Ethical dilemmas with little time for reflection: A discussion of the ethics of out-of-hospital refusals

In this article, we consider an approach for ethical decision-making for refusals in the out-of-hospital environment. Autonomy and beneficence are discussed as the two ethical principles central to guiding paramedic decision-making in this context. We describe some situations where the two principles may come into conflict and where the working paramedic may be faced with an ethical dilemma. These cases may involve temptations of medical paternalism, which we argue ought to be avoided if possible. A discussion on navigating between autonomy and beneficence will be presented in order to help paramedics sort through dilemmas when these principles conflict. We argue that when these principles are in conflict, autonomy should primarily be respected – however, we will examine situations where the principle of autonomy cannot be applied and the paramedic should either attempt to rectify the patient’s capacity for autonomous decision-making, or, if not possible, proceed with the principle of beneficence.

A comparison of Australasian jurisdictional ambulance services’ paramedic clinical practice guidelines series: Adult sepsis

IntroductionThis article forms part of a series that seeks to identify interjurisdictional differences in the scope of paramedic practice and differences in patient treatment based upon which jurisdiction a patient is geographically located within at the time of their complaint. Methods The current CPGs of each JAS were accessed during June 2020, and updated in August 2021. Content was extracted and verified. ResultsNine services provide antibiotics for meningococcal septicaemia, with dosage ranging from 1 – 4 grams. Five services provide antibiotics for non-meningococcal sepsis (three under doctor approval), with choice of antibiotic including Ceftriaxone, Benzylpenicillin, Amoxicillin, and Gentamicin. Three services provide antipyretics, one provides corticosteroids under doctor approval, and all provide fluids (with dosage ranging from 20 – 60 ml/kg). ICPs are allowed to provide adrenaline infusions in nine services, noradrenaline in three services (one requiring doctor approval), and metaraminol in three services. Two additional services restrict metaraminol to specialist paramedics, with one of these requiring doctor approval. Two services perform phlebotomy and one takes lactate. Paramedics perform unassisted intubation in one service, with nine restricting this to ICPs. Facilitated or Ketamine-only intubation is performed by ICPs in one service. Rapid or delayed sequence induction is performed by ICPs in six services, and restricted to specialists in two services. ConclusionThe domestic jurisdictional ambulance services in Australasia have each created unique treatment clinical practice guidelines that are heterogeneous in their treatments and scopes of practice. A review of the evidence underlying each intervention is appropriate to determining best practice.

Mentor or tormentor? A commentary on the fractured role of mentoring in paramedicine

The relatively quick evolution of paramedicine and the inevitable ‘growing pains’ associated with an evolving profession has seen mentoring and the role of the mentor become clouded in confusion, ineffective education and a lack of specific research. Paramedicine’s recent development as a registered profession has also seen mentoring explicitly outlined as being a capability expected of all registered paramedics. However, the paramedic-mentoring model in Australia seems to have been mostly left up to the individual paramedic to develop in isolation from adequate training and mentoring themselves. If paramedicine is to continue its evolution as a legitimate healthcare profession, the quality of clinical mentoring must be acknowledged as a significant factor by higher education institutions, and the public and private services who employ paramedics, and nurtured accordingly.

Motivating factors influencing student paramedic choice of paramedicine as a career

Introduction This study aimed to identify and assess the factors, motivations and influences on undergraduate students’ choice of paramedicine for their studies and ultimately a career in paramedicine. Methods A survey was available to 205 first-year Bachelor of Paramedic Science students to assess background, motivational factors and influences on choosing their undergraduate studies. Results The response rate to an online survey distributed to 205 students yielded an almost 25% response rate (n=51). Altruistic factors were the main reason students chose to study for a degree in paramedic science and ultimately a career in paramedicine. Although essential, extrinsic, sociodemographic and interpersonal factors were less motivating factors. Despite other research suggesting media coverage leads to increased student enrolments, the media coverage of paramedics as frontline health professionals during the COVID-19 pandemic and the ‘lights and sirens’ effect of ambulance/paramedic reality television shows as influences were not highly regarded. Conclusion The altruistic factors influencing career choices in paramedicine are generally similar across the healthcare industry. In this review, the motivating nature of extrinsic, interpersonal and sociodemographic factors was generally inconclusive. However, these factors may well apply to a university’s initial recruitment strategy and as a factor for ambulance services to consider when identifying the motivating factor of a student paramedic to join the workforce.

Describing a 12-hour ambulance shift during a second wave of COVID-19 in London

The coronavirus disease (COVID-19), caused by the virus SARS-CoV-2, has strained international healthcare systems, including ambulance availability. Ambulance officers and paramedics are at the frontline of this pandemic and are therefore particularly exposed. Under normal operational circumstances, ambulance delivery is challenging; the effects of COVID-19 have exacerbated both the delivery of services and the stress placed on paramedics. In this case report, we describe a 12-hour emergency ambulance dayshift in central London during the second wave city-wide lockdown. We also discuss the impact COVID-19 has on day-to-day operations and the strategies employed to reduce paramedic infection.

