April 11, 2013
by flobach
0 comments

PAD #02: Education | Analytics

Hello all,

As you realised, there will be no April discussion at The PAD – I’ve started a new job and uni semester has begun as well, which has left me now time (or much brainpower) for anything else. It will resume though…

In the meantime, here are some stats for last months discussion on education (via sympler):

  • 198 tweets
  • 23 participants

A full Transcript of the discussion is also available, as well as a list of participants.

Thank you to all who were involved, and hope to see you again at the next discussion!

 

February 28, 2013
by flobach
0 comments

PAD #02: Education | Background

For the up and coming discussion on the 3rd of March about Education over at The PAD we have prepared some background information for you to peruse at your leisure.

We wouldn’t want you to turn up not knowing what is currently happening in the world of Paramedic Education!

 

Paramedic Education

A short history

We’ll skip past the very early history (the Good Samaritan in the Bible, anyone?) and others more prepared to help rather than proficient in helping. Fast forward to the 1960′s and 1970′s, and the realisation was spreading around the world that rather than taking the sick and injured to hospital for treatment, treatment could be initiated at the scene of the emergency. In 1969, the LA County started up one of the worlds first paramedic programs (from which the show Emergency! came from), a year later the Victorian MICA Service started. Paramedics were born, and “Ambulance Drivers” were suddenly much more than just drivers!

But how much more?

 

The current state of Paramedic Education

I have picked some countries from around the world to showcase the differences of education:

 

Australia has largely moved from a vocational to a tertiary based educational system, with most states requiring new paramedics to undertake a three year Bachelor course. Student Paramedics Australasia has an information page on their website about paramedic education in Australia.

 

German Paramedics are trained in a two year course; the first year consisting of theory study and practical placements in different departments. After passing all tests, the next year is spent as a trainee paramedic working out of an ambulance together with a paramedic tutor. An overview of the training can be found here,  also the German Wikipedia page has some interesting information and a collection of links for further information. Please note that Emergency Physicians are the main ALS providers in Germany, and Paramedics have been traditionally kept in a BLS role.

 

In South Africa, there are currently three options

  1. Starting as an entry level paramedic, and working your way up to an advanced level through experience and further intermediate and advanced courses
  2. A four year university course (Bachelor), which will take you up to critical care level
  3. A two year full time course at certificate level ending in the second highest tier of paramedic qualification. This will allow further studies towards bachelor level if so desired.

Source: NetCare911

 

Switzerland requires paramedic students to have finished high school with their Abitur or with a vocational training prior to applying with a training agency. Becoming a paramedic is generally via a three year vocational education pathway (Regio144 shows their application pathway here, and interesting fact being the minimum age of 23), after which the graduate paramedic must find an agency that will employ them. The training includes theoretical studies, practical placements in an ambulance service, as well as interprofessional practical placements in anaesthesia, emergency department, geriatrics and care facilities, and dispatch; an overview can be found here. Topics covered within the course can be found here.  Costs for the education usually are around 30 000 Euro, which is covered by the training agency or the state. A big thank you to Matt Duschl for the links!

 

In the United Kingdom there are two pathways to become a paramedic

  1. Enrolment in a two year Foundation of Science (FdSc) university course, which after successful completion will lead to UK HCPC Paramedic Registration, and the ability to work on a frontline ambulance, often with little or no preceptorship. Included in these two years are supernumerary placements (i.e. third manning) on emergency ambulances. After graduating, an optional third year of study can be added to achieve the Bachelor of Science with Honours level (BSc Hons).
  2. Staff already working in the ambulance service, but at a lower clinical level (Emergency Medical Technicians or Emergency Care Assistants) can enrol in a four year part time degree with Open Universities, and study whilst working. Successfully completing this degree equates again in to a Foundation degree with HCPC registration.

A third route is being offered by the London Ambulance Service, the so called “Apprentice Paramedic” route. It is again based on a foundation degree, but together with initial training and working on the road spread out over five years until graduation. More information can be found here.

Additional general education information is available via the College of Paramedics.

