ABSTRACTS from the Australian College of Ambulance Professionals (ACAP) 2007 Asia-Pacific International Conference Gold Coast, Australia 26 to 29 September 2007

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

ISSN 1447-4999

Australian Prehospital Emergency Health Research Forum

Peer-Reviewed ABSTRACTS from The Australian College of Ambulance Professionals (ACAP) 2007 Asia-Pacific International Conference Gold Coast, Australia 26 to 29 September 2007

The Journal of Emergency Primary Health Care Management Committee gratefully acknowledges the support of ACAP, and all authors who submitted scientific abstracts for peer review to the Australian Prehospital Emergency Health Research Forum (APEHRF) and presentation at the ACAP 2007 Asia-Pacific International Conference.

Additionally, the Management Committee sincerely thanks the following peer reviewers and adjudicators for providing their valuable time and expertise in the peer review of abstracts, evaluation of posters or adjudication of selected oral presentations at the Conference, from which their collective results determined the winners of the 2007 APEHRF Best Paper Award and Best Poster Award:

Abstract Peer Reviewers: Kate Cantwell, Prof. Gerry FitzGerald, A/Prof Peter O’Meara, A/Prof. Helen Snooks Dr. Garry Wilkes, Andrea Wyatt.

Poster Adjudicators: Dr. Hugh Grantham, John Hall, Rod Sheather, Tony Walker.

Conference Adjudicators: Murray Black, James Blocker, David Burns, Michael Callinan, Garrie Carman, Alan Eade, Gerry FitzGerald, Grant Hocking, Paul Holman, Chris Huggins, Ian Johns, Toby Keene, Brad Kenyon, Mark McDonald, Peter McMurtrie, Mitch Mullooly, Andrew Pipkorn, Tim Rider, Rod Sheather, Matthew Steer, Gary Vincent, Tony Walker, Jenny-Lee Whittenbury, Prof. Malcolm Woollard.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

INDEX OF AUTHORS AND ABSTRACT TITLES

• Frank Archer, Mary-Lou Fleming, Jim Higgins, Jon Holloway, Tony Hucker, Lyn Pearson, Judith Walker, Tony Walker. Guidelines for the assessment and accreditation of university programs. • Ingrid Bielajs, Frank Archer, Skip Burkle, Heath Kelly Michael Coory, Vivienne Tippett, Konrad Jamrozik, Kristina Grant, Amee Morgans, Kerrianne Watt, Steve Raven. Ambulance call taking and dispatch data: new approaches to population based infectious disease surveillance and triage. • Karen Bilecki. Paramedicine is more than just templates, lingo, and algorithms. • Hayley Birch, Naomi McMaster, Daniel King. Community Support Card. • Natalie Blacker. Shift hours in the Australian ambulance industry: workforce health and safety, patient, and public safety. • Leanne Boyd, Frank Archer. Developing the ‘Ambulances for Asthma’ education program for health professionals and their patients in rural and remote areas. • Leanne Boyd, Frank Archer. Evaluating the ‘Ambulances for Asthma’ education program. • Malcolm Boyle. The nightmare of linking ambulance data with the State Trauma Registry. • Jennifer Cooper, Bridget Adams, Kassie Alford, Malcolm Boyle. Ambulance Clinical Placements – A Pilot Study of Students’ Experience. • Michael Coory, Heath Kelly, Vivienne Tippett, Frank Archer, Ingrid Bielajs. Ambulance dispatch data generate appropriate seasonal alerts for the surveillance of influenza-like illness. • Ahmad Reza Djalali, B Abdi Farkoush, V Hosseinijenab. Establish a team of pre-hospital emergency medical services for responding to HAZMAT accidents in Iran. • Kylie Dyson, Carol Grbich, Rob Elliott. Bicycle response units at community events: experiences and response times. • Carl Geelen-Baass, Briana Geelen-Baass. To prescribe or to administer? That is the question. • Cameron Glass. High rates of aeromedical transport of Inuit infants in the Baffin Region, Nunavut. • Phillip Good, Darren Hoschke, Katie Klarenaar. T.A.B.L.E.T.S are bagged letting emergency treat safely. (APEHRF Best Poster Prize) • Kate Goodden. Paramedics in community mental health crises – what are they good for? A Student's Perspective. • Peter Hartley. Semi-structured interviews indicate cultural misunderstandings amongst emergency paramedics and Muslims in Melbourne Australia. • Cindy Hein, Harry Owen, John Plummer. A twelve month audit of Laryngeal Mask Airway (LMA TM) use in a South Australian ambulance service. • Jim Higgins, Vivienne Tippett, Darren Hall. Securing Safety – Leadership in Pandemic Preparedness for the Emergency Prehospital Sector. • Chris Huggins. Simulation and critical thinking/clinical judgement. • Emma Jenkinson, Malcolm Woollard, Robert Newcombe, Iain Robertson-Steel. How accurately do ambulance staff and emergency department doctors identify acute cardiogenic pulmonary oedema in patients with respiratory distress? A prospective diagnostic study. • Bill Lord, James Cui. Ambulance call triage outcomes for patients reporting pain. • Veronica Madigan. Can someone please call the vet – I can’t communicate with my human patient.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

• Veronica Madigan, Brendan Smith. Predicting PHC students' first year academic performance at university - follow up study. • Trevor Matthews, David Tingey. Special Operations South Australia Style: A case mix review. • Ben Meadley, Stuart Hill, Brett Williams. Prehospital awareness of sudden cardiac death and cardiac arrhythmias in athletes. • Jamie Murdoch, Steve Raven, Vivienne Tippett, Arthur O'Brien. Queensland rural and remote expanded paramedic practice evaluation. • Ziad Nehme, Malcolm Boyle. Silent Myocardial Ischaemia – A Review of the Literature. • Ziad Nehme, Malcolm Boyle. So you think you can ventilate using the self-inflating bag? Think again. (APEHRF Best Paper Prize) • Madeleine O’Donnell. The congruence between a baccalaureate paramedic program and industry competency expectations. • Peter O'Meara, Judith Walker, Christine Stirling, Daryl Pedlar, Vianne Tourle. Mentoring paramedics as rural health researchers. • Lachlan Parker. Defining the professional responsibilities of flight paramedics: The results of a role delineation study. • Liz Perry, Brett Williams. Prehospital oxygen administration in COPD – how much is too much? A systematic review of the literature. • Timothy Pointon, Harry Owen. Impact of the Leatt-Brace™ on emergency pre-hospital care. • Timothy Pointon, Louise Reynolds. Innovative and affordable assessment techniques for practical simulations using Laerdal Simulation Technology. • Louise Reynolds. Ambulance change management or changing ambulance management? • Louise Roberts, Julie Henderson. Research into the implications of mental health call outs on paramedic practice. • Rod Sheather. The paramedic professional: A challenge of perception. • Erin Smith. Decision making during disasters: A case-study of first responders during the 9/11 World Trade Centre terrorist attacks. • Caroline Spencer, Rhona Macdonald, Frank Archer. Cultural competency in paramedic education courses. • Vivienne Tippet, Frank Archer, Konrad Jamrozik, Heath Kelly, Kerrianne Watt, Steve Raven. The Australian Emergency Prehospital Pandemic Influenza Project: A methodology for operational evidence. • Kerrianne Watt, Emma Enraght-Moony. Transportation of Aggressive Patients to Hospital: Rage against the Machine. • Kerrianne Watt, Vivienne Tippett, Steve Raven, Konrad Jamrozik, Frank Archer, Heath Kelly, Michael Coory. Pandemic Influenza: Australian paramedic risk perception study. • Brett Williams, Frank Archer. Is real really better? Can DVD simulations replace paramedic clinical placements? • Brett Williams, Mal Boyle, Bill Lord. Paramedic identification of ECG J Point and ST Segments: A Pilot Study. • Brett Williams, Mal Boyle, Peter O'Meara. Clinical estimations of age, weight and breath sounds: How accurate are undergraduate paramedic and nursing students? • Brett Williams, Ted Brown. Learning Styles of First Year Undergraduate Paramedic Students: A 12 month Longitudinal Study.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

• John Woodall, Kerrianne Watt. Evaluation of prehospital analgesia by Queensland paramedics. • John Woodall, Kerrianne Watt. Self-presentation vs ambulance transport of “urgent” conditions to an emergency department. • Malcolm Woollard, D Lighton, W Mannion, I Johns, Peter O’Meara, C Cotton, M Smyth. Airtraq versus standard laryngoscopy by experienced pre-hospital laryngoscopists in a model of difficult intubation: a randomized cross-over trial. • Malcolm Woollard, D Lighton, J Watt, C McCrea, L Hamilton, Peter O’Meara, M Smyth. Airtraq versus standard laryngoscopy by student paramedics in a model of difficult intubation: a pilot randomized cross-over trial. • Malcolm Woollard, W Mannion, D Lighton, I Johns, Peter O’Meara, C Cotton, M Smyth. Use of the Airtraq laryngoscope in a model of difficult intubation by pre-hospital providers not previously trained in laryngoscopy: a prospective cohort study. • Bronwyn Young, John Woodall, Vivienne Tippett. The Heat is On: An investigation of the effects of temperature on out-of-hospital cardiac arrest.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Guidelines for the assessment and accreditation of university programs Expanding Boundaries Stream

Council of Ambulance Authorities Interim - Paramedic Education Programs Accreditation Committee. Frank Archer F1, Mary-Lou Fleming2, Jim Higgins3, Jon Holloway4, Tony Hucker5, Lyn Pearson6, Judith Walker7, Walker T8. Council of Ambulance Authorities Interim - Paramedic Education Programs Accreditation Committee: 1Director, Department Community Emergency Health and Paramedic Practice, Monash University, Melbourne 2Queensland University of Technology, Queensland 3Commissioner, Queensland Ambulance Service 4Rural Ambulance Victoria, Australia 5Queensland Ambulance Service 6Executive Director, Council of Ambulance Authorities, Australia 7University of Tasmania, Burnie, Australia 8General Manager Clinical Governance, Rural Ambulance Victoria, Australia

Unlike medicine, nursing and many allied health professions, paramedic education does not have an external accreditation system, and there are no national guidelines for the assessment and accreditation of education programs leading to a qualification as Ambulance Paramedic now offered by the higher education and vocational education and training sectors.

The Council of Ambulance Authorities Ambulance Education Committee has developed Guidelines for the assessment and accreditation of university paramedic programs in consultation with the Australian College of Ambulance Professionals and higher education providers.

These Guidelines are an important milestone in the professionalism of the ambulance paramedic role. They are flexible and based on a set of principles that will accommodate workplace innovation and role redesign over time.

Accreditation is a necessary part of the quality improvement and safety agenda and will ensure that appropriate standards are maintained and that there is sufficient consistency in training approaches and course content across institutions.

The Guidelines will be trialled, evaluated and refined during 2007 as an ongoing process on continuing quality development in preparation for the commencement of a full accreditation program in 2008.

This presentation will provide an overview of the development of the Guidelines and the important role that they will play in the future development of the paramedic profession.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Ambulance call taking and dispatch data: new approaches to population based infectious disease surveillance and triage

Ingrigd Bielajs1, Frank Archer1, Frederick Burkle Jnr.2, Heath Kelly3, Michael Coory4, Vivienne Tippett 5, Konrad Jamrozik6, Kristina Grant3, Amee Morgans1, Kerrianne Watt7, Raven S7 1 Department Community Emergency Health and Paramedic Practice, Monash University, Melbourne 2Johns Hopkins University 3Victorian Infectious Disease Reference Laboratory 4 School of Population Health, University of Queensland and Queensland Health 5Director, Australian Centre for Prehospital Research and Chief Investigator 6School of Population Health, University of Queensland 7Australian Centre for Prehospital Research

Background In Australia, traditional strategies for infectious disease surveillance are focused on data reported from Emergency Departments and General Practice and Locum Services. To date, little attention has been paid to the potential utility of emergency pre-hospital call taking and dispatch data to contribute to infectious disease surveillance. In early 2006, a collaborative national and international team led by the Australian Centre for Pre-hospital Research and funded by a National Health and Medical Research Council Urgent Research Grant, commenced a multi-arm national study to address this discrepancy.

