Abstracts of the 2011 Paramedics Australasia Conference

Australasian Journal of Prehospital Care: 2013;10(2) Conference Abstracts

Sydney, New South Wales, Australia 7th and 8th October 2011

Conference Presentation Abstracts that may influence clinical decision making and subsequent actions when assessing patients with A model of paramedic decision making in a complaint of pain. cases involving pain. Bill Lord Conclusions This model of clinical decision making may help Monash University, Victoria, Australia. guide the education of paramedics to enable an Objectives awareness of factors that have the potential to Patients have a right to pain relief on humanitarian adversely influence their clinical decision making. grounds. In addition, unrelieved pain may be associated with morbidity such as the development of chronic pain syndromes. Epidemiology of acute heart failure Paramedics have an important role in relieving presentations and prehospital treatment pain. However, therapeutic interventions that aim by paramedics in New South Wales, to reduce pain depend on clinical judgments that Australia: a retrospective analysis of over involve assessment of the of the patient's reported 7000 patients. symptoms. As pain is a symptom that is difficult to 1 2 Paul Simpson and Jason Bendall objectively validate it is conceivable that clinician's beliefs and attitudes may modify clinical 1Ambulance Research Institute, Ambulance judgements and consequently influence decisions Service of New South Wales, Sydney, New to withhold or initiate care. To investigate factors South Wales, Australia influencing paramedics' clinical judgments in 2University of Sydney, Sydney, New South cases involving pain the following research Wales, Australia questions were developed: 1) What are paramedics' beliefs about pain and attitudes Objective towards the assessment and management of pain To describe the epidemiology of ambulance in a community-based health setting; and 2) How responses to patients with presumed acute could these beliefs and attitudes influence cardiogenic pulmonary oedema (ACPO), their paramedics' clinical judgements in cases involving initial clinical presentation, and the impact of patients reporting pain. prehospital treatment on physiological vital signs.

Methods Methods Paramedics and student paramedics were invited A retrospective analytic epidemiological study was to participate in focus group discussions that conducted into patients treated by paramedics for addressed pain and pain management in presumed ACPO between 1 July 2006 and 30 paramedic practice. Grounded Theory June 2008, utilising ambulance patient health care methodology was used to analyse transcripts of records (PHCR) linked with Medical Priority the focus group discussions, enabling the Dispatch System (MPDS) and Computer Aided development of theories of decision making in the Dispatch (CAD) data. Analysis was performed context of pain. using SAS 9.2 to calculate descriptive statistics and differences between groups. Results Four major thematic categories emerged from the Results data: expressing pain, assessing the patient, There were 7,243 presentations included in the believing the patient, and managing the patient final analysis. The median age of patients was 81 with pain. Sub themes from each category were years (IQR 74-87) and 53% were female. Median analysed to identify paramedic beliefs and scene time was 19 minutes (IQR 14-25) and total attitudes that may influence clinical judgements. A care time 31 minutes (IQR 24-40). Responses model of clinical decision making was occurred most commonly between 0600 and 0900 subsequently developed that uses an input- hours (19%) and during the colder, winter process-outcome taxonomy to illustrate variables months. Seventy percent of patients received

The Official Journal of Paramedics Australasia © 2013 Paramedics Australasia 2011 Conference Abstracts nitrates, 44% diuretics, and 22% morphine. The mmol/L was higher following 10% dextrose when most common drug regime was nitrates alone compared to 50% dextrose (p<0.001) whereas the (70%), followed by nitrate/frusemide (19%) and proportion of patients with a post-treatment BGL nitrate/frusemide/morphine (19%). No drug of > 11.1 mmol/L was higher following 50% therapy was administered in 18% of cases. dextrose when compared to 10% dextrose. Overall, there were statistically significant improvements in all vital signs, particularly systolic Conclusions BP (mean 159 to 141 mmHg) and SpO2 (median There appears to be no difference in the efficacy 88% to 98%). of 50% dextrose solutions compared to 10% dextrose solutions in restoring consciousness Conclusion following hypoglycaemia. The time to restore ACPO is a common presentation with a distinct consciousness was modestly faster with 50% temporal pattern of presentation. Prehospital dextrose than 10% dextrose and this may have treatment appears to generally improve operational benefits. A BGL below the optimal physiological variables; however its effect on range was more frequent following 10% dextrose longer term outcomes after leaving ambulance whereas a BGL above the optimal range was care is unclear and should be the subject of future more frequent following 50% dextrose. It is research. unclear which dextrose solution is optimal for the prehospital management of hypoglycaemia. Irrespective of solution chosen, titration of the A comparison of 10% and 50% dextrose in dextrose dose to within an ‘optimal' range may the management of prehospital improve clinical practice. hypoglycaemia: A before-and-after study James M Bews1, Bernard L Champion1 ,3, Jason C Bendall2 ,4 Mathematical ability of first year undergraduate paramedic students - A 1University of Sydney, NSW, Australia 2 before and after study Ambulance Service of NSW, Rozelle, NSW, Malcolm Boyle, Kathryn Eastwood, Nathan Australia Stam 3The Nepean Hospital, Kingswood, NSW, Australia Monash University, Frankston, Victoria, 4Ambulance Research Institute, Rozelle, NSW, Australia Australia Objectives Objectives An ability to accurately perform drug calculations To compare the efficacy of 10% and 50% unassisted is an essential skill for all health dextrose concentrations in the treatment of professionals, with various occupational-specific prehospital hypoglycaemia. stressors exacerbating mathematical deficiencies. The scientific literature reveals Methods practicing paramedics have alarmingly low levels This retrospective before-and-after study of of accuracy when performing unaided patients with hypoglycaemia (blood glucose level mathematical drug calculations. The objective of (BGL) < 4mmol/L) was conducted in a large this study was to determine the unaided Australian ambulance service. Patients were mathematic ability of first year undergraduate administered either 10% dextrose or 50% paramedic students before and after a dextrose. The main outcome measures were time mathematical and drug calculation program. taken for hypoglycaemia to be reversed, post treatment conscious level and post treatment Methods blood glucose level (BGL). Students were administered a demographic, drug calculation and arithmetic questionnaire in the first Results: The study population comprised 2316 week of semester and before starting the program patients who met the inclusion criteria. There were to establish baseline performance. During the no statistically significant differences between the semester students participated in three tutorials two groups in baseline measures of patient age, which included both mathematical and drug gender, pre-treatment blood glucose level and calculation sessions without assistance of pre-treatment GCS. Consciousness was restored computational devices. The effectiveness of the faster following 50% dextrose than 10% dextrose program was assessed in a formative drug (p<0.001). Post treatment BGL was significantly calculations examination at the end of semester. lower in patients treated with 10% dextrose than Descriptive statistics were used to describe the in patients treated with 50% dextrose (6.9 mmol/L demographic and calculation answers with a versus 10.2 mmol/L p<0.001). The proportion of paired t-test comparing the questionnaire and patients with a post-treatment BGL of < 6.7 exam results.

Findings FICB may ultimately benefit patients by Conceptual, arithmetical, and computation ability minimising the unwanted systemic effects was significantly improved following this education associated with conventional pain management program and when comparing the correct results protocols. for the same question type (n=63), there were statistically significant differences in four of five Conclusion different drug calculations: volume of drug drawn To date, the emergency medical community up 10 v 57 p <0.0001, infusion rate 29 v 31 involved have shown great support for the trial, as p=0.717, drip rate 16 v 54 p <0.0001, volume from they are witnessing firsthand the benefits patients a syringe 30 v 59 p <0.0001, and drug dose 42 v are receiving from this intervention in their initial, 62 p <0.0001. but critical phase of care. The results of the prospective randomised controlled trial will better Conclusions inform the role of paramedic performed FICB. First year undergraduate paramedic students initially demonstrated a poor ability to complete mathematical and drug calculations without the Identification of out-of-hospital cardiac assistance of computational devices on arrest in emergency calls in Victoria. commencement of their study that improved Janet Bray1 ,2, Jamie Walsh1, Tony Balm1, significantly following appropriate education and Karen Smith1 ,2 practice. An ability to accurately and timely 1 complete the mathematical and drug calculations Ambulance Victoria, Melbourne, Victoria, is essential for paramedic practice and further Australia study is required to determine the retention of this 2Monash University, Melbourne, Victoria, ability over time. Australia