Thanks to Kim Kirby for most of the background information!

 

 

And in the United States? Well, that is rather complicated, it depends on what city and/or state you are in. In general, it is a vocational based training which will bring you towards the mandatory National Registration of Emergency Medical Technicians (NREMT), but that’s where the uniformity ends. State registration and other regulations make it far too complex to list here, luckily there is a website out there for those who are interested: http://www.howtobecomeaparamedichq.com

 

 

Future possibilities

Higher Education is obviously one direction where paramedic education has been heading in the past few years, Australia and the UK leading the way for other countries possibly to follow. Reasons supporting this have been the increased scope of practice and knowledge base, autonomy to practice and development of the profession, amongst others. Read “Why” in this article in the Journal of Paramedic Practice.

- ~ -

So, that’s it for some information, all this should give us more than enough to discuss on Sunday, 1900hrs GMT.

See you then!

February 17, 2013
by flobach
0 comments

PAD #02: Education

Education Image Credit

Welcome to The PAD!

This month, The Paramedic’s ABC Discussion (a.k.a. The PAD) will be on Paramedic Education.

Log in to twitter, follow the #ParamedicABC hashtag, and have a good ol’ debate, deliberation and dialogue with fellow paramedics and others from around the globe.

We will be discussing the past, present and future of Paramedic Education; what have we done, and where do we want to take it? How has the shift towards tertiary education changed the profession, and what does the Paramedic of the future need to know?

All this and more at The PAD!

Check back here next week for up and coming information and articles on the blog which will be part of the discussion.

Remember, if you miss the conversation on twitter, a summary will be posted on here where the discussion can be continued amongst the comments section. More information on The PAD can be found here.

Looking forward to seeing you online!

February 16, 2013
by flobach
0 comments

New discussion hashtag

Further to thoughts and some feedback from some followers we are introducing a new twitter hashtag for our monthly online twitter discussions:

#The_PAD

As you are probably aware, The PAD is our own cozy discussion area – short for The Paramedic’s ABC Discussions, held every 3rd day of the month at 1900hrs GMT on twitter.

The reason for the change is simple: Five less characters! This means you can include an additional five characters in your discussion tweets, yay! #ParamedicABC will still continue as a hashtag, but in a more general form, relating to the ParamedicABC idea and website – please stick to #The_PAD hash tag for future discussions.

Until then, see you next month at #The_PAD !

February 15, 2013
by flobach
0 comments

symplur analytics

I have just been exploring the interesting world of social media stats and analytics. Symplur is a relatively new site/tool, and especially focussed on healthcare social media…just what we like to see here at The Paramedic’s ABC.

There are many hashtags and topics to be found on the website – #ParamedicABC is just one of many hash tags and topics, I recommend having a look around, you will undoubtedly come across some interesting finds.

In the men time, further to the discussion on Cardiac Arrest earlier this month, here is what I got from symplur:

Symplur Analytics:

  • 277 tweets were tweeted by
  • 35 participants that tweeted on average
  • 22 tweets and hour, with
  • 8 tweets each on average per participant

Click on the above analytics link to see who the participants were, and to see a fancy graph that shows when the tweets peaked at 167 tweets per hour.

These stats are only for tweets with the #ParamedicABC hash tag – remember there is always a bit of communication (retweets, replies, private messages etc) that miss out on the hashtag, these aren’t included in the stats. So remember to hash tag your tweets :-)

Click here for the Symplur Transcript.

And thanks again for making it a success!

February 4, 2013
by flobach
1 Comment

PAD #01: Cardiac Arrest | Summary

220px-CPROur first discussion was a great success! Thank you everybody who joined in the conversation, and a special thanks to those helping out behind the scenes (you know who you are).

Just goes to show that there is a great deal to be discussed in paramedicine, and a good number of professionals scattered around the globe that are willing to participate in serious, constructive discussions.