Objective The aim of this component of the study was to examine the utility of ambulance call taking and dispatch data to inform population-based models for surveillance and triage.

Methods We aimed to achieve this through exploration of the role of Ambulance Services as a key component of sentinel health surveillance systems, and the utility of a population-based triage tool to augment traditional triage systems to allow maintenance of usual services whilst simultaneously triaging additional pandemic-related workload. Using data secured from the Melbourne Ambulance Service and the Queensland Ambulance Service, researchers mapped the ability of this data to mirror data provided by the Victorian Infectious Disease Reference Laboratory on influenza-like illness (ILI). In addition, the theoretical basis for a population based triage instrument was developed and tested.

Findings/Conclusions In Australia, Ambulance Services do not traditionally have a role in monitoring the incidence of infectious disease, even though they are well-placed to contribute efficiently and effectively to influenza surveillance. In the event of a pandemic, Ambulance Services will also have a key role in ensuring early containment of infection, but new rules for triage will need to be applied. This paper will describe the results from this study and demonstrate the importance of emergency prehospital data to public health applications.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Paramedicine is more than just templates, lingo, and algorithms

Karen Bilecki Lecturer, Georgian College, Ontario, Canada

Introduction Recent lobbying efforts of paramedics in Canada to gain inclusion into the Regulated Health Professions Act and the privilege of self-regulation affords an opportunity to convey principles and methodology of the edification of paramedicine that has not been communicated previously. The submission premieres the conceptualization of the Canadian Paramedical Process Model (CPPM). The CPPM illustrates this crucial process.

Methods Application of collaborative processes using best evidence, ethical principles, seventeen years field observation/participation, and anecdotal evidences was used to develop a process model of paramedicine effectively illustrating phenomenon’s in emergency pre-hospital care occurring between “person” and paramedical practitioner.

Results The CPPM is a mid-range, integrative theory utilizing a systematic approach to interactions with and between patient and practitioner within the context of the therapeutic relationship. The foundational capstone encompasses three paradigms: systems theory, adaptation level theory, and humanism. The CPPM addresses holism, interdependence, control processes, and information sharing/feedback that embrace the complex nature of living systems. The focal point of this crucial process being patient as “person”.

Conclusion The CPPM is intended to articulate processes inherent to paramedicine. The demonstration of paramedical pedagogies indoctrinated in emergency pre-hospital care is paramount to understanding the unique processes paramedical practitioners. Knowledge dissemination aids scholarly dialogue. The CPPM could further develop qualitative research efforts in prehospital emergency care, optimize evidence based approaches to an individualized client- centred plan of care identifying particular needs, and influence best clinical practices. Although development of the CPPM occurred in Ontario, Canada for paramedicine, it could be implemented nationally, internationally, and across various disciplines, since therapeutic relationships are dynamic and evolutionary.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Community Support Card

Hayley Birch, Naomi McMaster, Daniel King. Bachelor of Emergency Health students, Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Health issues eliciting a paramedic response can have associated issues that are beyond the skill of the paramedic to assist with. Paramedics can come across people who need non- medical help but may not know what help is available or how to access it. Paramedics may also by unaware of this information.

We have designed a resource (a Community Support Card) that ambulance paramedics can hand out to patients or family members to inform them of whom they could contact in their time of need. The phone numbers we have used are mostly ‘1800’ numbers of government provided services so that there is no financial disincentive to accessing services. The cards can have phone numbers for different services such as Drug and alcohol abuse, sexual abuse, Kids help line and suicide help line. Ideally, the services listed should match local need to locally accessible resources. The card will be the size of a business card and will be waterproof so that it is durable and easy to carry for paramedics.

An initial survey of paramedic acceptance will be conducted. If favourable, a pilot trial will commence within a sector of the Rural Ambulance Victoria.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Shift hours in the Australian ambulance industry: workforce health and safety, patient, and public safety

Natalie Blacker Council of Ambulance Authorities, South Australia

The Council of Ambulance Authorities (CAA) is the peak body representing the principle statutory and other providers of ambulance services in Australia, New Zealand and Papua New Guinea.

The CAA commissioned its Strategic and Business Advisory Committee to develop a reference paper to provide an overview of available sources and evidence to enable individual ambulance jurisdictions to make informed decisions about shift length and fatigue and to raise awareness of the issue.

The compendium draws together issues, findings and policy positions from a large number of sources including; research evidence from Australia and Overseas, workplace health and safety papers, legislative responsibilities of both employers and employees, fatigue in the transport industry, and policy positions from national peak bodies including; Australian Council of Trade Unions, Australian Medical Association, and Australian Council for Safety and Quality in Health Care.

Leading Australian researchers have demonstrated a relationship between increased hours of wakefulness and the effects of moderate alcohol consumption (1). Amidst the increasing evidence that fatigue creates significant impairments to reaction times, decision making, memory, and cognition (2-7) both employers and employees have a responsibility in minimising individual, patient, and public risk.

The findings from this compendium of papers demonstrates that although fatigue is widely recognised as an occupational health and safety risk throughout health and transport industries in both Australia and Overseas; cultural factors, demand for services, funding, and workforce supply and sustainability are the challenges facing health industries in making significant changes to current shift work practices.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Medical support for police tactical operations

James Blocker EMS Coordinator, Oklahoma City Fire Department

Police Department tactical units are routinely activated on high risk operations without the immediate availability of Emergency Medical Services. The volatile environments that are often associated with SWAT Team deployment make entrance by untrained medical personnel dangerous and impractical. Patient survivability from critical injuries associated with this type of operation can be dependent on the availability of on scene clinical management by qualified medical providers. In situations such as an active shooter, Police Officers and civilian casualties can be pinned down under combat type conditions and remain untreated for minutes or hours.

The increasing number of violent crimes including school shootings underscores the need to provide a medical component to the local SWAT Team. SWAT Officers with the expertise to safely reach a downed officer or civilian casualty may lack the medical training to provide appropriate treatment and they can exacerbate injuries. On the other hand, when medical personnel without tactical training attempt to enter an unsecured area they often become casualties themselves. SWAT Teams are generally composed of highly trained, well disciplined, and motivated officers and nothing less should be expected from medical personnel attached to the team.

This presentation details the integration of medical personnel into the police tactical team including aspects of program set up, training, and operations. The presentation is intended for administrators and medics. The program adds a specialized resource to the SWAT Team providing a valuable asset to police officers and citizens.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Developing the ‘Ambulances for Asthma’ education program for health professionals and their patients in rural and remote areas

Leanne Boyd, Senior Lecturer Frank Archer, Director Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Introduction A needs analysis was conducted in 2003 and 2005, to investigate barriers to optimal emergency asthma care in rural Australia. The findings revealed that utilisation of ambulance services for asthma was suboptimal despite improved outcomes in cases where paramedic intervention was sought. Asthma Foundations of Australia, through their Asthma Targeted Intervention Grants funded the development, implementation and evaluation of the `Ambulances for Asthma’ education package to address this issue. The project was trialed in five rural Victorian towns and aimed to educate health professionals and their patients regarding when, why and how to call an ambulance for asthma.

Methods A Project Steering Group comprising key stakeholders was convened to establish best practice management of out-of-hospital acute asthma in rural areas. A multimedia education package incorporating a website, brochure/CD and poster was developed.Human-computer interface testing and focus groups were used to refine the program pre-implementation. Participant questionnaires were utilised to evaluate the program post implementation.

Results The vast majority (76%) of respondents agreed that the program was user friendly, with 80% stating that they could access online resources easily. A large proportion (90.5%) of participants felt more confident with their asthma knowledge and 64% of the participants were more likely to call an ambulance for their asthma as a result of the education package.

Conclusions The findings show that the program can augment decision making for people with asthma in rural Australia. Increased ambulance use and earlier intervention has the potential to improve asthma related morbidity and mortality within this population.

Note: Ethics approval for this project was granted by Monash University Standing Committee on Ethical Research in Humans

Needs analysis was conducted by Monash University Department of Community Emergency Health and Paramedic Practice and funded by Australian Government Department of Health and Ageing: Asthma subsection.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Evaluating the ‘Ambulances for Asthma’ education program

Leanne Boyd, Senior Lecturer Frank Archer, Director Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Introduction The ‘Ambulances for Asthma’ education program was trialled and evaluated in rural Victoria. Process evaluation was undertaken to assess program implementation and responsiveness to participant feedback. Impact evaluation assessed whether the objectives of the program were met. Outcome evaluation measures longer term effects and will be measured by morbidity and mortality data.

Methods A triangulation approach with focus groups of health professionals and people with asthma, evaluation questionnaire, and emergency department director interviews was utilised for the process evaluation. Impact evaluation included a review of ambulance patient care records for asthma cases in rural Victoria and facilitator debrief interviews. Patient care records were assessed 90 days pre and 90 days post intervention and were divided into test (Mildura, Ouyen, Apollo Bay, Wonthaggi and Hamilton) and control areas (rest of rural Victoria).

Results Focus group participants identified issues that could impede uptake of the program. These included limited access to resources such as computers/internet, poor geographical access, cost of ambulance subscription, negative past experiences with health professionals and the complexity of self diagnosis. A chi-square analysis of data from the patient care records revealed a significant difference between the test and control areas and the pre and post intervention areas.

Conclusions This study identified an increase in ambulance use for asthma post intervention in the project regions. The program achieved its impact objectives. With continued broader dissemination, this program has the potential to improve morbidity and mortality patterns and health outcomes for people with asthma in rural areas.

Note: Ethics approval for this project was granted by Monash University Standing Committee on Ethical Research in Humans

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

The Nightmare of Linking Ambulance Data with the State Trauma Registry

Malcolm Boyle Senior Lecturer, Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne

Objectives The linking of a large ambulance dataset with the large hospital datasets to determine patient outcomes has not previously been undertaken in Victoria, only small test linkages have been undertaken by the Department of Human Services. The objective of the study was to link a large ambulance trauma dataset with the Department of Human Services hospital datasets and the state trauma registry.

Methods The linking of the ambulance trauma dataset to the hospital datasets utilised probabilistic matching, fuzzy matching, and unique matching to link the ambulance and both hospital datasets. The linking of the ambulance trauma dataset to the state trauma registry utilised unique matching, probabilistic and fuzzy matching were not available.

Findings For patients in the ambulance dataset 66.7% were located in the VEMD. 96% of patients located in the VAED were defined in the VEMD as being admitted to hospital. The VAED was subsequently searched if ambulance records could not be located in the VEMD. There were 3.7% of patients located in the VAED that could not be found in the VEMD due to the hospitals not reporting to the VEMD. When linking the mechanism of injury only ambulance dataset to the state trauma registry the was a 221% increase in successful links, likewise there was a 46% increase in the sudden deterioration dataset, when using a manual link compared to a unique electronic link.

Conclusion This study demonstrates that the quality of ambulance data needs to be improved to ensure better linkage with other health related datasets.

Keywords data; data linking; emergency medical system; health datasets; trauma,

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Ambulance Clinical Placements – A Pilot Study of Students’ Experience

Jennifer Cooper;1 Bridget Adams;1 Kassie Alford;1 Malcolm Boyle.2 1Bachelor of Emergency Health students, Department Community Emergency Health & Paramedic Practice, Monash University, Melbourne. 2Senior Lecturer, Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne.

Objectives With university based undergraduate paramedic courses clinical placements in the ambulance environment are essential to augment the student paramedic’s education. Anecdotal evidence suggests some students have not had positive experiences on their placements. The objective of this study was to identify the type of experiences had by students during ambulance clinical placements.