Objective Identification of out-of-hospital cardiac arrest Paramedic performed Fascia Iliaca (OHCA) in the emergency call is vital to the Compartment Nerve Block for Patients delivery of life-saving CPR instructions and rapid with Suspected Femoral Fractures: A arrival of emergency medical services (EMS). The paramedics personal perspective. aim of this study was to examine rates of OHCA 1 ,2 1 ,2 Paul McRae and Jason C Bendall identification in metropolitan (computerised 1 dispatch system) and rural (mostly non- Ambulance Research Institute, Ambulance computerised dispatch system) regions of Service of NSW, Rozelle, NSW, Australia 2 Victoria, and to examine its impact on known Charles Sturt University, Bathurst, Australia predictors of survival (bystander CPR and EMS Objective response times). This paper presents a paramedics experience in performing fascia iliaca compartment blocks Methods (FICB), a form of regional anaesthetic nerve The Victorian Ambulance Cardiac Arrest Registry block, in the prehospital setting on adult patients (VACAR) was searched for EMS resuscitated with suspected or confirmed femoral fractures. adults cases of OHCA presumed to be of cardiac cause between 2003 and 2010. The proportion of Process these cases that were dispatched as a ‘cardiac Femoral (thigh) fracture is an important clinical arrest' was calculated and metropolitan and rural problem and is associated with high morbidity and rates were compared. Also examined were mortality, especially in the elderly. FICB has been differences in known predictors of survival. performed successfully in both the inhospital and prehospital settings however there are no Results published reports of paramedic performed FICB. A total of 11029 OHCA were included: 8421 In the Ambulance Service of NSW a small cohort metropolitan and 2608 rural cases. Significant of paramedics have been trained to perform FICB differences were seen the proportion of cases in order to enrol patients into a prospective dispatched as ‘cardiac arrest' between randomised controlled trial which is on-going metropolitan and rural regions, 78% vs 43% (ACTRN12610000504011). respectively (p<0.001); although rural dispatches were noted to increase over time, from 30% This paper will discuss pain management for identified in 2003-4 to 54% in 2008-10. The femoral fractures, the FICB procedure and a second most common dispatch type was the personal perspective as one of the first intensive ‘unconscious' event type (metropolitan 7% and care paramedics to perform this procedure in the rural 30%). In cases dispatched as ‘cardiac field. Enhancing paramedic scope of practice to arrest': bystander CPR rates were higher include specific regional anaesthesia such as (metropolitan: 57% vs 27%, p<0.001; and rural: 62% vs 47%, p<0.001), response times were Paramedics Australasia 2011 Conference Abstracts shorter (metropolitan: 7.4 vs 8.4 minutes, alcohol abuse (n=2), thyrotoxicosis (n=2), p<0.001; and rural: 10 vs 11 minutes, p=0.010), meningitis (n=1) and others (12). Compared with and rates of VF/VT were higher (metropolitan: coroner's diagnosed ‘non-cardiac' OHCAs, 41% vs 33%, p<0.001; and rural: 42% vs 37%, ‘confirmed cardiac' were more likely to be p=0.09). witnessed (41% v 23%, p=<0.01), receive bystander CPR (35% v 20%, p=<0.001), have a Conclusion shockable rhythm (27% v 6.3%, p <0.001) and The accurate dispatch of "cardiac arrest" is have EMS attempted resuscitation (62% versus related to known predictors of survival in OHCA. 44%, p <0.001). The divide in OHCA between metropolitan and rural regions may be reduced with the introduction Discussion of the computerised dispatch system across the Linking OHCA registries with coronial databases state in the next year. for aetiology of the arrest will improve the quality of the data and should be considered by all OHCA registries, particularly for young adult OHCA. Out-of-hospital cardiac arrests in young adults in Melbourne, Australia - Adding coronial data to a cardiac arrest registry Resuscitation of out-of-hospital cardiac Conor Deasy, Janet Bray, Karen Smith, arrests in residential aged care facilities in Stephen Bernard, Peter Cameron Melbourne, Australia. Conor Deasy, Janet Bray, Karen Smith, Department of Epidemiology and Preventive Stephen Bernard, Peter Cameron medicine, Monash University and Ambulance Vi Dept of Epidemiology and Preventive Medicine, Objective Monash University and Ambulance Victoria, We aim to describe the coronial findings of young Melbourne, Australia adults where the OHCA aetiology was ‘presumed cardiac.' Objective CPR in patients in residential aged care facilities Methods (RACF) deserves careful consideration. We Presumed cardiac aetiology OHCAs occurring in examined the characteristics, management and young adults aged 16-39 years were identified outcomes of out-of-hospital cardiac arrest (OHCA) using the Victorian Ambulance Cardiac Arrest in RACF patients in Melbourne, Australia. Registry (VACAR) and available coronial findings reviewed. Methods The Victorian Ambulance Cardiac Arrest Registry Results (VACAR) was searched for all OHCAs occurring We identified 841 young adult OHCAs where the in RACFs in Melbourne. The characteristics and Utstein aetiology was ‘presumed cardiac'. Of outcomes were compared to non-RACF patients these 740 died and 572 (77%) OHCAs were in the VACAR. matched to coroner's findings. On review of the coroner's cause of death, 230 (40.2%) had a Results ‘confirmed cardiac' aetiology, 221 (38.6%) were Between 2000 and 2009 there were 30,006 proven ‘non-cardiac', 97 (17%) were inconclusive OHCAs, 2,350 (7.8%) occurring in a RACF. and 24 (4.2%) cases remained ‘open.' Confirmed A shockable rhythm was present in 179 (7.6%) cardiac' causes of OHCA were ischemic heart patients on arrival of paramedics of whom disease (n=126, 55%), cardiomegaly (n=26, bystander CPR had been performed in 118 (66%); 11.3%), cardiomyopathy (n=25, 11%), congenital 173 (97%) received an EMS attempted heart disease (n=15, 6.5%), cardiac tamponade resuscitation. ROSC was achieved in 71 (41%) due to dissecting thoracic aorta aneurysm (n=10, patients and 15 (8.7%) patients survived to leave 4.3%), myocarditis (n=8, 3.5%), arrhythmia (n=7, hospital. Non shockable rhythm was present in 3%), other (n=13, 5.7%). ‘Non-cardiac' causes of 2,171 patients (92%) of whom 804 (37%) had an OHCA were epilepsy/sudden unexplained death attempted resuscitation by paramedics. ROSC in epilepsy (SUDEP) (n=56, 25%), pulmonary was achieved in 176 patients (22%) and 10 embolism (n=29, 13%), subarachnoid patients (1.2%) were discharged alive. Survival haemorrhage (n=17, 7.7%), other intracranial from OHCA occurring in a RACF was less than bleed (n=7, 3.2%), pneumonia (n=17, 7.7%), DKA survival in those aged > 70 years of age who (n=16, 7.2%), other complications of diabetes suffered OHCA in their own homes (1.8% v 4.7%, mellitus (n=8, 3.6%), complications of obesity p=0.001). On multivariable analysis, witnessed (n=9, 4%), haemorrhage (n=12, 5.4%), sepsis OHCA (OR 3.0, 95% CI 2.4-3.7) and presence of (n=8, 3.6%), peritonitis (n=6, 2.7%), aspiration bystander CPR (OR 4.6, 95% CI 3.7-5.8) was (n=6, 2.7%), renal failure (n=5, 2.3%), asthma associated with the paramedic decision to (n=5, 2.3%) complications of anorexia (n=3) and resuscitate.

