating AED placement on commercial aircraft was identified.</p><p><strong>Conclusion</strong></p><p>Despite the small, retrospective and observational nature of the reports identified, findings suggest in-flight AED use is feasible and associated with improved outcomes from IFCA.</p><p><strong>Keywords:</strong> cardiac arrest; defibrillators; AED; aircraft; flight </p>

Defining and recognising clinical deterioration in the prehospital setting (PRECLuDE study): a systematic scoping review

<p><strong>Introduction</strong></p><p>Early identification of high-risk patients in the prehospital environment is crucial as it enables early intervention, transportation, and may determine the trajectory of future care. Although early warning systems (EWS) in-hospital are well established, it remains unclear whether adaptations of these systems can simply be extrapolated to prehospital care. This scoping review aims to explore how the current literature defines and recognises clinical deterioration in the prehospital setting.</p><p> </p><p><strong>Methods</strong></p><p>In December 2019, a systematic search of five databases using a combination of terms describing ‘paramedic’, were integrated with terminology relating to ‘recognition’ of ‘clinical deterioration’. Additional reference chaining was also undertaken.</p><p> </p><p><strong>Results</strong></p><p>A total of eight papers met the inclusion criteria. Seven out of eight studies included a definition, however these were primarily ad-hoc and fundamentally formed to support the creation of varying EWS. The prevalence of prehospital clinical deterioration is poorly explored in the literature, with only two studies discussing the frequency deterioration (5.1%). Furthermore, studies reported that paramedics were inadequate at identifying clinical deterioration due to medical aetiology by comparison to trauma. Additionally, a number of articles reported an association between clinician experience and recognition of clinical deterioration. As the topic of prehospital clinical deterioration has rapidly moved to focus on the potential implementation of EWS, with few studies providing fundamental description of the concept and its characteristics, there is no standardised operational definition available in the literature. The development of this definition is crucial to assessing clinical deterioration and improving the efficacy of EWS. Not only could this lead to improving early identification of risk factors, but it can lay the foundations for the development of an effective EWS.</p><p> </p><p><strong>Conclusion</strong></p><p>This review has found that further quality research in this understated space is warranted to increase understanding and early identification of the deteriorating patient, prevent unnecessary harm, and ultimately, improve patient outcomes. </p>

A photo-elicitation study of paramedics’ perceptions of mental illness.

<p>The number of people with mental illness who are treated by paramedics is increasing and there are a variety of factors that can affect how well this service demand is met. One such factor is paramedics’ perceptions of mental illness. Photo-elicitation was used to explore how paramedics felt about mental illness and to generate new ways of thinking about this important aspect of paramedicine practice and education. Highlighted is that paramedics can feel helpless and under-prepared in treating people with mental illness and that two concepts of ancient Greek origins — <em>aporia</em> and <em>phronesis</em> — offer a useful way forward in thinking about and responding to this.</p>

Clinical presentations and practitioner levels appropriate for the introduction of ‘Treat and Referral’ into the Irish Emergency Medical Service: A survey of Consultants in emergency medicine.

<p>Objectives: Overcrowding in emergency departments (EDs) is an international issue and ambulance bypass is seen as one element of the solution to a complex problem. Irish EDs are not immune to this healthcare crisis, which, together with increased off-load delays for ambulances, is one catalyst for the introduction of Treat and Referral (paramedic non-ED disposition decision). The confidence of consultants in emergency medicine in paramedics and advanced paramedics offering Treat and Referral to patients presenting with hypoglycaemia or seizure was explored. Other specific clinical presentations were also investigated for suitability for Treat and Referral and a consensus was sought on an upper age limit for such patients. </p><p> </p><p>Methods: Public-sector consultants in emergency medicine in Ireland at the time of the study, were invited to complete an online survey. A 62% response was received from the targeted population.</p><p> </p><p>Results: Confidence was expressed in advanced paramedics offering Treat and Referral to patients with hypoglycaemia or seizure by the majority (78%) of respondents. However, confidence was reduced for paramedics (53%). Six of the twelve specific clinical presentations received clear support as suitable for Treat and Referral, with the remaining receiving reducing support and ‘falls in the elderly (without injury)’ was opposed. There was no consensus on an upper age limit for patients being offered Treat and Referral.</p><p> </p><p>Conclusions: Support for the highest level of EMS practitioner in Ireland, advanced paramedic, to expand their scope of practice to include Treat and Referral was identified. Clinical presentations have been identified that would be conducive to a Treat and Referral clinical care pathway. A trial implementation period may be essential to build confidence in the programme before a universal roll out.</p>

Esmolol for the treatment of refractory ventricular fibrillation: a systematic review and meta-analysis