Methods In this pilot study we employed a cross-sectional study methodology, using a convenience sample of undergraduate paramedic students available in semester one of 2007 to ascertain the student’s views on their reception by on-road paramedics and their overall experience on ambulance clinical placements. Ethics approval was granted.

Findings There were 77 students who participated in the survey, 64% were females, with 92% of students < 25 years of age and 55% < 65Kg in weight. There was a statistically significant difference in average height between the genders (Male 179cm vs Female 168cm, p < 0.001). Clinical instructors were available to 44% of students with 30% of students excluded from patient management they were experienced to undertake. 30% of students felt there was a lot of unproductive down time during the placement. Paramedics remarked to 40% of students that they doubted their ability to perform the physical role of a paramedic, of this group 36% were advised more than once.

Conclusion This study demonstrates that for a small group of students, ambulance clinical placements were not a positive experience clinically or educationally. Some qualified paramedics doubt if a number of students can perform the physical role of a paramedic.

Keywords clinical placement; cross-sectional study; education; paramedic

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Ambulance dispatch data generate appropriate seasonal alerts for the surveillance of influenza-like illness

Michael Coory1, Heath Kelly2, Vivienne Tippett3, Frank Archer4, Ingrid Bielajs.5 1 School of Population Health, University of Queensland and Queensland Health 2Victorian Infectious Disease Reference Laboratory 3Director, Australian Centre for Prehospital Research and Chief Investigator 4 Director, Department of Community Emergency Health and Paramedic Practice, Monash University 5Department of Community Emergency Health and Paramedic Practice, Monash University

Background The ambulance service is often the first point of call for the seriously ill. Ambulance dispatch data may be able to provide a surveillance system for influenza-like illness (ILI).

Objectives We aimed to investigate the utility of ambulance dispatch data as an alternative surveillance system, and to determine if appropriate automatic alerts could be generated for this system.

Methods Ambulance dispatch data were available for the years 1997-2005. Data classified to respiratory or breathing problems were evaluated. Data were analysed as rates, according to the convention for ILI sentinel surveillance. All data were aggregated over one-week periods. Ambulance data were recorded as ILI dispatches per 1,000 total ambulance dispatches; GP sentinel rates were recorded as ILI cases per 1,000 patients; while locum service data were recorded as ILI callouts per 1,000 calls. Ambulance data were inspected to assess how closely it matched the seasonal fluctuations in the locum service data for the period 2002 to 2005. The CUSUM method was then used to compare signals from the ambulance data with thresholds from the GP sentinel surveillance system (1997 to 2005).

Findings/Conclusions Analyses demonstrated that ambulance dispatch data can provide a surveillance system that functions as well as current general practitioner surveillance systems. Potential advantages of ambulance data include its reach into the community, its high existing levels of electronic data recording and its ability to be used in an emergency situation (e.g, influenza pandemic) without any additional input. Because the data are immediately entered into a database at the time of the dispatch, the system has the potential to provide real-time surveillance at low cost.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.

Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Establishing a team of pre-hospital emergency medical services for responding to HAZMAT accidents in IRAN

Djalali AR, Abdi Farkoush B, Hosseinijenab V Department of Disaster Management, Natural Disaster Research Institute, Iran.

Introduction: Emergency Medical Service of IRAN has been established since 1975. There are more than 1000 Emergency Medical Teams in this system. EMS of Iran is responsible for medical emergencies and casualties of accidents but not HAZMAT. Although there have been some HAZMAT accidents in Iran, including the Neishabor train accident that resulted in more than 100 victims, a HAZMAT EMT has not been established in Iran.

Methods: Initially, the risk of HAZMAT accidents in Iran was assessed, followed by a review of scientific documents by a scientific committee to determine requirements relating to staff, education, experience, equipments and procedures for the establishment of a prehospital HAZMAT EMT.

Results: Each HAZMAT EMT consists of a General Practitioner, a Nurse and a Paramedic. Equipment for the team includes: Personal Protective Equipment, preliminary decontamination equipment and substances, antidotes and ordinary medical equipments packages. Training requirements include, medical management of contaminated victims; determining the type of chemical substances, preliminary decontamination, transportation of contaminated victims, etc. The members should have more than 3 years work experience in EMS.

Discussion: Although pre-hospital EMS of Iran is a powerful system with a long record of service in the Middle East, there isn't any pre-hospital HAZMAT EMT in Iran for responding to chemical accidents. Our experience in establishing a HAZMAT EMT can be used by other emergency medical services in Iran and in other countries.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007. Journal of Emergency Primary Health Care (JEPHC), Vol.5, Issue 3, 2007

Bicycle response units at community events: experiences and response times

Kylie Dyson;1 Carol Grbich;1 Rob Elliott2 1Flinders University, South Australia 2South Australia Ambulance Service

Introduction A state-wide ambulance service is developing a bicycle response unit to attend community events where traditional ambulance access is difficult and response times are extended. This enables ambulance personnel to negotiate crowds quickly whilst carrying the necessary equipment and provide rapid assessment and intervention to patients but not transport.

Aims This paper will explore the experiences of those involved with the bicycle response unit and make recommendations accordingly. In addition this paper will compare the response times of the ambulance service at community events with and without a bicycle response unit.

Methods Focus groups will be held with the bicycle response unit organisers, paramedics and call takers and first aid services which will integrate with the unit. The community will be surveyed at the event and patients sent a questionnaire about their experiences with this unit. Response times of the ambulance service at community events with and without the bicycle response unit will be compared, in 2007 and 2006 respectively. The data collected will also be compared to the experiences and response times encountered by the local police and other ambulance services.

To prescribe or to administer? That is the question

Carl Geelen-Baass;1 Briana Geelen-Baass2 1Department of Community Emergency Health and Paramedic Practice, Monash University 2Business Coordinator of Ambulatory Services, Peter MacCallum Cancer Institute, Melbourne

Background Paramedics have the knowledge, skill base and authority to treat our patients using a vast list of drugs. We decide the type of medication, dose and route of administration and our patients follow our lead, either explicitly or implicitly. There are few other professions who are able to perform these actions without additional authorisation. Given this type of operational autonomy it is argued that, in the continuing endeavor to consolidate our position as a profession, we should recognise, and label this element for what it is: the ability to prescribe, as well as administer, drugs. This then extends to adding weight to our standing as a profession and on through to regulation and registration.

Objectives To answer the following questions: • What does it mean to “prescribe”? • Can paramedics claim that this is what we do? • In what ways does this make us different from other professions? • Why is this important? • Where does this fit in to existing frameworks for professionalism such as Greenwood’s?1 • What are the questions we will need to ask in the future?

Primarily our objective is to establish a rationale, from current literature, for claiming ownership to prescribing medications as opposed to simple administration in our daily patient care. Our secondary objective is to encourage the industry to take a hold of that ownership. This shows a powerful component of our uniqueness as a developing profession in comparison to other health professions.

Methods A literature review was conducted with two different focuses. First, was looking into varying definitions and formats of ‘prescription’ and the second extended to searching for formats and components of professions and professionalism. An analysis of the literature resulted in the basis of our argument.

Findings and Conclusions Our findings from the literature review show that there is much leverage to support our argument. We should claim we prescribe medications, not only administer them. Much of the literature is immersed in describing prescription from the Medical Officer’s or Practitioner’s point of view but not all. Particularly when considering prescription with the auspices of a profession, we as a profession, fit the criteria and inclusion to the ‘prescribing fraternity’. As we look to furthering our status as a profession we need to take ownership of clinical expertise that we perform; particularly those that distinguish us from other health professions. Prescription is one of those clinical expertises that distinguishes us from others.

References 1. Greenwood E. Attributes of a profession. In: B F, editor. Self-actualization for nurses. Maryland: Aspen: Rockville; 1984. p. 13-26.

High rates of aeromedical transport of Inuit infants in the Baffin Region, Nunavut

Cameron Glass Global Medical Services & Consulting Vancouver, Canada

Background Baffin Island is located in the Arctic Territory of Nunvut in Canada. This territory spans two million square kilometers of Canada extending north and west of Hudson’s bay, above the tree line to the North Pole. This area is one fifth the size of Canada. Inuit represent 85 percent of the population.

26 communities ranging in size and distance exist within this territory, none of these communities are accessible by road or rail & everything arrives by plane or sealift. Air ambulance service is provided in one of the most challenging environments in the world. Adverse weather can cause Paramedics to be stranded in remote nursing stations for days, 24 hours of darkness and winter temperatures of -59 celsius in the winter. 24 hours of daylight in the summer, long distance transports that can range from 2 hours round trip to as long as 8 hours with single paramedic manned planes.

Introduction Through this review statistical data showed a significant percentage of air ambulance flights involving pediatric patients (40%). Well above typical ground and air ambulance systems. These cases were further identified to be associated with a significant amount of respiratory problems (25%).

Methods A retrospective case review & data analysis was performed for a 12 month period requiring air ambulance transport from isolated communities to Baffin Regional Hospital. A focused pediatric case review was further performed to extrapolate key data.

Conclusions The challenges of providing care in addition to the high volume of pediatric cases supports the need to ensure Flight Paramedics have appropriate knowledge and skills to manage specific patient population. Using the data as part of an overall need analysis can allow for focused, evidence-based continuing medical education. This data has the potential to be used to develop further training aids to target the specific needs of the community, development of screening tools for certain types of patient presentations and to assist the community with key benchmarks within an overall Continuous Quality Improvement program. It also reflect the need for interdisciplinary and a community based approach to addressing high rates of pediatric lower respiratory tract infections.

References

1. Can J Public Health. 2006 Sep-Oct;97(5):362-8.Portrait of outpatient visits and hospitalizations for acute infections in Nunavik preschool children. Dallaire F, Dewailly E, Vezina C, et al. 2. Indoor Air. 2006 Aug;16(4):266-75 Indoor air quality risk factors for severe lower respiratory tract infections in Inuit infants in Baffin Region, Nunavut: a pilot study. Kovesi T, Creery D, Gilbert NL, et al.

3. CMAJ. 2001 Jun 26;164(13):1847-50.Lower respiratory tract infections in Inuit infants on Baffin Island. Banerji A, Bell A, Mills EL, et al. 4. Int J Circumpolar Health. 2001 Aug;60(3):375-9 High rates of hospitalisation for bronchiolitis in Inuit children on Baffin Island 5. Int J Circumpolar Health. 2001 Nov;60(4):649-58. Bronchiolitis in Inuit children from a Canadian central arctic community, 1995-1996. Orr P, Mcdonald S, Milley D, Brown R. 6. Int J Circumpolar Health. 2005 Feb;64(1):38-45. Costs associated with infant bronchiolitis in the Baffin region of Nunavut.Creery D, Lyer P, Samson L, et al.

Tablets are bagged letting emergency treat safely (Awarded APEHRF 2007Best Poster Prize)

Phill Good, Darren Hoschke, Katie Klarenaar Ambulance Service NSW

Introduction Ryde Emergency Department personnel reported an increased risk of adverse events and length of stay for patient arriving without their medications.

The aim of Tablets Are Bagged Letting Emergency Treat Safely (T.A.B.L.E.T.S) was to reduce the number of Ambulance patients over 75 years of age arriving at hospital without their medications.

Method Using the clinical practice improvement methodology and a multi-disciplinary team a diagnostic phase was undertaken. The 12 week intervention phase required several Plan Do Study Act cycles.

Results The final solution was a patient identified, sealable plastic bag, designed to hold a large quantity of medications. Ambulance Officers were directed to place the BP sphygmomanometer inside the plastic bag, which is routinely stored within the Oxy-Viva. The directive ensured easy access to the plastic bag, and minimised the task being forgotten, particularly if the patient required urgent transport.

Results of intervention indicated an improvement in patients arriving with their medications. Over the first three weeks an average of 27% of patients arrived with their medications. In the final three weeks of the project this average improved to 77%.