 

For those who couldn’t make it, and for those wanting to review what was discussed, below a summary of topics, thoughts and trends with the occasional new nugget of information thrown in by Yours Truly:

First off, most discussion participants were located in the UK & Ireland, although we did have a few from North America too. We are aware of time zones and the difficult barriers they can be, we’re looking in to options of being more inclusive of antepodeans and other wonderful international folk.

General consensus was that the uptake and implementation of the newest resuscitation council guidelines amongst the paramedic services within the UK was quick, although it was noted that some staff were initially skeptical at the de-emphasis of advanced airway management. Once the backgrounds and reasons had been explained and the procedures had been in place for a while, these critical voices died down and the new guidelines were accepted well.

But do the guidelines work? Generally people felt that following the new guidelines resulted in a higher rate of ROSC (Return Of Spontaneous Circulation). Which could be an indicator of higher survival rates, but the real goal is survival with good neurological outcome, not just ROSC.

Everyone knows that “Practice makes perfect”, but with whom and how many of them do we practice with? The so called “pit-crew approach” was mentioned, where – similar to a pit stop in car racing – everyone on scene has a single and specialised role. Everyone knowing what to do and working as a team towards a common goal – survival of the patient – sounds like a good idea, although there has been no hard evidence as such supporting this approach.

An number wise? How many paramedic staff should be on scene during an active resuscitation? What is the balance between must-have and nice-to-have? The TOPCAT2 study suggests that a two people is not enough for a cardiac arrest, and that survival rates improve dramatically with 3 or more rescuers on scene. Dublin  (Ireland) Fire Brigade sends a pump to back up an ambulance crew on a cardiac arrest call, similar to many  US systems. But the actual sweet spot, the balance between enough brawn for chest compressions, enough medical staff for medical procedures, not too many people on scene to crowd the incident and also cost effectiveness – that is an answer that currently must be decided by each service individually.

On the topic of staff numbers, the TOPCAT2 study also showed that strong leadership during a cardiac arrest  leads to improved outcomes. One designated paramedic would take a step back, and coordinate the resuscitation; making sure adequate compressions were being done, the drug regime was on time, airway was under control and so on. This supports the conclusion of an earlier paper by Simon Cooper, “Lighthouse Leadership“.

And  if we can’t get more human helpers, how about technological aids that are available on the market? Not many paramedics have had experience with mechanical compression devices, but they were generally seen as a step in the right direction, with more scientific evidence on this topic expected within the next few months and years. Some comments so far was that the Physio Control LUCAS was easier to apply, whilst the Zoll AutoPulse has been known to cause friction burns to patients. This will be an interesting development to keep an eye on in my opinion.

Compression feedback devices were another tool mentioned. A good idea, needing some thought prior to implementation. Paramedics need to be open to being criticised by a machine, and special care must be taken  with the audio feedback enabled (PUSH HARDER! PUSH DEEPER! PUSH FASTER!). Not something relatives ought to hear…

A few other topics were touched on: Ventricular Assist Devices were practically unheard of, ECMO is extremely rarely used for cardiac arrest patients, and continuous compressions during defibrillation is not a topic at any of the discussion participants services. All things I wouldn’t at all be surprised to see a fair bit of research coming our way in the near future.

At the end we all agreed that it boils down to results. Response, Organisation, Timing and Technology is useless if they do not contribute to a greater survival rate. And by that, I mean a person surviving with no or minimal neurological deficits. Severely brain damaged people are not our aim. Happy, healthy people are.

Outcomes…they are not published often. And if they are, comparing them is difficult as most services use different measuring tools. One registry mentioned was CARES in the USA; a start, but we need an internationally recognised registry, otherwise we may as well be comparing apples with oranges.

We ran out of time pretty quickly,the highly controversial topic of paramedic intubation was hardly touched upon (we could have probably gone for another three hours…), as well as therapeutic hypothermia, or terminating resuscitation on scene. Even after 75 minutes of discussion people just would not stop bringin up new ideas, topics and comments – love to see such an enthusiastic bunch!

- ~ -

If you want to relive the experience, the #ParamedicABC twitter hashtag transcript of the discussion can be downloaded here.