Conclusion Conclusions Resuscitation of patients in RACF is not futile. Whilst not ‘perfect', linkage of state-based OHCA However, informed decisions concerning registry data to the AIHW NDI is a feasible option resuscitation status should be made by patients to determine survival outcomes in both the short- and their families on entry to a RACF. Where it is term and long-term, especially for States without appropriate to perform resuscitation, outcomes developed data linkage systems. may be improved by the provision of BLS training and possibly AED equipment to RACF staff. Hospital characteristics are associated with patient outcomes following out-of- Out of hospital cardiac arrest outcomes - hospital cardiac arrest Is linkage to the National Death Index a Dion Stub1 ,2, Karen Smith3 ,4, Janet Bray3 ,4, viable option to determine survival rates? Stephen Bernard1 ,3, Stephen Duffy1 ,3, David 1 ,3 2 1 ,3 Judith Finn , Karen Smith , Ian Jacobs Kaye1 ,2 1 The University of Western Australia, Perth, 1Alfred Hospital, Melbourne Victoria, Australia, Western Australia, Australia 2Baker IDI Heart & Diabetes Institute, 2 Ambulance Victoria, Melbourne, Victoria, Melbourne Victoria, Australia Australia 3Monash University, Melbourne Victoria, 3 St John Ambulance (Western Australia), Perth, Australia, 4Ambulance Victoria, Victoria, Western Australia, Australia Australia Objectives Objective Most Ambulance Services in Australia already Post-resuscitation care may influence outcome have an out-of-hospital cardiac arrest (OHCA) following transport to hospital after resuscitation registry. For those States without a well- from out-of-hospital cardiac arrest (OHCA). We developed population health data linkage system, aimed to determine whether receiving hospital determining long-term survival outcomes is characteristics such as 24 hour cardiac pragmatically challenging. This study sought to catheterisation services, total bed number or ascertain the feasibility and accuracy of OHCA patient volume influence the rate of determining date of death through linkage to the survival. Australian Institute of Health & Welfare (AIHW) National Death Index (NDI). Methods We analyzed data from the Victorian Ambulance Methods Cardiac Arrest Registry (VACAR) of patients from Following AIHW ethics approval, the demographic January 2003 to March 2010 who were details of all metropolitan OHCA patients transported to hospital with return of spontaneous transported to hospital by St John Ambulance circulation after OHCA. (Western Australia) (or Ambulance Victoria) paramedics in 2009 were forwarded to AIHW for Results probabilistic linkage to the NDI. The accuracy of Ambulance paramedics attended 9971 patients the best match date of death from the NDI was with OHCA of suspected cardiac cause during the compared to the WA death records. (Analysis of study period. Of these, 2902 (29%) achieved the accuracy of linkage to Ambulance Victoria return of spontaneous circulation and were OHCA registry data is in progress.) transported to one of 70 hospitals. There were 1816 (63%) treated at hospitals with 24 hour Results cardiac interventional services. After adjusting for Of the 375 WA cases, 314 (83.7%) linked to a NDI differences in baseline characteristics, hospital death record. Of the 303 WA cases with both a factors significantly associated with survival were, WA death record and a NDI death record, the treatment at hospitals with 24 hour cardiac date of death was within 1 day difference for 294 interventional services (odds ratio 1.40; 95% CI (97%) of cases. Of the 54 cases without a WA 1.12-1.74, p=0.003) and patient reception death record, 10 cases linked to a NDI death between 0800 to 1700 (odds ratio 1.34; 95%CI record, although most had flags identifying 1.10 -1.64, p=0.004). OHCA patient volume and concerns about the linkage and 7 of the 10 total hospital bed number were not independently patients had matching name and address listings associated with outcome. in the current WA white pages telephone book. Of the 321 out of 375 WA cases with a WA death Conclusion record, 18 did not link to a NDI record - however Hospital characteristics are associated with the fact that most of the missing deaths occurred improved survival in patients with OHCA. This within a 3 week period suggests a systematic finding has implications for the establishment of error. Paramedics Australasia 2011 Conference Abstracts regionalised systems of care for patients who Palliative Care for Mass Casualty Events have been resuscitated from OHCA. with Scarce Resources Anne Wilkinson1, Maryanne Matzo2, Maria Gatto3, Joanne Lynn4, Sally Phillips5 Long-term survival after resuscitation 1 from out-of-hospital cardiac arrest. Edith Cowan University, Perth, Western Judith Finn1 ,2 and Ian Jacobs1 ,2 Australia, Australia 2University of Oklahoma Health Sciences 1 The University of Western Australia, Perth, Center, Oklahoma City, Oklahoma, U.S.A. Western Australia, Australia 3 2 Bon Secours Health System, Marriotsville, St John Ambulance (Western Australia), Perth, Maryland, U.S.A. Western Australia, Australia 4Consultant, Washington, DC, U.S.A. 5 Objectives Agency for Healthcare Research and Quality, To determine the long-term survival of out-of- Rockville, Maryland, USA hospital cardiac arrest (OHCA) patients who Objectives survived their initial arrest and identify factors Catastrophic mass casualty events (MCEs) can associated with increased risk of subsequent yield thousands of victims whose needs death. overwhelm local and regional health care systems, personnel, and resources. MCE Methods response requires making difficult decisions The Western Australian (WA) St John Ambulance regarding the allocation of scarce resources and cardiac arrest registry was used to identify all the alteration of standards of care in all care metropolitan OHCA patients discharged alive from settings. However, guidance regarding how to hospital between 1996-2010. The study cohort prepare for, manage, and provide medical care was restricted to adults (≥ 18 years) and persons under such circumstances remains limited. resident in WA. The WA death register was used Although the primary goal of a coordinated to identify the date of death up until 31 December response to an MCE is to maximize the number of 2010. The Kaplan-Meier method and log-rank test lives saved, a comprehensive response should was used to compare the survival distributions of also seek to minimize the suffering of those who different sub-groups. Cox proportional hazards may not survive. The purpose of this paper is to regression model was used to compute hazard explore the role of palliative care in the support of ratios(HRs) for the association between total individuals not expected to survive an MCE and to mortality and hypothesised prognostic factors, provide recommendations for specific actions for a including: initial cardiac arrest rhythm, bystander coordinated disaster response plan. CPR, aetiology and ambulance response intervals, with multivariable models adjusted for Methods patient age, gender and calendar period. Semi-structured telephone discussions with disaster management experts and an expert Results group meeting identified issues, roles, Between 1996-2010, 459 patients meeting the responsibilities, procedures, and resources inclusion criteria were discharged from hospital offering benefits of integrating palliative care into alive: 74% males; mean age 62±15 years; 38% disaster planning and response. paramedic witnessed; 37% bystander CPR; mean response (call-to-scene) 9.7±6.1 mins; 78% initial Results VF/VT and 91% of presumed cardiac aetiology. Of The investigations identified five domains of these 459 patients, 90% were alive at one year concern, along with guidance: (1) the role of and 70% were alive at five years post arrest. The palliative care in a mass casualty event with estimated median survival time from arrest to resulting scarce resources; (2) the triage and death was 11.7 years. The only significant ensuing treatment decisions for those "likely to predictor in the adjusted Cox regression model die;" (3) the critical palliative care services to was age group. Whilst patients aged 75 years and provide, along with the personnel and settings; (4) over had a three-fold increase in the (adjusted) the pragmatic plans needed for ensuring training, risk of death (HR=3.2, 95% CI 2.1, 4.6), almost supplies, and organizational or jurisdictional half (46%) of this older age group were still alive 5 arrangements; and (5) unusual issues affecting years after their cardiac arrest. palliative care under MCE scenarios.

Conclusions Conclusions Contrary to common misperceptions, the long- Palliative care minimizes the suffering of those term prospects for OHCA survivors are far from who die, ensures comfort, addresses the needs of bleak. Other than increasing age, there were no those who will not survive, and may also free up patient or arrest characteristics associated with a resources to optimize survival of others. higher risk of death.

Planning to provide palliative care during mass Paramedic Response to Suicide casualty events should be part of the current state Bombings: Learning from the Israeli and local disaster planning/training guidelines, Experience protocols, and activities. Christopher R. Foerster1 ,2 and Aaron Richman3

1 James Cook University, Townsville, Perceptions of clinical leadership in St. Queensland, Australia 2 John Ambulance Service WA: A research Lambton EMS, Lambton County, Ontario, Canada report 3 David Stanley and Joseph Cuthbertson Philadelphia University, Philadelphia, PA, USA Curtain, Perth, WA, Australia Objective Objectives Suicide bombings have been seen all around the To identify how clinical leadership is perceived by world, with particularly high numbers in Israel. paramedics and ambulance personal in the Paramedics are an integral part of the response to course of their everyday work and the these bombing incidents. Most countries have not effectiveness and consequences of the responded to a suicide bombing and without this application of clinical leadership in pre-hospital experience, the response to their first incident is care delivery. likely be suboptimal. By examining what the Israeli paramedics have learned in their experience with Methods suicide bombing, paramedics in other areas can A questionnaire was distributed via in-service be better prepared if they ever need to respond. training sessions to St. John Ambulance The objective of this research was to determine operational staff in WA between February 2010 the important components of the Israeli and November 2010 (n = 250). The Emergency Medical Services (EMS) response to methodological principals of the study were based suicide bombings that allow for their success. on phenomenology. Analysis of the quantitative data was via SPSS software and the qualitative Methods data was analysed by spreadsheet and word Reviews of open source information were used as documents. well as visits to multiple suicide bombing sites in Israel with reviews of these bombing incidents and Results their responses. These were analysed for Of the 250 ambulance service staff who attended common themes important to effective suicide in-service education between February 2010 and bombing responses. November 2010, 104 returned questionnaires, a return rate of 41.6%. Of those respondents, their Results average length of service with the St. John It is essential that the first arriving ambulance Ambulance Service was just under 7 years (6.9 crew be fully capable of initialising the medical years), with the longest service of any respondent response to the incident. While doing so, they being 30 years. must maintain a strong situational awareness, considering both secondary devices and Most respondents recognised that clinical leaders confirmation of neutralisation of known threats. were involved in team work, the generation of new The Israeli approach include immediate initiation ideas, effective communication and involved of command and triage with patients being others appropriately. While clinical experience evacuated from the scene quickly. Coordination was valued highly, research skills or qualifications between front-line commanders is even more were less well recognised as an aspect of a important at these incidents. Practising a scaled clinical leader. What mattered was that the values response and working to establish a collective of the clinical leaders were matched by their knowledge as well as joint training is important in actions and abilities. preparing for these types of responses.