Discussion T.A.B.L.E.T.S is now a key performance indicator for Ambulance, which is reported to the Department of Health.

Feedback from emergency department personnel following statewide rollout includes:

• Faster and more accurate understanding of patient medical history; and • Improved ability to recognise potential issues with patient current medication regime

In 2006 T.A.B.L.E.T.S. was nominated for a Minister’s innovation award and was awarded a Baxter award for Safety of health care.

Paramedics in community mental health crises – What are they good for? A Student’s Perspective

Kate Goodden Bachelor of Emergency Health student, Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne

In a grossly under-serviced mental health system, the ambulance service is often called to people in the community experiencing mental health crises. The principal paramedic role in non-medical mental health crises is to transport the patient safely to a hospital Emergency Department (ED). However, paramedics have expressed dissatisfaction with this role; citing frustration with what they perceive is their lack of skills and expertise in managing mental health patients and the inappropriateness of their current skills and equipment to responding to such non-medical cases.

Part of the frustration resides in paramedics feeling powerless to help mental health patients and that their limited role of transporting to the ED, is contributing to ED overcrowding and the overwhelming demand for inpatient acute psychiatric beds.

In view of this paramedic frustration and the often inappropriate use of emergency medical resources, ambulance services are an important factor in the review and restructuring of the mental health system that is required to meet vast unmet mental health needs.

This presentation investigates the current involvement of the ambulance service in the management of mental health patients and the appropriateness and benefit of these paramedic interventions. Possible future roles for paramedics in the care of people in the community experiencing mental health crises will be discussed and recommendations made.

Project Hydra - pandemic planning in the Queensland Ambulance Service

Darren Hall Project Manager Pandemic Planning Queensland Ambulance Service

Background An influenza pandemic will have a catastrophic impact on the community of Queensland. As pandemic phases escalate towards pandemic level, demand for the services of the Queensland Ambulance Service will be extreme. In order to address this emerging issues, the Queensland Ambulance Service initiated the Pandemic Planning Project

Objectives The objectives of the project were to develop strategies and initiatives which would see the Queensland Ambulance Service well placed to continue service delivery whilst protecting as far as possible, the health and safety of its workforce.

Methods The task was managed utilising contemporary project management methodologies and techniques. The project team reported to a Steering Committee which consisted of key representatives of the Department of Emergency Services.

Findings and Conclusions Project outcomes to date have included engaging the workforce, the acquisition, distribution and allocation of the Scott M98 Air Purifying Respirator to over 2,800 operational staff including volunteers, development and delivery of detailed PPE and pandemic specific training programs, stockpiling of infection control consumables across the State, detailed logistics management arrangements for pandemic equipment and supplies, development of surveillance and early warning capabilities, development of robust command and control procedures with a specific focus on pandemic operations.

Other initiatives have included an increased focus on general infection control principles in the workplace, the development of mutual assistance arrangements with stakeholder organisations, closer ties with Queensland Health.

The project has presented many multi faceted complexities, thus the title, “Project Hydra”.

Semi-structured interviews indicate cultural misunderstandings amongst emergency paramedics and Muslims in Melbourne Australia

Peter Hartley Course co-ordinator, Paramedic Sciences Victoria University School of Health Science, Melbourne

Background Religion and culture can impact profoundly onto healthcare practices and health outcomes. In Australia the second largest religious group is the Muslims, and at times of medical emergency the paramedic will be increasingly required to respond to healthcare needs of Muslims. This is an exploratory pilot study designed to identify the features of Islam that need to be met by emergency paramedics during pre-hospital health care for Muslims living in metropolitan Melbourne, Australia.

Methods Thematic analysis was used to identify common threads in responses from two independent volunteer groups: Muslims (n=6) and paramedic practitioners (n=6). The purpose and nature of and satisfaction with the paramedic callout were investigated using semi-structured interviews during a 90 minute focus group with the Muslims and individual face-to-face 30 minute interviews with paramedics.

Findings Themes indicate that the paramedics had both an absence of knowledge and a presence of incorrect knowledge on Islamic practices that impact directly onto professional practice. In relation to suggestions from the Muslim participants to ambulance paramedics, communication and respect were the strongest themes. Whilst the paramedics acknowledged the importance of cultural and religious values in pre-hospital practice, themes of frustration and increased anxiety as well as a lack of useful cross-cultural education and training were consistent throughout.

Conclusion This study recommends strategies to improve interventions for Muslims in the prehospital setting, and identifies areas of cross-cultural curricula that should be incorporated into paramedic training to improve overall health outcomes for both Muslims and emergency paramedics.

A twelve month audit of Laryngeal Mask Airway (LMA TM) use in a South Australian ambulance service

1Cindy Hein, 2Harry Owen, 3John Plummer 1Department of Paramedical & Social Health Sciences, Flinders University & SA Ambulance Service, Adelaide, South Australia 2Department of Medical Education and Department of Anaesthesia & Pain Medicine, Flinders University, Adelaide, South Australia 3Department of Anaesthesia & Pain Medicine, Flinders University, Adelaide, South Australia

Introduction The LMATM is a vital piece of equipment recommended by major resuscitation councils for use by emergency services personnel {Australian Resuscitation Council, 2006 #723; American Heart Association Inc., 2005 #722; Nolan, 2005 #721}. Ambulance services that use this device should monitor its use to ensure quality and safety standards are maintained.

Methods A clinical audit of LMATM use within SA Ambulance Service (SAAS) was registered with the director of clinical governance at Flinders Medical Centre in South Australia. Data were collected prospectively in a state wide all inclusive study over 12 months (February 2006 – January 2007). The primary outcome variable was overall success rate.

Results Insertion of an LMATM was attempted by 179 paramedical staff in 164 patients. Patient demographics are shown in Table 1.

Table 1. Patient demographics Total no of Age (yrs) Gender Weight (kgs) patients Mean Range M F Mean Range *164 64 0.1 - 96 107 57 82 6-210 *In 14 patients, the LMA was attempted by 2 or more staff members.

The percentage of patients who had a successful LMA TM insertion and the number of attempts to achieve success are shown in Table 2.

Table 2. LMA TM success rate by attempt per patient Total Overall 1st 2nd 3 or more patients success rate attempt attempt attempts No 164 121 74 33 13 (%) (74) (45) (20) (9) Note: Number of attempts was unknown in one patient.

Reported failures were ascribed to; patient anatomy (13), technique (9), airway soiling (7), device (6), trismus (1), high Glasgow Coma Score (GCS) (1), trauma (1) or unknown (5). The LMA TM was removed on 21 occasions due to; soiling (10), increased GCS/gag reflex (4), dislodgment (6) or unknown (1).

Conclusion

The clinical audit presented here provides an accurate account of current practice of LMA TM use within SAAS and identifies issues that could lead to constructive training for paramedics and methods of improving clinical care and patient safety.

References

1. Australian Resuscitation Council. Adult advanced life support: Australian Resuscitation Council Guidelines 2006. Emergency Medicine Australasia 2006;18:337-356. 2. American Heart Association Inc. Part 7.1: Adjuncts for Airway Control and Ventilation. Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(24):(Supplement), IV-51-IV-57. 3. Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European Resuscitation Council Guidelines for Resuscitation 2005: Section 4. Adult advanced life support. Resuscitation 2005;67(Supplement 1):S39-S86.

Securing safety – leadership in pandemic preparedness for the emergency prehospital sector

Higgins J,1 Tippett V,2 Hall D3 1Commissioner, Queensland Ambulance Service. 2Director, Australian Centre for Prehospital Research, Queensland Ambulance Service and University of Queensland. 3Project Manager, Queensland Ambulance Service Pandemic Preparedness Strategy

Background Queensland Ambulance Service is the fourth largest Ambulance Service in the world. The QAS provides state-wide coverage to an area of 1.77million sq/km from 282 service locations serviced by 2800 clinically active staff. Queensland has a high tourist population and in the north is proximate geographically to areas of South East Asia affected by Avian Influenza. Since early 2006, the Australian Centre for Prehospital Research has been leading a national collaborative research consortium examining risk perception among paramedics and their partners and new opportunities for emergency prehospital sector contribution to early warning and surveillance systems for infectious disease, particularly pandemic influenza.

Findings/Conclusions Preliminary results from the national paramedic and partner surveys and focus groups emphasise the fact that paramedics and their partners place most emphasis on ensuring that personal protective equipment, new operational standards and communications strategies for working in infectious disease environments ensure the highest possible levels of safety and information exchange. This work complements proactive strategies being implemented in Queensland to secure the safety of paramedics who may be required to work in these and other biohazard conditions. This includes the introduction of the Scott M98 Air Purifying Respirator into service for operational staff on a personal issue basis. A state-wide fit testing program has commenced and the development of other safety strategies will be informed by the results of the national survey to inform health and safety messages and training to staff and builds on the.

Pandemic preparedness in the prehospital sector is crucial in securing the safety of EMS personnel and the wider community. The QAS State Chemical, Biological and Radiological Awareness package implemented in 2005 served as the basis for pandemic planning, which was further enhanced by the development of collaborative, evidence-based strategies that will continue to inform health and safety messages, as well as staff training.

Simulation and critical thinking/clinical judgement

Chris Huggins Lecturer, Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

The education of heath care professionals is challenging, furthermore, it’s not easy to provide these students with experiential learning in an authentic setting. When we educate trades personnel, we can provide them with materials to work with, and this work can be identical to the authentic workplace. However, when educating health care professionals, we can not wheel in a person and break their leg, throw them in front of a moving vehicle or give them cancer so that we can develop our clinical skills.

In the past clinical placement has been the main stay of experiential learning during a health care professional’s studentship, however, this has become problematic due to the reduced number of places, the cost of providing these placements, plus the increased demand from other professions. One of the ways around this gap in providing experiential learning is simulation. Simulation can be a powerful educational tool for fine motor skills development, however, can simulation develop, or speed up the development of critical thinking in students?

This research is a part of doctorial studies, and is attempting to answer this complex question. During this research, both educators and students across three heath care disciplines and one other emergency related service are being interviewed. This is a qualitative study and as such will draw on the rich nature of human activity, and thought. This research is a work in progress, however, the trends in the research carried out so far will be discussed, and this should provide us with some incite as to the effectiveness of simulation in the development of critical thinking.

Key words clinical judgement; critical thinking; simulation

How accurately do ambulance staff and emergency department doctors identify acute cardiogenic pulmonary oedema in patients with respiratory distress? A prospective diagnostic study

Emma Jenkinson1, Malcolm Woollard2, Robert Newcombe3, Iain Robertson-Steel4 1University of Birmingham School of Medicine 2Faculty of Pre-hospital Care Research Unit, Middlesbrough, UK 3University of Cardiff School of Medicine 4West Midlands Ambulance Service NHS Trust, Birmingham, UK

Aims To evaluate the accuracy with which ambulance staff diagnose acute cardiogenic pulmonary oedema (ACPO) in patients with respiratory distress.

Methods Data were collected prospectively for 1334 respiratory distress patients transported to a UK Emergency Department (ED) by ambulance. The ED and hospital discharge (HD) diagnosis was obtained via notes review by a researcher blinded to pre-hospital diagnoses.

Results Paramedics attended 716/1334 patients (brackets =95% CIs). Compared with HD diagnosis, prevalence was 15.7% (12.5 to 19.4%); sensitivity 27.8% (17.9 to 39.6%); specificity 94.6% (91.8 to 96.6%); +veLHR 5.1 (2.9 to 8.8); -veLHR 0.8 (0.6 to 0.9). For the same cases ED doctors sensitivity was 45.1% (33.2 to 57.3%); specificity 98.1% (96.2 to 99.3%); +veLHR 24.3 (11.4 to 52.1); -veLHR 0.6 (0.4 to 0.7). EMTs attended 434/1334 of patients. Compared with HD diagnosis, prevalence was 15.3% (11.4 to 19.9%); sensitivity 4.4% (0.5 to 15.2%); specificity 98.0% (95.4 to 99.4%); +veLHR 2.2 (0.5 to 9.5); -veLHR 1.0 (0.9 to 1.0). ED doctors sensitivity was 36.6.2% (22.1 to 53.1%); specificity 96.7% (93.5 to 98.5%); +veLHR 10.9 (5.0 to 23.6); -veLHR 0.7 (0.5 to 0.8).