The next discussion will be on Sunday the 3rd of March, 1900hrs GMT (London). Topic: Education.

In the meantime, please stay in touch via twitter, facebook & the web, and be good to each other!

February 1, 2013
by flobach
2 Comments

PAD #01: Cardiac Arrest | Background

220px-CPR

For the up and coming discussion on the 3rd of February about Cardiac Arrest over at The PAD we have prepared some background information for you to peruse at your leisure.

We wouldn’t want you to turn up not knowing what is currently happening in the world of resuscitation!

 

 

Cardiac Arrest and Resuscitation

A short history

Bringing people “back from the dead” has been a fascination of generations. Early attempts, for example with tobacco smoke enemas, weren’t exactly evidence based or particularly effective, but a step towards modern resuscitation nonetheless.

Artificial (emergency) ventilation started with similar rudimentary techniques: moving the victims arms, laying them on their side and twisting them, laying them prone and compressing their lower back; all sounding like a good idea at the time, but nothing really standing out as distinctly life-saving. Mouth to mouth resuscitation had been mentioned and tried from ancient times, but only in 1959 did scientists properly acknowledge it as the best way of emergency pulmonary resuscitation, providing good insufflation together with basicc airway patency.

Acceptance of closed chest cardiopulmonary Resuscitation (CPR) followed shortly afterwards in 1960. Peter Safar is widely credited to ‘inventing’ CPR in the 1950′s, although he did not accept this himself, stating he merely brought techniques already known to man together in to what is widely now known as the “ABC’s” – Airway, Breathing, Circulation. That makes him a co-founder of our websites name too!

If you’re interested in the history of resuscitation, Howard P Liss wrote “A history of resuscitation” in 1986. You’ll need access to the Annals of Emergency Medicine, so if you don’t have journal access yourself, ask your employer or find a colleague or student that does.

 

Current state of cardiac arrest management by paramedics

Since then, CPR has been taught to laypeople and professionals worldwide, in different variations.  In 2005 new resuscitation guidelines were revealed – all major councils (American, Australian, European an UK amongst others) recommended a 30:2  compression:ventilation ratio, simplifying and standardising (adult) resuscitative efforts. This has been continued in the 2010 revision.

Have the changes from 15:2 towards 30:2 actually had a positive effect on outcomes? A weak trend can be considered, as these two trials show. Sunday we will discuss implementation and change within your service – maybe you have experienced similar barriers as mentioned in this article?

What has had a demonstrably good effect on outcome is so called “CCR” – Cardiocerebral Resuscitation, a.k.a. compressions only CPR by bystanders. Have you noticed the effects in your community?

 

Future possibilities

We can read and remember the past, we live in the present…but we can’t see in to the future!

But – we can predict, debate, philosophise and dream; nothing wrong with that. On the basis of current trends we can get a feel of where the science of resuscitation may be heading. Above we mentioned the new 2010 guidelines and CCR; have they already been implemented in your service, or is it a thing of the future?

 

Organisation is the key

A growing trend in medicine, not only for cardiac arrest, is the systematic review and organisation of data and procedures. Dr Richard Lyon (I was lucky to see his presentation last November) helped pick apart every aspect of Edinburgh’s (Scotland) paramedic response to cardiac arrest, and with the implementation of data collection, performance review, and training according to best current knowledge and practices managed to improve survival rates significantly.

Watch the video:

Improving outcome from OHCA: The TOPCAT 2 project from Resuscitation 2012 on Vimeo.

Here is the article in the EMJ about “Establishing a specialist, second-tier response to out-of-hospital cardiac arrest“.

Have you experienced similar ‘makeovers’, does your service have dedicated and trained cardiac arrest paramedics or do you think your service would benefit from something similar?

 

Mechanical Compression Devices

Another “new big thing” in the last couple of years are mechanical compression devices, e.g. the LUCAS or the Autopulse. Research so far is inconclusive (you will find supportive as well as not so supportive trials). Warwick University (UK) is currently running the PaRAMeDIC trial (Prehospital randomised assessment of a mechanical compression device in cardiac arrest) with the LUCAS-2 Device. The results will be interesting; a well setup trial with a goal sample size of 3650 should hopefully produce some solid results which I’m sure many services around the world will be interested to review.