Conclusion Conclusions It is hoped that with a better understanding clinical Suicide bombings are unique incidents that will leadership and how it is perceived by paramedics challenge any EMS system, particularly if they are and ambulance officers they will be able to play a not experienced in suicide bombing response. more effective part in service improvement, the Knowledge of these unique response implementation of a quality agenda and impact considerations is essential for paramedics to be positively on pre-hospital care delivery. A better able to respond safely and effectively to these understanding of clinical leadership may support a incidents. more responsive and effective ambulance service where the focus can remain on the clinical aspects of the paramedic's role. Paramedics Australasia 2011 Conference Abstracts

The influence of research on the policy Disaster preparedness in small and practice of ambulance services in the communities with a known threat. United Kingdom: Lessons for Ambulance Mieke Couling Authorities and Paramedics AUT University, Auckland, New Zealand Peter O'Meara1 ,3 and Malcolm Woollard3 ,2 1 Background La Trobe University, Bendigo, Victoria, Small communities lack many of the advantages Australia 2 of larger cities when it comes to emergency Charles Sturt University, Bathurst, NSW, management support. However, historically they Australia have held a reputation for being self-sufficient and 3 Coventry University, Coventry, Midlands, UK resilient in the face of adverse situations. Despite this image of self-sufficiency and resilience, small Background Ambulance services recognise the importance communities with a known hazard are not necessarily better prepared or informed than and value of using evidence in their decision- 1 making. This represents a shift in process that is residents of larger cities . The isolated East Coast communities of the Coromandel Peninsula in New challenging to implement given the paucity of 2 robust evidence to support pre-hospital Zealand are at high risk of tsunamis . In interventions and the dearth of expertise in September 2009 a complete evacuation of the interpreting research findings. town Pauanui was undertaken following the Samoan Tsunami.

Objective This study examined how and to what extent Objectives policy makers in United Kingdom Ambulance This study aims to establish how well prepared Trusts use evidence to inform their decision- people in Coromandel are for a Tsunami by making. exploring the knowledge, understanding and feelings about disaster preparedness of people living in this small community. Methods Data was collected and analysed using a ‘process model' of evidence utilisation to examine the Method translation of research into policy and practice. Qualitative data exploring people’s reactions and Semi-structured interviews were conducted with knowledge was collected from fifteen semi- established academic researchers in paramedic structured interviews of evacuated residents of the practice / ambulance systems, members of the Coromandel. The interviews were thematically College of Paramedics, and key decision makers analysed and revealed common themes and gaps within each of the participating Trusts. where the emergency management systems were deficient. The actions taken by the First Responders (police, fire and ambulance) were Results Decision making in UK Ambulance Trusts is partly included in the analysis driven by evidence. Researchers see varying levels of research engagement and turning Results copious data into good research is a challenge. Overall, this study found gaps in the residents’ Trusts have appointed research leads and formed knowledge of the hazards facing their community a collaborative National Ambulance Research and found a concerning lack of preparation for Steering Group. However, there remain few quick evacuation. The study also highlighted that research educated paramedics and managers people have a high reliance on official warning who are ready to embrace evidence based systems and struggle to interpret natural warning practice. signals such as earthquakes. Conclusion If emergency services appreciate the strengths Conclusions One of the major challenges is how ambulance and weaknesses of preparedness in small services and researchers manage their communities that are at risk of a particular threat relationships when they may have very different or hazard, they can better prepare their own views of the world, with many researchers response plans and contribute more effectively to allegedly placing ‘evidence' above other the community plans and education. considerations such as public confidence [and organisational image that managers are required to consider when making policy decisions. This clash of values revolves around their respective concepts of what evidence is and the importance they attach to the influence of context in the decision-making processes.

A model for the management and provide a salaried ambulance service staffed with leadership of volunteer emergency health professionally qualified paramedics. providers Peter O'Meara1, John Rae2, Vianne Tourle2 Peer-assisted teaching and learning in 1La Trobe University, Bendigo, Australia, 2 paramedic education: Preliminary findings Charles Sturt University, Bathurst, Australia Michael Fox, Christian Winship, Whitney Background Williams, Sinead Leaf, Brett Williams, Leanne Ambulance services operating in rural and remote Boyd areas are highly reliant on volunteer and first Monash University, Melbourne, Australia responder models of service delivery. Despite the importance of this volunteer workforce, little has Objectives been reported on the management of these Peer-assisted teaching is growing internationally emergency health providers. as a beneficial pedagogical strategy in health professional education. Paramedics are Objective continually engaged in teaching students, patients To identify those factors that may facilitate the and their families - so these developments are successful integration of volunteer emergency highly relevant to our discipline. This project seeks health providers into ambulance services and to explore: i) third year students' experiences of make recommendations highlighting good teaching and assessing junior students, and ii) management practice. first year students' experiences of being taught and assessed by senior students. Methods Senior executives of ambulance services from Method one region of New Zealand and seven states of An investigation of peer-assisted teaching and Australia were surveyed and interviewed. They learning among first and third years at Monash were asked to describe their ambulance service's University was investigated using the Peer approach to volunteers and first responders. Teaching Experience Questionnaire (14 items) Three researchers analysed these data using and the Clinical Teaching Preference classic content analysis techniques and computer- Questionnaire (11 items). Both self-reporting assisted programs - NVIVO and Leximancer to measures used a 5-point Likert scale (1=Strongly develop a volunteer emergency health provider Agree and 5=Strongly Disagree). management model. Results Findings A total of 154 students participated in the study: Analysis of interview transcripts and publicly n=127 first years (n=87 control group, n=40 available data revealed facilitative factors intervention group), and n=27 third years (n=8 associated with strong, vibrant ambulance control group and n=19 intervention group). The volunteer systems. These facilitative factors are: majority of students were <26 years of age n=130 commitment to the volunteer model of service (84%) and female n=100 (63%). Ninety-four delivery; a degree of management percent (n=120) first year students felt (strongly decentralization and volunteer input into decision- agree or agree) ‘teaching is an important role for making; commitment of resources toward the paramedics'. Almost two-thirds n=82 (64%) felt volunteer model; and the organizational (strongly agree or agree) ‘being taught by peers integration of volunteers into the ambulance increased their collaboration with other students service. These facilitative factors informed a compared with their instructor'. There were volunteer emergency health provider several items that were statistically significant management model which consists of four (p<0.001) between the first years: ‘I am less components: leadership; integrative processes; anxious when performing a paramedic skill in the resource commitment within the lead organisation; presence of my peers', and ‘I can communicate and the relative autonomy of the volunteers. more freely with my peers than with my instructor'. All third year students n=27 (100%) ‘felt teaching Conclusions is an important role for paramedics', and that This model aims to encourage the adoption of ‘there should be more opportunities for peer positive and innovative strategies to improve the teaching in the curriculum' integration of ambulance volunteers and first responders in ambulance services. If elements of Conclusion the model were replicated more widely, a viable Results from this study support a larger scale and effective volunteer emergency health study in the future. Preliminary results support the response system could be established in those utility of peer-assisted teaching and learning. areas where it is uneconomic or impractical to Consideration should be given for inclusion into existing paramedic curricula nationally. Paramedics Australasia 2011 Conference Abstracts