Conclusions Paramedics and EMTs’ specificity was high, implying that if they treated a patient for ACPO this was mostly appropriate. EMTs achieved a significantly lower sensitivity than paramedics and ED doctors, suggesting that they fail to identify most ACPO patients (<5%). Paramedics also achieved a low sensitivity, missing more than 70% of ACPO cases. Ambulance staff require additional training in ACPO diagnosis to ensure more patients receive appropriate treatment.

Ambulance call triage outcomes for patients reporting pain

Bill Lord1, James Cui2 1Senior Lecturer, Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne 2Senior Research Fellow, Department of Epidemiology & Preventive Medicine Monash University, Melbourne

Objective To identify any association between the triage category generated during the call for an ambulance made to the ambulance communication centre and the patient’s report of pain severity.

Methods A retrospective study of patient care records of all adult patients with a Glasgow Coma Score >12 transported to hospital in a major metropolitan area over a 7-day period.

The outcome of interest was the triage category assigned to the case. Explanatory variables include age, gender, pain severity, pain cause and duration of pain. Descriptive statistics and univariate and multivariate logistic regression analysis were used in the analysis.

Results A total of 3357 patients were transported by paramedics, with 1766 (53%) reporting pain. Data included initial pain score using a 0-10 Numeric Rating Scale, and the call triage category from the Medical Priority Dispatch System (MPDS) response code calculated on acuity of the patient’s complaint.

Results found that patients with an initial pain severity of NRS 8-10 (severe pain) were more likely to be assigned to response code 2 (non-urgent) than response code 1 (urgent) or 3 (OR 1.9, 95% CI 1.2 -3.1). After adjusting for gender, age, cause of pain and duration of pain, patients with severe pain are more likely to be assigned to response code 2 than other categories (OR 1.66, 95% CI 0.98-2.81), but this is marginally significant at P=0.057.

Conclusion People in the highest pain severity category tend to influence triage category and ambulance response in this study setting.

Can someone please call the vet – I can’t communicate with my human patient

Veronica Madigan Charles Sturt University, Bathurst, NSW, Australia

Human medicine relies on patient communication to assist with a medical diagnosis and the instigation of appropriate clinical treatment protocols. Medicine is driven by verbal communication where patients are expected to answer key questions concerning their illness, injury or disease as well as furnish relevant information about their medical history. However, what happens if there is no effective verbal communication? What happens when non English speaking patients, paediatric patients, the mentally ill, the semi conscious, unconscious patients, or even the anxious, frightened or autistic patients require medical attention? Health care practitioners can often appear uncertain of the appropriate medical steps to take both in the pre-hospital and hospital environment.

Veterinary practitioners are faced with this situation every day. They do not rely on verbal communication with their animal patients yet they have well developed skills to effectively understand, diagnose and treat their furry patients. Could there be lessons to be learnt from the examination of animal treatment models that could benefit human medicine, particularly on road paramedics? My PhD is researching this very question and this presentation challenges participants to ask the animals and they will teach you!

Predicting pre hospital care students’ first year academic performance at university – a follow up study.

Veronica Madigan1, Brendan Smith2 1Senior Lecturer, Pre Hospital Care Emergency Medicine Charles Sturt University School of Biomedical Sciences, NSW, Australia 2Staff Anaesthetist/Intensivist, Bathurst Base Hospital, Bathurst , NSW, Australia

With increasing demand for pre hospital care university places and several problems of unsatisfactory student progression and retention, a rural university embarked on a four year study to try and predict academic performance of first year pre hospital care students in an attempt to resolve these issues.

The four year study (1998-2001) used six previously identified indicators of academic performance to predict first year academic success of 135 on campus, pre hospital care students. The study found that a UAI>50, previous health related experience, post secondary educational qualifications, background, student entry type and gender were all found to be significant predictors of first year academic performance in selective cohorts. Further, a study generated Student Selection Tool to assist in selection of first year pre hospital care students was recommended for use in the pre hospital care arena and allied health care fields.

A four year follow up study (2002-2005) utilising 351 first year on campus pre hospital care students has recently been completed. This research utilised the same six indicators of academic performance to predict academic success as the previous study. In addition, the study investigated the academic performance of both single degree and double degree pre hospital care students with challenging results.

Did the second study replicate the findings of the first study? Did the increased sample size discover more confronting findings? What of the Student Selection Tool – was it successful in selecting first year students? The answers to these questions and more will be addressed in the conference presentation!

Queensland rural and remote expanded paramedic practice evaluation

Jamie Murdoch1, Steve Raven1, Vivienne Tippett1, Arthur O’Brien2 1Australian Centre for Prehospital Research; 2Queensland Ambulance Service

Introduction The Queensland Ambulance Service, together with Queensland Health and James Cook University has developed the Graduate Certificate of Isolated Practice – a program for paramedics in rural and remote locations to expand their skill set and address the major challenges of health care inequity in their communities.

The first cohort of isolated practice paramedics (IPPs) will be operational in their communities in November 2007. They will have gained skills in injury and disease prevention, health promotion and the management of non-acute, chronic illness.

In line with recognised best practice, the Queensland Ambulance Service is currently undertaking a comprehensive evaluation of the IPP program.

Aims The evaluation has three key objectives. To measure the impact of: • New skill sets and approaches to health care on patients and the community; • Educational opportunities for paramedics and the impact of new skill sets and practices on usual ambulance activities; and • Initiative for other health care providers in the community

Method Interviews will be conducted with key stakeholders including IPPs, local medical officers/GPs, Nurse/health clinic staff, allied health professionals and community groups at strategically selected IPP locations, to capture a range of demographic and geographical profiles. Perceptions of key health issues, gaps in health provision, perceptions of the IPP role and other issues will be explored.

Findings This paper will outline some of the methodological and practical challenges involved with conducting an evaluation in isolated and remote areas. It will also provide some preliminary results from the evaluation being conducted to date.

Silent Myocardial Ischaemia – A Review of the Literature

Ziad Nehme1, Malcolm Boyle2 1Honours student, Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne 2Senior Lecturer, Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne

Objectives There has been little emphasis in paramedic education about silent myocardial ischaemia, its implications, and management in the prehospital environment. There is also minimal information about the aetiology and prehospital management of silent myocardial ischaemia. The objective of this study was to review the literature on silent myocardial ischaemia, including the prehospital management.

Methods A review of the Medline database was conducted from 1950 to the beginning of March 2007. Inclusion criteria were, any study type reporting the epidemiology, pathophysiology, clinical concepts, and management of silent myocardial ischaemia. References of relevant articles were also reviewed. A review of prehospital clinical implications and management was also undertaken.

Findings The search located approximately 1,300 articles, 110 articles met the inclusion criteria. Silent myocardial ischaemia is not limited to patients with significant coronary artery disease or cardiovascular risk profiles, it may affect up to 10% of patients with asymptomatic coronary artery disease. Silent myocardial ischaemia is also associated with greater adverse outcomes, and has been defined as the single strongest factor attributing to cardiac death in patients with concurrent angina pectoris. All patients with coronary artery disease presenting with and without pain can be managed with GTN and aspirin, in the absence of contra-indications.

Conclusion This study demonstrates that silent myocardial ischaemia is not limited to patients with significant cardiovascular risk profiles and may affect up to 10% of patients with asymptomatic coronary artery disease. There is little prehospital care providers can achieve with current clinical practice guidelines and management regimes.

Keywords angina; angina pectoris; chest pain; emergency medical services; emergency medical technicians; myocardial infarction; myocardial ischemia; unstable

So you think you can ventilate using the self-inflating bag? Think again (Awarded APEHRF 2007Best Paper Prize)

Objectives The correlation between hypo/hyperventilation and mortality has long been established in patients with severe head injuries, hypovolemic shock and cardiopulmonary resuscitation. In light of recent changes to the International Liaison Committee on Resuscitation guidelines for resuscitation, there is a need to identify the best method of ventilation for the prehospital environment. The objective of this study was to review the efficiency of bag-valve-mask ventilation in relation to operator delivery of ventilation rate, volume and pressure.

Methods A review of select electronic databases was conducted from their commencement to the end of April 2007. Inclusion criteria were, any study type reporting manual ventilation (including operator technique), ventilation in simulated clinical scenarios, and ventilation in cardiac arrest, severe hypovolaemic sock, severely head injured patients, a focus on haemodynamic changes during cardiac arrest and severe head injury. References of relevant article were also reviewed.

Findings The search located approximately 1,100 articles, 150 articles met the inclusion criteria. There has been a tendency for emergency care providers to ventilate patients excessively causing secondary complications and poorer outcomes. There is a need for re-evaluating self- inflating bags after smaller capacity bags were seen to reduce inspiratory pressure and gastric inflation, while maintaining oxygenation. The one-handed compared to the two-handed technique for ventilation has been demonstrated as the best method for providing adequate ventilation in patients requiring ventilatorary support.

Conclusion Scientific evidence suggests using a smaller volume self-inflating bag with a one-handed technique the preferred method to deliver adequate ventilation with less secondary complications in the prehospital setting.

Keywords barotrauma; capnography; carbon dioxide; hyperventilation; hypoventilation; pulmonary ventilation; tidal volume

The congruence between a baccalaureate paramedic program and industry competency expectations

Madeleine O’Donnell School of Education, Flinders University Adelaide, South Australia

Introduction Paramedic programs are offered in universities; there is no record in paramedic literature that examines how graduates are prepared in competencies required for the work environment. This study examined one baccalaureate program to scrutinise the extent to which it fulfils industry-relevant entry- level competencies.

Research Questions Are National Ambulance Competencies (NAC) reflected in the Bachelor of Health Science (Paramedic) curricula documents?

Do graduates, and their clinical supervisors, perceive graduates meet industry standards as described in the NAC?

Methods Document analysis was undertaken to verify existence of NAC within the course documents. Graduates and supervisors who monitored their clinical practica were surveyed. Data were analysed through Rasch Unidimensional Measurement Model software to determine strength between graduates’ and supervisors’ perceptions of competency achievement.

Results All but one NAC is evidenced within this baccalaureate program. Guttman Pattern misfit was identified in one response. Reliability Indices and Cronbach Alpha were both 0.929. Collectively, graduates (n=37) ranked their perception of overall competence in terms of employment-readiness at 51.7%, and supervisors (n=33) ranked graduates’ overall employment-ready competence at 52.5%. This outcome would present different results if one competency was relocated to the higher competency level, removal of Guttman Pattern misfit codes, and increase dedicated clinical practica.

Conclusion Participants undertaking the paramedic baccalaureate program from this university desire more clinical skills development factored into classroom skills laboratories. Both graduates and supervisors strongly indicated the need for more clinical practica to enable competency development and the transfer of theoretical knowledge into essential patient care practices to meet employer and industry competency achievement.

Reference Keeves J, editor. Educational research, methodology, and measurement: an international handbook. 2nd ed. New York: Pergamon 1997.

Keywords emergency medical services; paramedic education

Mentoring paramedics as rural health researchers

Peter O’Meara1, Judith Walker2, Christine Stirling3, Daryl Pedler4, Vianne Tourle1 1Charles Sturt University, Bathurst, Australia 2University of Tasmania, Burnie, Australia 3University of Tasmania, Hobart, Australia4Monash University, Traralgon, Australia

Background For the paramedic profession to grow and develop, practising paramedics need appropriate education and training to undertake research into their own field of practice. The Beyond Emergency Response project exploring how rural paramedic roles interact with other health professionals, health consumers and ambulance services was designed to mentor ambulance paramedics as novice researchers.