Care in the field: adult anaphylaxis for paramedics

This paper presents an overview of the definition, clinical features, epidemiology, classification, pathophysiology, evaluation and risk assessment and treatment pharmacodynamics of anaphylaxis from the perspective of Australasian paramedic practice.

A comparison of Australasian jurisdictional ambulance services’ paramedic clinical practice guidelines series: Adult anaphylaxis

IntroductionThis article forms part of a series that seeks to identify interjurisdictional differences in the scope of paramedic practice and, consequently, differences in patient treatment based on which jurisdiction a patient is geographically located within at the time of their complaint. Methods The current Clinical Practice Guidelines of each Australasian domestic jurisdictional ambulance service (JAS) were accessed during June 2020 and updated in August 2021. Content was extracted and verified by 18 paramedics or managers representing all 10 JASs. ResultsAll JASs use intramuscular adrenaline as a first-line agent for adult anaphylaxis. Beyond this, significant differences exist in all treatments: five services provide nebulised adrenaline; 10 services provide adrenaline infusions (one requires doctor approval; one provides repeat boluses); six services provide nebulised salbutamol; two services provide salbutamol infusions (one requires doctor approval; one provides repeat boluses); five services provide nebulised ipratropium bromide; eight services provide corticosteroids (two restricted to intensive care paramedics (ICPs)); five services provide antihistamines for non-anaphylactic or post-anaphylactic reactions; four services provide glucagon (one requires doctor approval); magnesium is infused by ICPs in two services; 10 services allow unassisted intubation in anaphylactic arrest; one service allows ICPs to provide sedation-facilitated intubation or ketamine-only breathing intubation; eight services allow rapid sequence induction (two restricted to specialist roles). ConclusionThe JASs in Australasia have each created unique treatment clinical practice guidelines that are heterogeneous in their treatments and scopes of practice. A review of the evidence underlying each intervention is appropriate to determining best practice.

A comparison of Australasian jurisdictional ambulance services’ clinical practice guidelines series: An introduction

Introduction There are 10 emergency paramedic services in Australia and New Zealand (Australasia), referred to as jurisdictional ambulance services (JASs). All 10 of the JASs in Australasia produce their own clinical practice guidelines (CPGs). With differing approaches to their review and implementation of new evidence, there is opportunity for differences to arise between guidelines. This article outlines a new series that will aim to identify interjurisdictional differences in CPGs and paramedic scopes of practice, and consequently differences in patient treatment depending on which jurisdiction a patient is geographically located within at the time of their complaint. Methods The current CPGs of each JAS will be obtained from each JAS, and content extracted by registered paramedics. The scope of practice for each intervention presented in the guideline will be classified as being at the level of ‘paramedic’, ‘intensive care paramedic’ (or equivalent, as titles vary by jurisdiction), or ‘restricted’. Each paper will be provided to each JAS for optional verification of content before publication, and the results of this will be stated. Conclusion This series will aim to provide a contemporary overview of Australasian JAS clinical practice guidelines and scopes of practice.

Fall from standing height, or greater, and mortality among ambulance-transported patients with major trauma from falls

Introduction This study describes the relationship between falls from standing height, or greater, and mortality in ambulance-transported patients with major trauma from falls. Methods Road ambulance records from 1 January 2013 to 31 December 2016 were linked with WA State Trauma Registry records to identify ambulance-transported falls patients with major trauma. Results Of the patients who fell from standing level, 114/460 (25%) died within 30 days, compared with 47/222 (21%) who fell from height (p=0.64). Conclusion Mortality is relatively high, and fall height is not associated with 30-day survival, among ambulance-transported patients with major trauma in metropolitan Perth, Western Australia.

The preparedness of emergency care providers to deal with death, dying and bereavement in the pre-hospital setting in Dubai

Introduction This study sought to investigate how prepared emergency care providers are to deal with death, dying and bereavement in the pre-hospital setting in Dubai, and to make recommendations related to such events. Methods A quantitative descriptive prospective design was utilised. Data was collected using an online self-report questionnaire sent to all operational emergency care providers in the Dubai Corporation of Ambulance Services. The data was analysed using the IBM Statistical Package for Social Sciences version 25.0. Results Nearly 65% of participants (n=316) reported that they had not received any formal education or training on death, dying and bereavement. Those that did, reported that the training was conducted mainly by nursing (25.9%; n=124) and paramedic (13.6%; n=65) instructors. One-quarter of participants (25.4%; n=126) reported experiencing intrusive symptoms such as sleep loss, nightmares and missing work as a result of a work-related death or dying incident, but only 4.1% (n=20) had received professional counselling. Conclusion This study found that emergency care providers are underprepared to deal with death, dying and bereavement. A comprehensive death education program encompassing the unique challenges that emergency and pre-hospital setting presents should be implemented to reduce emotional anxiety and help emergency care providers cope better with death, and decrease abnormal grief reactions of the bereft. Abnormal grief reactions can include restlessness, searching for the lost person and disrupted autonomic nervous system functions.