Can relief from chest pain with nitrates Assessment of the Glasgow Coma Scale: inform a clinical diagnosis? A pilot study examining the accuracy of Laura Roberts, Lynsey Smit, Ziad Nehme, Brett paramedic undergraduates. Williams Christian Winship, Brett Williams, Malcolm Boyle Monash University, Melbourne, Australia Monash University, Melbourne, Australia Objectives The administration of nitrates in the setting of Objectives ischaemic chest pain has been a mainstay of Accurate assessment of a patient's conscious paramedic practice for many years. Its state using the Glasgow Coma Scale (GCS) is an longstanding use has led to the belief that chest important skill for paramedics as it may determine pain eased by nitrates is predictive or diagnostic the patient's initial and ongoing management, of active coronary artery disease. To examine this including advanced airway management and assumption, we conducted a review of the synchronised cardioversion. To our knowledge, literature to determine whether chest pain relief there are no previous studies that have reported with nitrates can predict a diagnosis of underlying the accuracy of undergraduate paramedics' cardiac aetiology. interpretations of a patient's conscious state using the GCS. Therefore, the objective of this study Methods was to determine if undergraduate paramedic A literature review was undertaken using the students from an Australian University were able electronic databases Ovid Medline, CINAHL Plus to accurately interpret a variety of conscious and the Cochrane Library from their states using a simulated patient. commencement to the end of May 2011. Keywords used in the search included: Methods [Myocardial Ischaemia or "chest pain" or "angina"] A prospective single-blinded observational pilot and ["anginine" or "glyceryl" or "nitrate" or study requiring students to interpret the conscious "nitroglycerin" or "NTG" or "GTN"]. Studies were state of four adult patients using the GCS by eligible for inclusion if they reported the effect and viewing a simulation DVD package. diagnostic accuracy of nitrate use for predicting underlying active coronary artery disease. Results There were 137 students that participated in the Findings study, of which 65% (n=87) were female. The Of the initial 608 articles, 38 potential studies were results demonstrated that undergraduate identified after screening title and abstract. From paramedic students were unable to accurately these, 4 studies met the eligibility criteria. interpret a range of patient conscious states with Considerable heterogeneity was identified in the only 20% and 37% of participants able to prevalence of disease, description of the accurately identify the GCS of patients 2 reference standard, and definition of ‘response to (GCS=12) and 3 (GCS=7). For patient 2 there nitrates'. No study was blinded. The predictive was a statistically significant difference between value and likelihood ratios of chest pain relief by the BN/BEH students and the BEH year one nitrates were generally poor. Sensitivity varied (p<0.0001) and year two (p=0.022) students. The considerably between studies (0.35 to 0.92), motor component of the GCS appeared to be the however all reported low specificity (0.12 to 0.52). component where the least accurate interpretation In all studies the positive and negative likelihood occurred, with only 47% of students being able to ratios closely approximated 1.0 accurately identify the criteria that patient 3 displayed. Participants were however able to Conclusion accurately interpret the GCS of both patient 1 While nitrates may be clinically indicated to (GCS=14) (86%) and patient 4 (GCS=15) (92%). reduce chest pain in patients with angina, there is no empirical evidence to support its use as a Conclusion predictor of active coronary artery disease. Thus, This study demonstrates that undergraduate relief from chest pain with nitrate use does not paramedic students from an Australian university indicate nor exclude underlying cardiac aetiology are unable to accurately interpret a patient's and should not be used to inform a clinical conscious state if their GCS score was < 14. diagnosis. These findings have provided staff with important data for considering alternative teaching and learning approaches in conscious state assessment.

Is the standard 4.5cm cannula long Occupational Risks on Undergraduate enough for a needle thoracostomy? Paramedic Clinical Placements Chloe Abel and Malcolm Boyle Tegwyn Bath, Jade Sheen, Leanne Boyd Monash University, Frankston, Victoria, Monash University, Frankston, VIC, Australia Australia Background Objectives Clinical placements are a vital part of Tension pneumothorax is a life threatening undergraduate prehospital education, aiming to condition which is treated in the pre-hospital provide ‘on the job' skill acquisition and link theory setting by needle thoracostomy. Studies have with practice. A number of occupational risks may shown that the needles commonly used to be of occur during these clinical placements, potentially inadequate length to penetrate the pleural cavity. putting in jeopardy student learning opportunities The objective of the study was to identify if chest as well as student health and wellbeing. Clinical wall thickness and/or catheter length were a placements have been identified as having a reason for failed prehospital needle thoracostomy. strong impact on students career plans, and it is vital that safe learning environments are provided Methods for students. A literature search was conducted using medical electronic databases, MEDLINE CINHAL, Objectives EMBASE, and Cochrane Central Register of • To examine the nature and context of Controlled Trials (CENTRAL). These databases occupational risks encountered by were searched from January 1996 until the end of undergraduate students on paramedic clinical March 2011. References from articles retrieved placements were reviewed. Search keywords included • To gain an understanding of risk management prehospital, EMS, EMT, chest wall thickness, strategies either in place or required to tension pneumothorax, pneumothorax, minimise the consequences and impact of thoracostomy, needle thoracostomy, and occupational risks on students. decompression. Articles were included if they reported the prehospital use of needle Methods thoracostomy and failure rates relating to needle Firstly, a literature review was undertaken to length and chest wall thickness. Non-English and identify literature related to occupational risk in the hospital based articles were excluded. clinical placement and prehospital settings. Secondly, a cross sectional study using paper- Results based questionnaires was undertaken by There were 3,828 articles located by the search undergraduate students who had undertaken a with six articles meeting the inclusion criteria. The minimum of four days of paramedic clinical mean chest wall thickness at the second placement. Thirdly, a series of focus groups were intercostal space mid clavicular line varied held to allow in-depth exploration of the nature between 2.2cm and 5.36cm, with the thickest and context of student experiences of chest wall being 9.35cm. A variation between left occupational risk on clinical placement. Ethics and right side chest wall thickness also exists. approval was granted. One study identified a 30% increase in females and 18% increase in males for arms by the side Findings compared to raised above the head. The majority Initial findings (final data to be collected June of studies used the 4.5cm catheter with one study 2011 and analysed by the time of the Conference) using a 5cm catheter and another a 3.2cm indicate that undergraduate students encounter a catheter. Failure rates varied from 81% with the range of occupational risks while on paramedic 3.2cm catheter to 23% with the 5cm catheter. The clinical placements. Key themes include failure rate for the 4.5cm catheter ranged from workplace injury, occupational violence, stress, 10% to 50%. bullying and harassment. The incidence of bullying and covert harassment by qualified Conclusions paramedics towards undergraduate students The study findings suggest a large proportion of under their supervision was of particular concern. the population have chest walls thicker than the Students demonstrated an awareness of the standard 4.5cm catheter and that larger catheters physical and psychological risks associated with may be warranted. this part of their training, but a lack of interest in incident reporting. Of the students that reported physical or psychological injury occurring on clinical placement, few sought help.

Paramedics Australasia 2011 Conference Abstracts

Australian EMS in an international undertaken. Data was obtained from dispatch, comparison: a social media experiment clinical and workforce data. The study was Florian Breitenbach approved by the Monash University Human Research Ethics Committee. Analysis was Edith Cowan University, Perth, Western undertaken using logistic regression techniques. Australia, Australia Differences were considered significantly different when p<0.05. Objective To compare Australian EMS systems and their environment with that of the UK & the US Results The study population comprised 42,051 patients, 51% of which were administered an analgesic Methods Professionals from three countries (England, agent. The median age of patients was 57 years Scotland and the United States) were contacted (IQR 38-75) and 50.4% were female. Pain via their online presence (blog and/or twitter management was provided by 1,255 paramedics account), via personal recommendation and of whom 19% (n= 239) were female. A female chance encounter. All interviewees were paramedic provided treatment for 13% of patients paramedics in their system, additional receiving analgesia. For the outcome of qualifications included some being supervisors, receiving any analgesia, neither patient gender university lecturers, clinical educators and film nor paramedic gender was predictive (p=NS). In makers. All paramedics were interviewed on a set a multivariate model for the outcome of receiving list of questions regarding their subjective any analgesia, patient gender, paramedic gender experience of working in their area and country. and the interaction between patient and Additional objective information was obtained from paramedic gender were all statistically non- clinical guidelines and laws from the respective significant (p=NS). For the outcome of receiving services, states and countries. opiate analgesia (i.e. morphine or fentanyl), male patients were at greater odds of receiving an opiate (OR 1.28 95% CI 1.23-1.33 p<0.0001). Conclusion Australian EMS systems and structures don’t Paramedic gender was not predictive of whether need to shy away from an international an opiate was given (p=NS). In a multivariate comparison, and are leading on many levels. model for the outcome of receiving opiate Working conditions, paramedic autonomy, and analgesia, whilst patient gender remained especially the widespread university-led education significant (p<0.0001), paramedic gender and the are amongst the factors that puts Australia in an interaction between patient and paramedic gender excellent position in an international comparison. remained statistically non-significant (p=NS).