In my humble opinion, these devices could be the way of the future in cardiopulmonary resuscitation, especially in the environments that paramedics regularly find themselves in. Even if they don’t (yet?) show a direct clinical benefit, they relieve someone on scene from having to do continuous compressions, which in my mind: a) eliminates rescuer fatigue, b) reduces disorganisation from rotating rescuers to counteract rescuer fatigue, c) increases patient ‘mobility’, being able to move the patient with effective compressions being done whilst moving people from incident scene to location of definitive care (ED, cath lab etc), also contributing to paramedic safety.

 

What can be done in hospital that can’t be done on scene?

An important question to ask! If nothing additional can be done at hospital compared to on scene paramedic efforts, why transport a victim in cardiac arrest? This is obviously dependant on the equipment and training of the staff on scene, but ALS resuscitation according to the ERC guidelines can be performed without having to move the patient from the incident: Hypoxia, Hypovolaemia, Hypothermia, Tension Pneumothorax and even some Toxins  and Thrombi can be dealt with on scene.

But what about the other H’s & T’s?

Hypo-/hyperkalaemia/metabolic issues and Toxins are difficult to detect without blood analysis – maybe the future holds the key (or rather: the device)?

Thrombosis: Apart from on scene thrombolysis administration by paramedics in rural and regional areas, mobile cath labs are (if at all) something of the distant future.

 

And what else?

ECMO!

Still a fairly new ‘weapon’ in the fight against premature death following cardiac arrest, ECMO, or Extra Corporeal Membrane Oxygenation, is quite fascinating. Similar to a heart-lung machine, blood is diverted out of the body, oxygenated by a machine, and then pumped back in to the body. This gives doctors and nurses additional time to try and sort out the cause of the cardiac arrest without having to worry about continuous compressions getting in the way. EMCrit has a very interesting podcast on this topic I can recommend, as well as Resus.Me showing two papers on the topic, one supportive, one more cautiouof it.

 

- ~ -

 

So, that’s it for some information, all this should give us more than enough to discuss on Sunday, 1900hrs GMT.

See you then!

January 27, 2013
by flobach
0 comments

PAD #01: Cardiac Arrest

220px-CPRWelcome to The PAD!

Our very first discussion, and we would love to have you join us.

This month, The Paramedic’s ABC Discussion (a.k.a. The PAD) will be on Cardiac Arrest.

Log in to twitter, follow the #ParamedicABC hashtag, and have a good ol’ debate, deliberation and dialogue with fellow paramedics and others from around the globe.

We will be exploring  the following ideas:

  • The past, present and future of out of hospital cardiac arrest (OOHCA) management
  • End of life and “Do Not Resuscitate” scenarios and decisions

Check back here tomorrow for up and coming information and articles on the blog which will be part of the discussion.

Remember, if you miss the conversation on twitter, a summary will be posted on here where the discussion can be continued amongst the comments section. More information on The PAD can be found here.

Looking forward to seeing you online!

January 16, 2013
by flobach
0 comments

Hello!

Welcome to The Paramedic’s ABC, where you will find knowledge, discussions and more on paramedicine and related topics.

We’re glad you have found your way here. Have a poke around our site, check out what we are all about, and be sure to visit The PAD - we want YOU to be part of the discussion!

 

We will be launching this website in two stages:

  • Stage 1 will see The PAD go live – discussions on current & controversial topics in paramedicine (on the 3rd of February to be precise!)
  • Stage 2 will see the introduction of The PAK, our knowledge base, the core of understanding on which we base our profession upon (date tbc)

 

If I can grab your attention before you surf off again: the first discussion will be held on twitter at the beginning of February – the topic is Cardiac Arrest. There will be much to discuss…more information to be released shortly.

We’re looking forward to it, see you then!