<p><strong>Introduction: </strong>In light of recent research the efficacy of current advanced life support treatments has been questioned. Ventricular fibrillation refractory to standard therapy is a presentation which may benefit from an updated approach to management, with the b₁-adrenoreceptor antagonist esmolol considered a therapy which may confer benefit. This systematic review and meta-analysis aimed to summarise the available evidence for esmolol in refractory ventricular fibrillation and identify if it may have any role in ACLS guidelines.</p><p><strong>Methods: </strong> The Cochrane Library, MEDLINE, CINAHL and EMBASE were systematically reviewed, along with trial registries and the grey literature. Studies were included in the review and subsequent meta-analysis if they examined adult patients in cardiopulmonary arrest with ventricular fibrillation refractory to at least three attempts at defibrillation and one dose of adrenaline or anti-arrhythmic therapy, who subsequently received intravenous esmolol.</p><p><strong>Results: </strong> 2,617 results were obtained with 12 full-text articles reviewed for inclusion. Ultimately, two unique results fulfilled the inclusion criteria. A total of 66 patients were included in the meta-analysis, of whom 22 received esmolol. Esmolol appears to improve to survival to hospital admission (RR 2.63, 95% CI 1.37-5.07, p=0.004), temporary (RR 2.34, 95% CI 1.09-5.02, p=0.03) and sustained ROSC (RR 2.63, 95% CI 1.37-5.07, p=0.004) and favourable neurological status at hospital discharge (RR 3.44, 95% CI 1.11-10.67, p=0.03). The use of esmolol also appeared to likely confer a benefit in survival to hospital discharge (RR 2.82, 95% CI 1.01-7.93, p=0.05). However, significant bias was observed across all outcomes and overall these results were considered to be of low to very low certainty.</p><p><strong>Conclusion: </strong>The use of esmolol in refractory ventricular fibrillation appears to improve survival to hospital admission, temporary and sustained ROSC and neurological status at hospital discharge, but not survival to hospital discharge. However, these results should be interpreted with caution in light of the limitations of included studies and the subsequent impact of these limitations on the outcomes included in the meta-analysis. Further high-quality, prospective research is required prior to recommending esmolol for use in refractory ventricular fibrillation.<strong></strong></p>

Improving Critical Listening skills in EMT Students

<p>Introduction: Although the importance of EMT students utilizing critical listening skills is apparent, there is little research focused on EMT students or EMTs and critical listening. Ensuring EMT students develop critical listening skills can be an asset that reaches beyond the goal of improving their education. It also has the potential to improve the quality of care they go on to deliver. EMTs may have the only verbal contact with the patient while they are still conscious, or with bystanders that witnessed the incident, or family members/health aides that can give vitally important information on the patient’s condition. If an EMT is not adept at critical listening, vital information may be lost, and the repercussions can be serious. This project was designed to determine whether EMT student critical listening ability and class performance would improve from engaging in critical listening exercises.</p><p>Methods: Critical listening exercises were emphasized during an EMT course by assessing student knowledge of the Patient Assessment module through two listening exercises modelled after the <em>Ferrari, Lynch, and Vogel Listening Test </em>that measures for critical listening skills. The Patient Assessment module was assessed twice within four weeks in a test-retest design.</p><p>Results: The data analysis of a total of <em>n</em> = 51 students’ performance in the pre and post-assessments yielded positive results and showed students significantly improved their listening ability within the four-week period. An overall score increase of 34.50 % was found between the pre and the post assessment results. Moreover, the data analysis showed that as the result of the listening exercises, students scored significantly higher in the section of the certifying exam that included critical listening exercises than in all other sections.</p><p>Conclusion: The results suggest performing critical listening exercises and assessments can help EMT students properly develop critical listening skills and improve performance.</p>

Wellbeing series: Meditation for paramedics

<span>In this wellbeing series we present practical advice for prehospital care providers, responders, and other shift workers. These articles are produced by experts in their field. Many of these topics were presented at the Irish College of Paramedics Wellbeing Symposium in University College Cork in May 2019.</span>

Wellbeing series: Empathy and paramedic wellbeing

<p>In this wellbeing series we present practical advice for prehospital care providers, responders, and other shift workers. These articles are produced by experts in their field. Many of these topics were presented at the Irish College of Paramedics Wellbeing Symposium in University College Cork in May 2019.</p><p> </p>

Wellbeing Series: Compassion Fatigue.

In this wellbeing series we present practical advice for prehospital care providers, responders, and other shift workers. These articles are produced by experts in their field. Many of these topics were presented at the Irish College of Paramedics Wellbeing Symposium in University College Cork in May 2019.

Wellbeing Series: Shifting the Focus to Nutrition

In this wellbeing series we present practical advice for prehospital care providers, responders, and other shift workers. These articles are produced by experts in their field. Many of these topics were presented at the Irish College of Paramedics Wellbeing Symposium in University College Cork in May 2019.