Conclusion Paramedic gender does not appear to influence Impact of paramedic and patient gender the administration of analgesia in this study. Male on prehospital pain management patients are more likely to receive opiate Bill Lord1, Jason C Bendall2 ,3, Tracie Reinten- 2 ,4 analgesia. This finding is not explained by Reynolds paramedic gender. 1Department of Community Emergency Health and paramedic Practice, Monash University, Melbourne, VIC, Australia Do younger women have better OHCA 2Ambulance Research Institute, Rozelle, NSW, survival rates than men? - Exploring the Australia "oestrogen effect". 1 ,2 2 ,3 1 3Ambulance Service of NSW, Rozelle, NSW, Janet Bray , Dion Stub , Stephen Bernard ,2 1 ,2 Australia , Karen Smith 4 NSW Biostatistical Officer Training Program, 1Ambulance Victoria, Melbourne, Victoria, NSW Health, North Sydney, NSW, Australia Australia 2 Objective Monash University, Melbourne, Victoria, To better understand the influence of patient Australia gender and paramedic gender on analgesic 3Baker IDI Heart Diabetes Institute, Melbourne, administration in the prehospital setting. Victoria, Australia

Objective Methods Recent studies have suggested women of a child- A retrospective study of analgesic administration bearing age have better cardiac arrest outcomes in lucid adult patients (16-100 years old) with than men of a similar age. We aimed to moderate to severe pain (verbal numerical rating investigate this finding using the Victorian score 4-10) by paramedics authorised to Ambulance Cardiac Arrest Registry (VACAR) in a administer opiate and non-opiate analgesia was

The Official Journal of Paramedics Australasia © 2013 Australasian Journal of Prehospital Care: 2013;10(2) group of non-traumatic out-of-hospital cardiac weight estimation formulae for a western arrests (OHCA). population of children.

Methods Methods VACAR was searched for OHCA between 2003 The Ovid Medline database was searched utilising and 2010 meeting the following inclusions criteria: a simple search strategy with the search terms 1) EMS resuscitated, 2) presumed cardiac [“paediatric” or “children”] and “weight” and aetiology, 3) arrest was not witnessed by [“estimation” or “formula” or “calculate” or paramedics, and 4) aged 18-44 years. Statistical “equation”] from 1996 to 9th March 2011. A highly differences between men and women were selective eligibility criterion was devised to extract assessed, including differences in the known articles that were considered relevant to the predictors or survival and logistic regression research objective: 1) Recruitment of patients survival analysis. post-2000; 2) Recruitment within the emergency department or acute care setting; 3) Patients aged Results at least 1 to 11 years inclusive; 4) Derived in a For the study period, there were 921 OHCA select western population, and; 5) Reported the meeting inclusion criteria; 282 females and 639 derivation or validation of an age-based linear males (representing 10% of male OCA and 10% formula. of female OHCA). Differences were seen in the known predictors of survival between males and Results females. Females were slightly younger (38 vs 39 This review identified two new paediatric weight years, p=0.01) and less likely to: arrest in a public estimation formulae that are more accurate than location (15% vs. 36%, p<0.001), have a the current APLS formula. Both the Luscombe witnessed arrest (46% vs. 58%, p<0.001), receive and Best Guess methods have been derived and bystander CPR (56% vs. 63%, p=0.06); have an validated in a large western population of children. initial shockable rhythm (35% vs. 47%, p=0.002). A mean percentage error of +4.2% for infants, Similar rates of survival to hospital discharge were +2.6% for the preschool-aged, and +7.7% for seen between males and females both overall school-aged children was observed with the Best (16% vs 14%, p=0.47) and for shockable rhythms Guess formula. The proportion of Best Guess (30vs 31, p= 0.80). In multivariate analysis, weights within 20% of the recorded weight was as adjusting for known predictors of survival, gender high as 83% in preschool and 60% in school-age was not an independent predictor of survival (OR children. The performance of the Luscombe 1.24, 95%CI: 0.77-2.02). formula was similar to the Best Guess and better than the APLS formula. Conclusion Although young women are less likely to have Conclusions factors linked to survival -they have similar The Australian Best Guess formula offers a survival rates to young men. Though this may locally-derived and validated method of age- suggest some impact of gender on survival, based weight estimation for children that is more gender was not independently associated with accurate than the APLS formula. While the survival. Therefore, our findings do not support Luscombe formula offers similar accuracy, it is yet evidence from in-hospital studies demonstrating to be validated in a population of critically ill increased survival in women of a child bearing patients. age.

Oxygen therapy for acute stroke: Is it time Are we under-resuscitating our children? to rethink our approach? A review of paediatric age-based weight Stuart Howard, Anthony Mead, Chloe-Eloise estimation formulae for the western Verhees, Ziad Nehme, Brett Williams population. Monash University, Melbourne, Australia Ziad Nehme Objective Monash University, Melbourne, Victoria, The administration of routine oxygen therapy for Australia acute stroke remains widespread in prehospital Objectives care. Recently, the National Stroke Foundation For almost 20 years, the Advanced Paediatric Life revised acute stroke guidelines to recommend a Support (APLS) weight estimation formula has shift away from the use of oxygen therapy in non- been widely adopted to estimate paediatric hypoxic patients. In light of this change, we sought weights in emergency settings. In light of the to appraise the evidence-based literature to increasing weight of children in Australia, we identify the effect of intervention for all acute conducted a review of contemporary age-based stroke patients receiving normobaric oxygen therapy. Paramedics Australasia 2011 Conference Abstracts

Methods community. The change from institutional to A literature review was undertaken utilising the community based care in mental health reform electronic databases Ovid Medline, EMBASE, and has seen increases in emergency department CINAHL from their commencement to the end of attendance of individuals needing mental health May 2011. Keywords used in the search included: care. A large majority of these individuals are ["stroke" or "cerebrovascular" or "CVA"] and attended to and transported by paramedics. As "oxygen". Clinical trials were included if they the link between pre-hospital and further care provided measurable clinical outcomes for acute paramedic have a vital role to play, but to date stroke patients randomised to receive normobaric paramedics' ‘on-road' experiences and culture oxygen therapy or room air within 24 hours of surrounding what they do when attending symptom onset. Eligible studies were limited to psychiatric presentation had not been widely those in English-language and involving human researched. participants. Methods Findings This ethnographic study was conducted in 2009 to The search strategy identified 90 potential studies, early 2010 and involved observation of a tertiary of which 4 clinical trials met the eligibility criteria. hospital emergency department and the Short-term functional outcomes were improved in ambulance arrival area over an eleven month patients randomised to oxygen therapy. An period. It included a series of twenty unstructured improvement in stroke scale scores up to 3 interviews and informal conversations with months follow up was observed in one study paramedics and document analysis of the (p=0.03), while another reported the benefits of Ambulance Patient Report Form. The neurological recovery with oxygen therapy to be ethnographic method allowed paramedics to as limited as 1 week (OR 2.9; 95% CI 1.59 to 5.4). openly communicate how they viewed their One large quasi-randomised trial reported a practice and actions with patients they considered significant reduction in death for mild to moderate psychiatric presentations. strokes randomised to room air at 7 months follow-up (OR 0.45; 95% CI 0.23 to 0.90). Results This paper focuses on the themes of compliance Conclusion and non-compliance, caution and risk and the role The benefits of oxygen therapy in stroke patients that knowledge and paramedics' perception of appear short-term, with improvements in their work plays in their approach and neurological recovery limited to 1 week. Long term assessment. outcomes show an increase in death for select patients receiving routine oxygen therapy. Until Conclusion further studies can demonstrate its safety, the Understanding the organisational, social and routine use of oxygen therapy in stroke cannot be contextual nature of paramedic work with patients recommended. suffering a mental illness will assist future developments in education, policy and service provision by paramedics. Paramedics & "psych" patients: What we see & hear, our actions & our rationale. An ethnographic study exploring paramedic Ketamine is superior to morphine alone culture, understanding, beliefs and for the management of traumatic pain in actions when attending psychiatric the prehospital setting: A randomized controlled trial presentations. 1 ,2 1 ,3 Louise Roberts Paul Jennings , Peter Cameron , Stephen Bernard1 ,2, Tony Walker2, Mark Fitzgerald3, Flinders University, Adelaide South Australia, Kevin Masci2 Australia 1Monash University - Department of Objective Epidemiology and Preventive Medicine, Paramedics are currently in a world where their Melbourne, Australia role and scope of practice is rapidly changing. 2 Ambulance Victoria, Melbourne, Australia They are in a position where the boundaries are 3The Alfred Hospital, Melbourne, Australia being repositioned and they find themselves confronted by situations that require extended Objectives care and patients that do not fit the traditional To assess the efficacy of intravenous (IV) mould of emergency care. The research question ketamine compared to IV morphine in reducing for this doctoral study asks how in this changing pain in adults with significant pre-hospital environment do paramedics identify, assess and traumatic pain despite initial treatment with 5mg manage psychiatric presentations in the IV morphine. We also aimed to assess the safety