Objectives The project aimed to increase the research capacity of Australian ambulance services through the mentoring of paramedics as researchers in a qualitative research project.

Methods Ambulance authorities in Tasmania, Victoria, South Australia and New South Wales nominated paramedics as research associates who were then brought together for training in basic qualitative research methods, including interview and analysis techniques. The paramedic researchers each completed a State-based case study under the supervision of experienced rural health researchers. They participated in the analysis of four case studies and contributed to the writing of the final project report.

Findings and Conclusions Using paramedics to capture the views of practicing health professionals, paramedics and members of local communities added complexity and depth to the research process. The novice researchers acquired data collection, analysis and writing skills through their participation in the research project. They learnt a great deal about development outside their own jurisdiction through the opportunity to network between themselves and the research mentors. Since the completion of the Beyond Emergency Response project they have continued to develop as researchers through participation in other research studies, conference presentations, publication of papers and enrolment in research degrees.

Defining the professional responsibilities of flight paramedics: The results of a role delineation study

Lachlan Parker Flight Paramedic, Queensland Ambulance Service

Background Flight paramedicine is a relatively new and evolving specialty; one which optimises the care of critically ill and injured patients through air transportation. Due to varying flight paramedic (FP) roles within Queensland, an examination of the scope of practice of Queensland Ambulance Service (QAS) FPs is warranted.

Objective The purpose of this study (funded by the Kenneth James McPherson foundation) was to describe the roles, levels of responsibility and backgrounds of FPs employed by the QAS.

Methods QAS FPs completed a web-based survey designed to explore perceptions in five areas of FP practice: personal and operational demographics; employment and orientation requirements; patient care problems; clinical skills and procedures; and aircraft responsibilities. Perceived roles were then compared to actual taskings following the development of a new database at Emergency Management Queensland, Brisbane.

Findings and Conclusions Currently the role of the FP varies enormously, mainly due to clinical level and medical crew configuration. The majority of respondents were Intensive Care Paramedics (ICP) with few occupying designated FP roles. Six of the ten operators have regular availability to critical care medical personnel on varying support rosters. Other crew configurations included: ICP alone and advanced care paramedic alone. Patient care problems were analysed by primary and secondary taskings. Traffic/transportation accidents represented the majority of primary trauma taskings, with cardiac conditions identified for interhospital transfers. Clinical skills and procedures varied with clinical level and crew configurations. The FP performs a unique role, often practising extended and specialised procedures within an undefined framework. A designated QAS FP training program and classification is worth further discussion and consideration.

Keywords flight paramedic; practice analysis; role; skills.

Prehospital oxygen administration in COPD – how much is too much? A review of the literature

Elizabeth Perry1, Brett Williams2 1BEH Student, Department Community Emergency Health & Paramedic Practice. Monash University, Melbourne 2Lecturer, Department Community Emergency Health & Paramedic Practice. Monash University, Melbourne

Introduction Perpetual debate continues regarding the amount of oxygen that should delivered by paramedics to patients with acute exacerbations of COPD. Studies have reinforced that providing excessive levels of oxygen in COPD patients can result in hypercapnic respiratory failure. Despite the prevalence of COPD there continues to be a paucity of prehospital literature on this topic.

Search Strategy The search involved reviewing the Cochrane Database of Systematic Reviews (2nd Quarter 2007), the Cochrane Central Register of Controlled Trials (2nd Quarter 2007), MEDLINE (1950-May 2007), EMBASE (1974-week 22, 2007), CINAHL (1982-May week 4 2007) and PubMed (May 2007).

Findings This literature review reaches the same finding of a recent Cochrane systematic review, that no randomised control trials have been completed to determine the ideal oxygen concentration for the treatment of acute exacerbations of COPD. (1) There is a lack of high quality evidence in determining the most appropriate level of oxygen provision in patients with exacerbation of COPD. A recent study of 101 patients demonstrated that FiO2 > 0.28 is commonly provided to COPD patients with potential deleterious effects. (2)

Conclusion Following this literature review, the authors suggest several recommendations. Firstly, randomised controlled trials are required to establish the level of oxygen that can be safely prescribed to patients with acute exacerbation of COPD in the prehospital setting. Secondly, widespread access to pulse oximetry should be provided to paramedic personnel to ensure patients receive a level of oxygen that prevents hypoxia. And finally, that appropriate respiratory medicine is integrated in paramedic curricula from basic to advanced levels of training.

Keywords COPD; Oxygen; Prehospital Emergency Care.

Impact of the Leatt-Brace™ on emergency pre-hospital care

Timothy Pointon, Harry Owen Flinders University Adelaide, South Australia.

Introduction Many motor sport professionals wear a Leatt-Brace™ for cervical spine protection. It is designed to allow normal neck movement but prevent extreme neck movement in a crash. The Leatt-Brace™ is now being marketed for everyday use by motorcyclists so paramedics need to know how to care for a crash victim wearing one.

The device has an anterior and posterior assembly which buckle laterally. It conforms securely to the thorax and shoulders and has projections to limit movement of a rider’s full- face helmet.

Methods A Leatt-Brace™ was obtained from the Australian distributor and set up following the manufacturer’s guidelines on a patient simulator. Emergency care of a motorcycle crash victim was then provided by experienced paramedics. Procedures trialled included helmet removal, airway care and cervical spinal immobilisation. Interference from the device on delivering this care was noted.

Results The Leatt-Brace™ as worn interfered with helmet removal but when the front assembly was removed most basic care and procedures except applying a cervical collar could be performed. The rear assembly lifts the body so once the helmet has been removed the head requires support.

Implications The Leatt-Brace™ is expected to reduce the incidence of spinal cord injury when worn correctly however it does have some impact on treatment of unconscious crash victims. Paramedics should learn how to remove the front assembly quickly in an emergency. There are situations where the whole system will need to be removed at the scene and how this can be achieved safely will be discussed.

Innovative and affordable assessment techniques for practical simulations using Laerdal Simulation Technology

Timothy Pointon, Louise Reynolds Flinders University Adelaide, South Australia

Introduction Valid and reliable assessment of practical skills frequently presents a challenge to a busy teaching team. Using a combination of programmable simulation ability of the Laerdal Resusci Anne™, a video camera and a peer assessment sheet the research team undertook to assess student’s practical skills in a reliable and valid manner. This discussion paper reports the outcomes and informal student feedback from this exercise.

Method Scenarios were programmed into a Laerdal Resusci Anne™ simulator. Students were asked to undertake a randomly selected scenario while being video recorded. A peer assessor was instructed to enter pre-set events with each intervention the student performed.

Assessment was by peer assessment and later by viewing the video. Grades were awarded based on a combination of the two assessments.

Results Students reported preferring the technique due to feeling less nervous in the presence of their peers. The topic coordinator was able to manage time and budgets more effectively by viewing and assessing students at convenient. Very few technical problems were reported with and those that did occur related to familiarity with the technology. Reliability and validity of the assessment was ensured by monitoring the video times, the peer assessment process and the random selection of carefully constructed scenarios.

Discussion Using the simulation capabilities of the a Laerdal Resusci Anne™, together with a video recording system allows for greater student satisfaction, cost effectiveness, valid and reliable assessment of clinical practice. Improvements could be made by further technical instruction of students.

Ambulance change management or changing ambulance management?

Louise Reynolds Flinders University Adelaide, South Australia

This paper presents case studies which apply the theory of ambulance organisational culture. The paper begins with brief overview of the doctoral study from which the theory has been developed. Using qualitative methodology, the doctoral study generated a theory of ambulance organisational culture. The main focus of the presentation will be three case studies, each examining differing aspects of the ambulance culture theory. The first case study examines how changing dynamics of “space”, when applied to ambulance team membership, can be challenging for ambulance managers especially when configurations are changed. The second theoretical aspect, “time” explains why ambulance managers find changing roster configurations difficult. Lastly, “interaction” examines the cultural aspects of how and why ambulance personnel interactions can be difficult to manage. In examining these three scenarios, ambulance culture theory will be applied in order to gain a better understanding of the implications of change and organisational culture management. This paper is targeted at ambulance managers who actively engage in change management or are seeking to implement changes in their organisations.

Research into the implications of mental practice

Louise Roberts Honours Degree Student, Bachelor of Health Sciences Flinders University Adelaide, South Australia

The National Mental Health Strategy has combined mental health services with health call outs on paramedic the general health system and a community based system of treatment and support. Decreased reliance on stand alone psychiatric hospitals and “main streaming” of acute beds into general hospitals has led to a marked increase in the number of people living in the community with a mental illness. This research aims to investigate how these changes affect the ambulance service and paramedic practice in South Australia.

South Australian Ambulance Service (SAAS) data, a survey and focus groups with ambulance personnel will be used to determine what percentage of SAAS caseload deals with people presenting with disturbed behaviour; the resources currently available to ambulance personnel to manage cases of mental illness and the experience of paramedics in relation to management and assessment of possible mental health patients, resources used, training needs and perception of their role when dealing with mental illness. SAAS data will be collated on the length of time at scene, how often ambulance personnel attend the some person for disturbed behaviour, and how often other agencies are required at the scene. The research aims to show the extent to which mental health cases are becoming a part of ambulance personnel workload, the impact that is having on their practice, and the resources, training, policy and procedures to be considered to manage the workload in this area.

The paramedic professional: A challenge of perception

Rod Sheather Queensland Ambulance Service

Background Paramedics view themselves as professionals, but are they? Is it important for paramedics to be considered professionals?

Method A literature review has been conducted into the nature of professions and professionals. A further review of literature relating to paramedic professionalisation has also been conducted. The literature relating to paramedic professionalisation has been examined in the context of the findings from the review into professions and professionals.

Results A number of models exist that define the nature of professionals however the dialogue amongst paramedics around the issue of professionalism is inconsistent. This lack of a common understanding and professional agenda is restricting the progression of the paramedic profession.

Paramedics are an emerging profession which has reached a crossroad. A number of emergent professions have stalled in their development. It is time to challenge our professional boundaries.

This paper will examine the problems associated with paramedics identifying as professionals. What are the issues that impact on the paramedic’s perception and how are they affecting the professionalisation of paramedics? The issues of culture, professional knowledge, education, autonomy and division of labor will be examined for the impact they have upon perception and practice. These will be examined in the light of the changing role of paramedics and the changing nature of professionals.

In conclusion the paper will draw these issues together to identify an area for research around the issue of the paramedic professionalisation.

Decision making during disasters: A case-study of first responders during the 9/11 World Trade Centre terrorist attacks

Erin Smith Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Background Disasters are exceptional events that require first responders to make non-routine decisions quickly. When these decisions can have a direct impact on the health and safety of not only the first responders, but on the ultimate survivability of a community, gaining an understanding of this non-routine decision making process is of paramount importance. The World Trade Centre (WTC) terrorist attacks of September 11, 2001 provide us with a unique “laboratory” to investigate how first responders made decisions in regards to their perception of risk and willingness to work during a disaster and in the immediate aftermath. Previous Australian based research proposed a “decision making hierarchy” that may influence non- routine decision making during disasters.1 This decision making hierarchy hypothesised that paramedics make non-routine decisions based on issues of safety, training, communication/information, and trust in employers.

Objectives The objective of this research was to test the face validity of this “decision making hierarchy” and to determine whether the themes identified in this hierarchy influenced non-routine decision making during the initial response to the 9/11 WTC attacks.

Methods A focus group was conducted with New York based first responders to discuss their non- routine decision-making and response to the 9/11 attacks.

Findings and Conclusions First responders moved through levels of the “decision making hierarchy” as they made non- routine decisions during their response to the WTC attacks. They reported primary concerns regarding safety and having adequate training and equipment to respond effectively. An information “overload” was reported which hindered effective non-routine decision making.