The Official Journal of Paramedics Australasia © 2013 Australasian Journal of Prehospital Care: 2013;10(2) of ketamine compared to morphine by comparing 7François-Xavier Bagnoud Center for Health changes in vital signs and conscious state, and and Human Rights, Harvard School of Public the incidence of side effects including, excessive Health, BOSTON, USA sedation, significant hypotension or hypertension, arrhythmia, nausea and emesis. Objectives St John's Ambulance together with Royal Perth Methods Hospital and The University of Western Australia This study was a prehospital, prospective, investigated how exposure to traumatic scenes at randomized, controlled, open-label study. Patients work impacted mental health outcomes among with trauma and a verbal pain score of > 5 after paramedics and pre-hospital workers in rural and 5mg IV morphine were eligible for enrolment. remote Western Australia. Patients allocated to ketamine received a bolus of 20mg followed by 10mg every 3 minutes. Patients Methods allocated to morphine alone received 5mg IV Questionnaires were distributed evaluating the every 5 minutes until pain free. Pain scores were experience, frequency and nature of dealing with measured at baseline and at hospital arrival. trauma exposure while at work, experience of support services, mood, coping, post traumatic Results stress, depression, anxiety symptoms, alcohol A total of 135 patients were enrolled between consumption, general health and well-being, level December 2007 and July 2010. There were no of work stress and perceived organisational differences between the groups at baseline. support. Following the initial 5mg dose of IV morphine, patients allocated to ketamine received a mean of Results 40.6 (+/-25) mg. Patients allocated to morphine • Of the most commonly experienced stressful alone received a mean of 14.4 (+/-9.4) mg. There events, prehospital workers reported highest mean pain score change was -5.6 (95% CI -6.2 to levels of fear for unavailability of trained -5.0) in the ketamine group compared with -3.2 medical personnel, unavailability of suitable (95% -3.7 to -2.7) in the IV morphine group transport, and unavailability of reliable (p<0.0001). The IV morphine group had 9/65 communication. (14%) side effects reported compared with 27/70 • 55% and 16% of respondents reported being (39%) side effects in the ketamine group exposed to verbal and physical abuse (P=0.001). respectively, and 10% sustained damage to property while on the job. Conclusion • 5% and 3% of respondents reported post The use of ketamine significantly decreases pre- traumatic stress and depressive symptoms hospital pain scores compared with morphine above clinical cut-offs on standardised tools. alone in adult patients with moderate to severe • 31% of respondents reported seeing a mental traumatic pain but is associated with an increase health professional for emotional difficulties. in the rate of minor side-effects. • 21% reported taking medication to assist with emotional difficulties • 11% were regularly drinking alcohol at harmful Evaluating the effects of exposure to levels. trauma for paramedics and pre-hospital • Job burnout and secondary trauma were both workers in rural and remote Western significantly and positively associated with the Australia severity of PTSD and depressive symptoms Joseph Cuthbertson1, Allyson Browne2, (p <0.001). Stephan Shug3, Elizabeth Newnhman4 Conclusions 1St John Ambulance WA Inc., WA, Australia These early findings suggest that resource 2Statewide Trauma Service of Western limitations unique to rural and remote parts of Australia, Royal Perth Hospital, WA, Australia Western Australia may be among the most 3Pharmacology and Anaesthesiology Unit, stressful traumatic exposures experienced by pre- School of Medicine & Pharmacology, University hospital workers in these areas. Very few pre- of Western Australia., WA, Australia hospital workers admitted to reported 4Burn Injury Research Unit, School of Surgery, experiencing symptoms suggestive of mental University of Western Australia., WA, Australia health disturbances on formal measures of 5National Drug Research Institute, Curtin psychological function, however nearly a third had University of Technology, Western Australia, sought treatment for emotional difficulties. Further research is required to monitor the effects of WA, Australia exposure to trauma in the pre hospital 6Department of Anaesthesia and Pain environment and develop appropriate staff Medicine, Royal Perth Hospital, WA, Australia support strategies. Paramedics Australasia 2011 Conference Abstracts

Recurrent patterns in prehospital adverse I MIST AMBO - A minimum data set to events improve clinical handover between Roger Price, Jason Bendall, Jillian Patterson, paramedics and emergency department Paul Middleton clinicians Ambulance Research Institute, Rozelle, NSW, Jacinta Young Australia Ambulance Service of NSW, Rozelle, NSW, Objective Australia Adverse events are a major issue for healthcare University of Technology, Sydney, NSW, with 1 in 10 inpatients experiencing an adverse Australia event that results in a prolonged hospital stay, Background injury or death. Despite being repeatedly identified A standardised approach to clinical handover as a high risk area, little prehospital research between paramedics and emergency clinicians exists in this field. This study aimed to examine has recently been developed and implemented prehospital adverse events, and determine and across NSW. The new clinical handover tool was describe recurrent patterns. initially designed by an Intensive Care Paramedic using the Australian Commission on Safety and Methods Quality in Health Care "OSSIE" Guide to Clinical In June 2010, Ambulance Service of NSW Handover Improvement. In NSW, paramedics paramedics were invited to participate in on on- have been using the MIST mnemonic for clinical line survey. They were asked to recall an adverse handover. MIST stands for Mechanism of Injury; event and detail the factors they felt may have Injury or Illness; Signs and Symptoms and contributed to its occurrence. Data were Treatment and Times. MIST is an integral part of interrogated using regression and principal paramedic handover practice yet evidence has component analyses (PCA). shown it is inadequate for conveying all the necessary information required by emergency Results: clinicians e.g. allergies. To develop a 371 replies were received, 75% from paramedics comprehensive minimum data set for clinical with > 3 years service. This represents a response handover between paramedics and emergency rate of 10%. clinicians that ensures patient safety and • 8 single components were nominated by continuity of care whilst retaining its uniquely pre- paramedics as factors they considered to hospital focus. have contributed to their adverse events, including; a deteriorating patient, decreased Method level of consciousness (LOC), paramedic The MIST mnemonic was adapted to become I uncertainty, and an unusual or understated MIST AMBO. Each letter represents a step in the patient presentation. handover process. The tool can be used for both • PCA revealed 14 patterns of grouped trauma and medical cases depending on the components but only 2 of these situation. Identification of the patient; Mechanism ("Overwhelmed" and "communication") were of injury or Medical Condition; Injuries or Illness; linked to significant adverse outcomes for Signs and Symptoms; Treatment and Trends; patients. The average number of contributory Allergies; Medications; Background to event and components per/ case was 10. Other relevant information related to the case.

Conclusions Results Whilst the applicability of study findings is limited The effectiveness of the I MIST AMBO mnemonic by the low survey response rate, the impact of was researched by the University of Technology certain patient characteristics (deteriorating, Sydney in collaboration with the Ambulance decreased LOC, unusual or deceptively benign Service of NSW. A pre and post implementation presentation), paramedic features (uncertainty) study of I MIST AMBO was undertaken. Results and situational issues (adapting from low to high showed improved outcomes for clinical handover acuity or severity) on serious adverse events in a number of areas including; information being emerged. The multi-causal and synergistic nature handed over in a more predictable order; fewer of adverse events and the impact of external questions being asked by emergency department factors upon good clinical judgement also became staff and a reduction in handover duration. clear. An understanding of this work within the wider human factors literature may help Conclusion organisations to prioritise their patient safety I MIST AMBO has proven to be an effective agenda and build awareness among paramedics mnemonic for clinical handover and is widely about risk prone areas of practice. accepted by paramedics and emergency clinicians alike.