Reference 1. Smith E. Paramedic’s Perception of Risk and Willingness to Work during Disasters. Proceedings of the Australian College of Ambulance Professionals (ACAP) Conference, 2006 November; Adelaide, Australia

Cultural competency in paramedic education courses

Caroline Spencer, Rhona Macdonald, Frank Archer Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Introduction Literature suggests that there is a growing recognition among health professionals of the need to provide students with cultural competency skills as an aid to assist their professional involvement with a progressively more diverse population. The development and evaluation of cross-cultural and cultural competency units and courses now proliferate internationally, however currently there are no Australian or New Zealand studies that reviews those programs.

Objectives The purpose of this study was to review cultural competency programs that are being offered by Australian and New Zealand universities and other providers of paramedic education.

Methods A systematic search of the literature from 2002 to 2007, was conducted to identify models and programs of cultural competency utilised in the primary health care environment, nationally and internationally during the past five years, followed by the development of a study specific questionnaire based on open and closed questions to qualitatively analyse data relating to content and context of cultural competency programs offered by Australian and New Zealand universities, or other providers of paramedic education.

Results Data from surveys is currently being collected for analysis using statistical and qualitative research software.

Discussion This research will provide a basis for Australian and New Zealand paramedic preparation in cultural competency, using The National Health and Medical Research Council’s 2006 publication, ‘Cultural competency in health: A guide for policy, partnership and participation’ (1) as the rationale for this study.

Conclusion This research contributes to a growing body of international knowledge that considers the development of cultural competence in education programs for health professionals.

Reference: 1. Australian Government National Health and Medical Research Council. Cultural competency in health: A guide for policy, partnership and participation. Commonwealth of Australia 2006.

The Australian Emergency Prehospital Pandemic Influenza Project: A methodology for operational evidence

Tippett V1, Archer F2, Jamrozik K3, Kelly H4, Watt K5, Raven S6 1 Director, Australian Centre for Prehospital Research and Chief Investigator 2 Director, Monash University Department of Community Emergency Health & Paramedic Practice 3 Professor of Health Services Policy and Practice, School of Population Health, University of Queensland 4 Victorian Infectious Disease Reference Laboratory 5 Project Manager, Australian Centre for Prehospital Research 6 Paramedic Research Officer, Australian Centre for Prehospital Research

Background In early 2006, a collaborative national and international team led by the Australian Centre for Pre-hospital Research and Monash University Centre for Ambulance and Paramedic Studies was funded by a National Health and Medical Research Council Urgent Research Grant to examine the perception of risk of Australian paramedics and their families to working and living in pandemic conditions and to assess the utility of ambulance call taking and dispatch data to inform population-based models for surveillance and triage. This project secured early support from the national Council of Ambulance Authorities and the 8 individual Ambulance Service jurisdictions across the country. The consultative approach and methodology applied for this Project have provided an important platform for the development of evidence based approaches to issues of national significance for Ambulance Authorities in Australia.

Findings/Conclusions This paper will describe the methodology applied to this ambitious project and emphasise the opportunities the project presented to facilitate national engagement and develop a governance structure to ensure good practice in the transition of research into operational policy.

Transportation of Aggressive Patients to Hospital: Rage against the Machine

Watt K1 Enraght-Moony E1. 1Australian Centre for Prehospital Research

Background Transportation of aggressive patients is an increasing concern among the prehospital workforce in Australia, and internationally. In order to effectively manage aggressive patients with minimal risk (to the patient, and to those who transport them), an understanding of their presentation profile is crucial.

Objectives The aim of this study was to examine the incidence and presentation patterns of aggressive patients transported to hospital via ambulance.

Method Data were collected as part of the PADIE study (Prevalence of Alcohol and Drugs in Emergency) 24 hours per day, over a two-week period in October 2005, from patients presenting for treatment at the Gold Coast Hospital ED (16-79 years). For this study, data were collected on transported patients only. Patient aggressiveness was rated independently on a likert scale (1-5). Data on presentation type (injury type, etc), day of week, and time of day were also collected, together with information on alcohol/drug use and mental health (anxiety/depression).

Findings/Conclusion Analyses of data are currently underway. A patient profile of the “aggressive patient” will be discussed in this presentation (presentation type; alcohol/drug use; and concurrent mental health issues). These data will facilitate identification of patients likely to be aggressive, and in the development of appropriate strategies for treating these patients.

Pandemic Influenza: Australian paramedic risk perception study

Watt K1, Tippett V2, Raven S3 Jamrozik K4, Archer F5, Kelly H6, Coory M7

1 Project Manager, Australian Centre for Prehospital Research 2 Director, Australian Centre for Prehospital Research and Chief Investigator 3 Paramedic Research Officer, Australian Centre for Prehospital Research 4Professor of Health Services Policy and Practice, School of Population Health, University of Queensland 5 Director, Department of Community Emergency Health & Paramedic Practice, Monash University, 6 Victorian Infectious Disease Reference Laboratory 7 School of Population Health, University of Queensland and Queensland Health

Background Paramedics are front-line health professionals and will be among the first in the community to face exposure during a pandemic event. There is little published data on pre-event risk perceptions of the pre-hospital workforce, and in Australia, little prior exposure to working in infectious environments such as an influenza pandemic.

Objective This study was designed to investigate pre-event knowledge, attitudes and behaviours of paramedics and their partners in relation to a potential human influenza pandemic, and to determine predictors of these attitudes and behaviours. The outcome of this research will facilitate development of responsive health and infection control messages for paramedics and their families.

Methods Surveys were distributed to a random stratified (service; gender; rurality) sample of 20% of the national prehospital workforce (n=3000 approx) in May 2006. A series of logistic regressions were performed in order to determine the predictors of attitudes and behaviours among the prehospital workforce and their families.

Findings/Conclusions Preliminary analyses highlight some important messages for the pre-hospital community. Among paramedics, high risk perception is associated with less confidence in provision of adequate strategies by employers to protect them from exposure, and less willingness to work during pandemic conditions. Knowledge about avian influenza and/or human pandemic influenza does not appear to be associated with confidence in employer, levels of concern or willingness to work in pandemic conditions (OR=1.91; 95% CI=1.1-3.3). Paramedics report that the information most likely to mitigate their level of perceived risk relates to confidence in Personal Protective Equipment and intra/inter-organisation communications and alert systems. Results of this study will be described in full, together with an analysis of strategies in Australian prehospital services to respond to these messages.

Is real really better? Can DVD simulations replace paramedic clinical placements

Brett Williams, Frank Archer Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne

Background The purpose of this study is to report the final results of a funded project that explored the undergraduate paramedic students’ attitudes towards DVD simulations and potential impact these results might have on clinical placements.

Method This study used a mixed methodology approach that used a convenience sample of students over two university semesters in 2006 and 2007. Students were enrolled full-time in the Bachelor of Emergency Health (BEH) degree. The BEH students (n=97) were asked to complete a 7-point Likert Scale (1 = strongly disagree - 7 = strongly agree) paper-based questionnaire that aimed to assess the clinical relevance and students’ general perceptions and attitudes of viewing clinical simulations via DVD. Thematic analysis was also undertaken using two focus groups (n=6). Ethics approval was sought and approved.

Results Overall, the DVD simulations produced positive results. Data was analysed under the following headings: Sustained Attention mean 4.3 (95% CI 4.1 to 4.5), Learner Satisfaction mean 4.9 (95% CI 4.8 to 5.1), Clinical Relevance mean 4.3 (95% CI 4.2 to 4.4). The focus groups produced interesting themes, these included: Engendered more respect between health care disciplines, identification that efficient and effective learning does not consistently take place on clinical placements, and certain clinical placements could be entirely replaced with DVD simulations.

Conclusions The findings have highlighted the potential to maximise student clinical learning, potentially reduce student-patient contact and overall provide better linkage between theory and practice by integrating patient DVD simulations.

Keywords clinical placements; DVD simulations; education; paramedic emergency care.

Paramedic identification of ECG J Point and ST Segments: A pilot study

Brett Williams, Malcolm Boyle, Mr Bill Lord Department of Community Emergency Health & Paramedic Practice, Monash University

Background: The objective of the study was to determine if undergraduate paramedic students could accurately estimate ECG ST segment elevation and J Point location.

Methods: This study was a prospective single blinded observational study that used a convenience sample of students over one university semester in 2006. Students were enrolled full-time in the Bachelor of Emergency Health (BEH) degree offered at Monash University. The questionnaire contained 4 enlarged ECG’s all of which illustrated different levels, patterns and characteristics of ST segment elevation. Ethical approval for the study was granted.

Results: The findings showed significant variations in students’ accuracy with both J Point and ST Segment identification. Only 16% correctly identified the ST segment elevation being present in each ECG, with 40% correctly identifying ST segment elevation in 3 out of the 4 ECG’s. A large proportion of students 41% reported ST elevation was not present in ECG 4 when ST segment elevation existed. ECG 2 reflected 6mm of ST elevation; however, only 6% of students correctly identified this. Only 7.6% correctly estimated the J point on all 4 ECGs. Overall, the students were 0.55mm (95% CI 0.147mm to 0.959mm, range -6.5mm to 3.5mm) from the J point on the horizontal (x) axis and -0.22mm (95% CI -0.378mm to - 0.063mm, range -2.8mm to 1.3mm) on the vertical (y) axis.

Conclusion: Undergraduate paramedic inaccuracies occurred with ST segment measurements and precise location of J Points. The results from this study should inform the educational design of programs that aim to teach this skill.

Keywords education; electrocardiography; emergency medical technicians; J Point, ST segment.

Clinical estimations of age, weight and breath sounds: How accurate are undergraduate paramedic and nursing students?

Brett Williams1, Malcolm Boyle1, Peter O’Meara2 1Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne 2School of Biomedical Sciences, Charles Sturt University, Bathurst, NSW.

Objectives This study will establish if undergraduate paramedic/nursing students can accurately estimate age, weight and breath sounds. Recent literature has begun to address these clinical assessment issues in emergency departments; however, a paucity of literature still exists on undergraduate paramedic/nursing clinical estimations.

Methods This study was a double blinded observational study that used a convenience sample of undergraduate paramedic/nursing students from two universities, during semester 1, 2007. Students were provided with seven patients of varying age, weight and accompanying breath sounds. Ethics approval was granted.

Results There were 234 students who participated in the study. There were no demographic relationships between the students and their overall estimations. Generally, the students overestimated the patient’s weight and underestimated the age. However, the greatest inaccuracy with weight estimation occurred with patient 4 (actual weight 105kg) who had a mean estimation of 88kg (95% CI 86 – 89). Patient 5 (actual age 60 yrs) produced the largest discrepancy in the age estimations with a mean of 49yrs (95% CI 48 – 50). Generally, the breath sound interpretations were poor with <10% of each sound being correctly identified. Students were unable to correctly distinguish between coarse and fine crackles, as typified in Audio # 4 (actual fine crackles), only 1.2% of students correctly recognised this sound.

Conclusion These findings are important in the current higher-education climate of research-led teaching. Results have emphasised the need for improved teaching of breath sounds. Paramedic and nurse educators should consider the integration and assessment of age and weight assessments in their respective curricula.

Keywords: nurses; paramedic; paramedic education; undergraduate

Learning Styles of First Year Undergraduate Paramedic Students: A 12-month Longitudinal Study Brett Williams, Department of Community Emergency Health & Paramedic Practice, Monash University, Melbourne Ted Brown, Department of Occupational Therapy, Monash University, Melbourne

Background The purpose of this study is to report the results of a project that explored the learning style preferences of first year undergraduate paramedic students.

Methods First year paramedic students (n=45) studying the Bachelor of Emergency Health (BEH) degree at Monash University completed two self-report learning style inventories (the Kolb Learning Style Inventory and the VARK Questionnaire) on two occasions (at the beginning and end of the 2006 academic year). The Kolb Learning Style Inventory determines what a person’s preferred learning mode is: (i) concrete experience, (ii) reflective observation, (iii) abstract conceptualisation or (iv) active experimentation. The VARK Questionnaire measures a person’s preferred ways of gathering and utilising information through Visual (V), Aural (A), Read/Write (R) and Kinesthetic (learning by physical activity) (K) means. Ethics approval was sought and approved.

Results Paramedic students exhibited specific learning style preferences. The majority of students favoured either experimenting with new ideas through practical classes (‘converging’), or brainstorming and receiving personal feedback (‘diverging’). There was a reduced preference for (‘accomodating’) – solving problems in an intuitive trial and error manner and (‘assimilating’) – ability to create theoretical models. Students also exhibited a greater preference for kinesthetic learning, supporting practical experiential components of education.

Conclusion The authors will highlight that by determining students’ learning style preferences, particularly from a first year perspective, may assist to inform what pedagogical approaches optimise students’ learning experiences.

Keywords education; learning style; prehospital emergency care.

Evaluation of prehospital analgesia by Queensland paramedics

John Woodall, Kerrianne Watt Australian Centre for Prehospital Research, Brisbane, Australia

Background Opinion within emergency medicine indicates that analgesia is applied inconsistently and inadequately. This may be particularly true of the prehospital environment. Some studies report analgesia rates as low as 12.5% for patients transported by ambulance with painful extremity injuries. Little information exists to describe the use or effectiveness of prehospital analgesia by Australian paramedics.

Objectives This study aims to describe prehospital administration of analgesia by paramedics in the Queensland Ambulance Service. This study will describe rates of analgesia administration, and the effectiveness of the pain relief given.

Method Data was collected over a two-week period during October/November, 2005 and captured all patients aged 16-79 years who attended the ED at the Gold Coast Hospital. All injured patients transported to hospital by ambulance were included in this study. Cases were matched with ambulance records to capture data on prehospital treatment and reduction in pain. Data on mechanism and type of injury were obtained, as well as drinking and drug use patterns, and mental health status.

Findings And Conclusions A total of 474 patients presented with an injury, of whom 128 were transported to hospital by ambulance (27.0%). Of these patients, 79 cases (61.7%) were male and another party contributed to the injury in 40 cases (32.3%). Linkage with ambulance case records is ongoing at the time of writing. All results will be interrogated to see if they differ as a function of demographics, injury mechanism, alcohol/drug use and mental health status. These analyses will powerfully inform discussion and policy on prehospital analgesia.

Self-presentation vs ambulance transport of “urgent” conditions to an emergency department

John Woodall, Kerrianne Watt Australian Centre for Prehospital Research, Brisbane, Australia

Background Despite dedicated public information campaigns, patients with urgent complaints continue to transport themselves to hospital rather than call for an ambulance. These patients represent a challenge to prehospital providers, as bypassing ambulance transport may place the patient at serious risk of increased harm.

We have little information on the demographics or aetiology of patients who bypass ambulance treatment and transport to hospital.

Objectives This study aims to describe those seriously ill and injured patients who self-present to a busy metropolitan emergency department.

Method Data was collected over a two-week period during October/November, 2005 and captured all patients aged 16-79 years who attended the ED at the Gold Coast Hospital. All patients who were allocated a triage category of 1 or 2 upon presentation at the ED were included in the study. Data on method of presentation (self-presentation vs. ambulance transport); presenting complaint; and demographic variables were obtained.

Findings and Conclusions A total of 102 patients presented to the ED with urgent conditions (injured: n= 18; uninjured: n= 84). Of these patients, 40 self-presented, and 62 were transported by ambulance. The most common cause of presentation for both patient groups was chest pain (self-presentation: n= 17; transported by ambulance: n= 23). Notably, hospital attendance was recommended by a GP in 10 of the self-presenting patients (25%). A comprehensive array of demographic variables will be interrogated to identify those factors that may predict self-presentation. This is one of the only examples where a complete population of self-presenting patients has been identified and described in the literature.

Airtraq versus standard laryngoscopy by experienced pre-hospital laryngoscopists in a model of difficult intubation: a randomized cross-over trial Malcolm Woollard1, David Lighton2, Warren Mannion,3 Ian Johns,3 Peter O’Meara4, Chris Cotton5, Mike Smyth6 1Visiting Professor, School of Biomedical Sciences, Charles Sturt University, Bathurst, Australia 2School of Biomedical Sciences, Charles Sturt University, Bathurst, Australia 3Ambulance Service of New South Wales, Sydney, Australia 4Charles Sturt University, Bathurst, Australia 5South Australia Ambulance Service, Adelaide, Australia 6West Midlands Ambulance Service NHS Trust, Birmingham, UK

Background This trial evaluated the impact of a new laryngoscope design (the Airtraq) on the management of a model of difficult intubation by experienced pre-hospital laryngoscopists.

Methods This randomized cross-over trial compared between-device differences in first-time intubation success rates in a convenience sample of experienced intubation-trained prehospital providers using the Airtraq and a Macintosh laryngoscope with flexible stylet to manage a manikin model of a Cormack and Lehane grade III / IV view. Participants were attendees at the Australian College of Ambulance Professionals conference in November 2006. Approximately five minutes of training was provided in the use of the Airtraq immediately before data collection.

Results First-time intubation success rates for the Macintosh and Airtraq respectively were 14/56 (25%) versus 47/56 (84%) (59% difference, 95% CI 42 to 72%, P<0.0001); esophageal intubation rates 9/56 (16%) versus 0/56 (0%) (-16% difference, 95% CI -9 to -28%, P=0.0014); subject-rated difficulty of use scores 86 (IQ range 71 to 93, range 12 to 100) versus 20 (IQ range 5 to 28, range 1 to 75), p<0.001.

Conclusions Pre-hospital providers with training and experience in laryngoscopy achieve significantly higher first-time intubation success rates and have lower rates of oesophageal intubation when managing a manikin model of a grade III / IV difficult intubation with an Airtraq in comparison with standard intubation techniques. Despite receiving very minimal training in the use of the new laryngoscope, volunteers rated it as significantly less difficult to utilize than a standard Macintosh device.

Airtraq versus standard laryngoscopy by student paramedics in a model of difficult intubation: a pilot randomized cross-over trial

Malcolm Woollard1, David Lighton2, Jim Watt, Corinne McCrea2, Leanne Hamilton2, Peter O’Meara2, Mike Smyth3 1Visiting Professor, School of Biomedical Sciences, Charles Sturt University, Bathurst, Australia 2School of Biomedical Sciences, Charles Sturt University, Bathurst 3West Midlands Ambulance Service NHS Trust, Birmingham, UK

Background This trial evaluated the impact of a new laryngoscope design (the Airtraq) on the management of a difficult intubation model by inexperienced laryngoscopists.

Methods This randomized cross-over trial compared between-device differences in intubation success rates in a convenience sample of third-year paramedic students using the Airtraq and a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III / IV view. Participants were students attending Charles Sturt University, Australia and had previously undertaken a minimum of eight hours of intubation training using ‘standard’ techniques. Twenty minutes of training was provided in the use of the Airtraq immediately before data collection.

Results First-time intubation success rates for the Macintosh and Airtraq respectively were 0/23 (0%) versus 10/23 (44%) (44% difference, 95% CI 26 to 63%, P=0.0003); cumulative intubation success rates (after 3 attempts) 7/23 (30%) versus 18/23 (78%) (48% difference, 95% CI 19 to 69%, p=0.0015); first-time oesophageal intubation rates 15/23 (65%) versus 3/23 (13%) (- 52% difference, 95% CI -25 to -72%, P=0.0004); student-rated difficulty of use scores 88 (IQ range 78 to 97, range 37 to 100) versus 21 (IQ range 15 to 50, range 0 to 100), p<0.001.

Conclusions Student paramedics using an Airtraq following minimal additional training achieve significantly higher first-time intubation success rates, require fewer attempts to successfully place an endotracheal tube, and have lower rates of oesophageal intubation and failed intubation in comparison with standard laryngoscopy when managing a manikin model of a grade III / IV difficult intubation.

Use of the Airtraq laryngoscope in a model of difficult intubation by pre-hospital providers not previously trained in laryngoscopy: a prospective cohort study

Malcolm Woollard1, Warren Mannion2, David Lighton3, Ian Johns2, Peter O’Meara3, Chris Cotton4, M Smyth5 1Visting Professor, School of Biomedical Sciences, Charles Sturt University, Bathurst, Australia 2Ambulance Service of New South Wales, Sydney, Australia 3School of Biomedical Sciences, Charles Sturt University, Bathurst, Australia 4South Australia Ambulance Service, Adelaide, Australia 5West Midlands Ambulance Service NHS Trust, Birmingham, UK

Background This study evaluated the impact of a new laryngoscope design (the Airtraq) on the management of a model of difficult intubation by pre-hospital providers without previous training in laryngoscopy.

Methods This prospective cohort study evaluated first-time success rates of a convenience sample of pre-hospital providers without previous laryngoscopy training in intubating a manikin model of a Cormack and Lehane grade III / IV view using an Airtraq laryngoscope. We also recorded oesophageal intubation rates, time to intubation, and subject-rated difficulty of use scores. Participants were attendees at the Australian College of Ambulance Professionals conference, Adelaide, in November 2006. Approximately five minutes of training was provided in the use of the Airtraq immediately before data collection.

Results First-time intubation success rate for the Airtraq was 26/33 (79%) (95% CI 61 to 91%); oesophageal intubation rate was 0/33 (0%) (95% CI 0 to 11%); and the median subject-rated difficulty of use score was 21 (IQ range 7.5 to 35.5, range 1 to 65). The median time to intubation was 17 seconds (IQ range 10 to 25 seconds, range 5 to 30 seconds, data available for 23/26 successful attempts).

Conclusions Pre-hospital providers not previously trained in laryngoscopy had a high first-time intubation success rate when managing a manikin model of a grade III / IV difficult intubation with an Airtraq laryngoscope, following only minimal training. Users evaluated the device as being easy to use and were able to achieve placement of an endotracheal tube within an acceptable breath-to-breath interval.

The Heat is On: An investigation of the effects of temperature on out-of-hospital cardiac arrest.

Bronwyn Young; John Woodall; Vivienne Tippett Australian Centre for Prehospital Research

Background Several studies have described the effect that extremes of temperature have on out-of-hospital cardiac arrest. Typically these studies have been conducted in cold climates where conditions of extreme temperature may vary greatly from the experience in sub-tropical Brisbane. It remains unclear what effect temperatures extremes will have on out-of-hospital cardiac arrest in the setting of a warmer climate.

Objectives The objective of this study is to review the 2000 to 2005 climate and cardiac arrest data to describe any effect that temperature may have on out-of-hospital cardiac arrest.

Methods Queensland Ambulance Service collects data from all cases of out-of-hospital cardiac arrest in the Cardiac Arrest Database. This data is checked and cleaned by a team of dedicated auditors. This study extracted data for all adult cases in the Brisbane region between 2000 and 2005. Cases were excluded where the presumed aetiology of arrest was SIDS, overdose, trauma, drowning, carbon monoxide poisoning or hanging.

The Australian Bureau of Meteorology supplied a database of Brisbane daily maximum and minimum temperatures for the same time period. These databases have been linked to allow analysis of the relationship between temperature and cardiac arrest.

Findings/Conclusions Preliminary results have demonstrated a marked increase in cardiac arrest rates during the 2004 Brisbane heatwave. Using models found in the literature an effect during colder temperatures has also been found. Analysis is continuing and we hope to identify those conditions which may precipitate increased numbers of patients suffering cardiac arrest.

Australian Prehospital Emergency Health Research Forum Peer-Reviewed Abstracts from The ACAP 2007 Asia-Pacific International Conference, Gold Coast, Australia, 26 to 29 September, 2007.