Patient Safety in Pre-hospital Emergency Utilisation of extended clinical skills by Care - A review of the literature Paramedic Emergency Care Practitioners Andrea Wyatt at the London Notting Hill Carnival Tim Edwards Ambulance Victoria, Victoria, Australia Monash University, Victoria, Australia London Ambulance Service NHS Trust, London, UK Objectives The quality agenda within health care has a long Objectives and evolving history. Influenced by a number of To quantify the use of extended clinical skills by landmark reports the term ‘quality assurance' has Paramedics with Emergency Care Practitioner (P- largely fallen out of favour, and the term ‘patient ECP) training deployed at the 2007 London safety' is becoming more accepted. However, to Notting Hill Carnival date much of the focus and research concerning patient safety relates to hospitals and the acute Methods inpatient care setting. The pre-hospital P-ECP staff were equipped with specific P-ECP environment is characterised by complexity and equipment and deployed at static treatment uncertainty, where the Paramedic is called on to centres around the carnival route. Each P-ECP make judgments and decisions that may have was provided with a study specific form to significant impact on patient outcomes and patient prospectively record brief demographic and safety. Therefore it would be expected that there treatment details for each patient attended. would be a growing interest in quality and patient Service patient report forms were completed safety issues in this area. The purpose of this contemporaneously and reviewed retrospectively review is to examine the international literature, to provide additional clinical information for each and determine if ambulance services have made case. attempts to adopt the ‘patient safety' paradigm that is evident across other health disciplines. Results P-ECP staff treated a total of 92 patients over two Methods days. Of these, 73% (n=68) were treated and A literature review was undertaken to explore: discharged, with the remaining 27% (n=25) What research has been undertaken regarding referred to hospital. The most common patient safety in pre-hospital emergency medical presenting complaints were wounds (n=32), care that provides evidence of the adoption of the allergic reactions (n=11), soft tissue injuries patient safety paradigm by pre-hospital (n=10) and head injuries (n=10). 21% of patients emergency care services? were treated with medications only available to P- ECPs, including antihistamines (n=10), analgesics Results (n=5) and antibiotics (n=4). A quarter of patients The initial search results identified 548 articles, received treatments or investigations beyond and following a review of the abstracts and current paramedic scope of practice, with wound application of the exclusion criteria, 27 articles closure accounting for the majority of these cases remained. (n=20). Two patients underwent Ear-Nose-Throat and examination and one had urinalysis Conclusions performed. P-ECPs utilised advanced life support Common themes identified in the pre-hospital skills in a number of cases, including establishing patient safety literature include: intravenous infusions (n=6), recording 12 Lead • more research needs to be undertaken on electrocardiograms (n=6) and administering drugs patient safety in pre-hospital emergency care; including adrenaline, hydrocortisone and • the importance of developing a workplace bronchodilators (n=4). safety culture; • developing paramedic clinical decision Conclusions making; P-ECPs deployed to static treatment posts are • development of health/pre-hospital data able to teat and discharge an appreciable systems; proportion of patients seeking care at the London • development of specific pre-hospital Notting Hill Carnival. The management of a emergency care quality/patient safety quarter of the cases seen required treatments or indicators. investigations beyond current UK paramedic There is a recognition of many of the key issues scope of practice. A small number of patients identified within other healthcare domains, and at were treated using advanced life support least preliminary initiatives undertaken to address procedures, highlighting the need for all these issues. However more effort still required to practitioners working in a see and treat capacity at align with other health professions and to more events to maintain standard paramedic advanced rigorously research the highlighted concerns. life support skills.

Paramedics Australasia 2011 Conference Abstracts

Developing a Prioritised Vehicle An assessment of undergraduate Equipment Check-sheet (VECS): A paramedic students' empathy levels: A modified Delphi Study. multi-institutional study Edward Duncan1 and David Fitzpatrick2 Brett Williams1, Malcolm Boyle1, Richard 2 3 4 1 Brightwell , Scott Devenish , Peter Hartley , University of Stirling, Stirling UK 5 5 2 Michael McCall , Paula McMullen , Graham Scottish Ambulance Service, Edinburgh UK 6 7 Munro , Peter O'Meara Background 1 The number, type; and complexity of equipment Monash University, Melbourne, Australia 2Edith Cowan University, Perth, Australia carried on frontline ambulances is increasing each 3 year. Whilst this enhances the range of pre- Queensland University of Technology, Brisbane, Australia hospital interventions available, it also results in 4 lengthy equipment checks which, on occasion, are Victoria University, Melbourne, Australia 5 interrupted by emergency calls. This can lead to University of Tasmania, Hobart/Sydney, ambulances arriving at an incident without vital Australia 6 equipment, or with equipment that malfunctions. Charles Sturt University, Bathurst, Australia Although equipment check-sheets have previously 7Latrobe University, Bendigo, Australia been developed to support ambulance clinicians, Objectives an informal audit of Scottish Ambulance Service Evidence suggests that improved empathy practice indicated that these were outdated, un- behaviours among healthcare professionals prioritised and not in routine use. To develop a directly impacts on healthcare outcomes. prioritised vehicle equipment check-sheet for However, the ‘nebulous' properties of empathic routine use behaviour often means that educators fail to

incorporate the explicit teaching and assessment Methods of empathy within the curriculum. This represents Participants: 99 ambulance clinicians were a potential mismatch between what is taught by purposively selected and invited to participate. universities and what is actually needed in the

healthcare industry. The objective of this study Design: A modified Delphi study was undertaken. was to assess the extent of empathy in paramedic A list of all routine ambulance equipment was students across seven Australian universities. collated and developed into the initial Delphi study questionnaire. Participants were then asked to Methods prioritise each item (on a scale from 1 [low priority] A cross-sectional study involving a paper-based to 7 [high priority]) in two rounds. The questionnaire employing a convenience sample of questionnaire was distributed and returned by first, second, third and fourth year undergraduate email. paramedic students. Student empathy levels

were measured using two standardised self- Analysis: Means and Standard Deviations were reporting instruments: Jefferson Scale of calculated for each item from round two. Physician Empathy (JSPE) (maximum score 140),

and Medical Condition Regard Scale (MCRS) Results (maximum score 66). 27 participants completed both rounds of data collection. Items which were required for life Results saving intervention rated the highest. These were A total of 783 students participated in the study of followed by items relating to personal protection which 57% were females. The overall JSPE and infection control. mean was 106.74 (SD=14.8). Females had

greater mean JSPE empathy scores than males Conclusions 108.69 v 103.58 (p=0.042, d=0.37). The JSPE This study has enabled the development of a also identified that first year undergraduate prioritised vehicle equipment check-sheet with paramedic mean empathy levels were the lowest, high face validity. Its prioritised nature means that 106.29 with fourth years the highest at 110.60. vital equipment is accounted for first, ensuring The lowest MCRS mean score was substance their presence and functionality even if the vehicle abuse (M=41.57, SD=12.29), and was also is dispatched before a full check can be statistically significant between genders (p=0.008, completed. The check-sheet is now being d=0.19) and universities (p=0.004, d=0.19). introduced throughout the Scottish Ambulance

Service and would have applicability to other Conclusions emergency medical services. This study suggests that undergraduate

paramedics improve their empathy towards

patients over the duration of the course and that they lack compassion for some patients in certain

The Official Journal of Paramedics Australasia © 2013 Australasian Journal of Prehospital Care: 2013;10(2) situations. These results are significant in the The Professional Socialisation of emerging paramedic discipline and provide Paramedics: The Transition from educators with important data in terms of guiding University Student to Paramedic Intern. the paramedic curricula that is directly responsive Scott Devenish1, Michele Clark2, MaryLou to requirements of contemporary out-of-hospital Fleming3, Stephen Loftus4 healthcare. 1 Lecturer, Paramedic Practice, School of Public Health, Queensland University of Technology, Interprofessional graduate program: Brisbane, QLD, Australia 2 providing new professional opportunities Director of Research, School of Public Health, for nursing - paramedic graduates Queensland University of Technology, Tina Ivanov2, Julie Considine1, Tony Walker2, Brisbane, QLD, Australia 3 Fiona Middleton3, Danielle Waddell3, Vanessa Head of School, School of Public Health, Gorman3, Bart Wunderlich1 Queensland University of Technology, 1 Brisbane, QLD, Australia Deakin University-Northern Health Clinical 4Deputy Director, Education for Practice Partnership, Victoria, Australia 2 Institute, Charles Sturt University, Sydney, Ambulance Victoria, Victoria, Australia NSW, Australia 3The Northern Hospital, Victoria, Australia Objectives Professional socialisation is defined as the The first double degree graduates with dual process by which professionals learn the values, qualifications as Registered Nurses and behaviours and attitudes necessary to assume Paramedics completed their studies at the end of their chosen professional role. The socialisation 2010 and the numbers of graduates from double process consists of three distinct phases namely, degree programs will increase in Australia in pre-socialisation (Anticipatory), socialisation coming years. Current nursing and paramedicine (Encounter) and post-socialisation (Change and graduate programs are discipline specific, Acquisition) phases. This research explores the defeating the purpose of a double degree and lived experience of paramedic interns, during their resulting in poor use of graduates' skills and encounter phase of their professional knowledge. In January 2011, a collaboration socialisation, as they make the transition from between Northern Health and Ambulance Victoria university student to paramedic intern. resulted in the launch of the Interprofessional Graduate Program enabling graduates to practice Methods as novice practitioners in paramedicine and Participants were sought from several of emergency nursing. This innovative program is an Australia's larger ambulance services and UK Australian first and presents new opportunities for NHS Ambulance Trusts to take part in this study. workforce redesign and graduate experience Participants were recruited through Ambulance through interprofessional learning. The program Service Research Institutes, Clinical Governance takes advantage of the similarities between Departments and university databases. To be emergency nursing and paramedicine but also included in this study, participants were required maintains the unique features of each profession. to be university educated, be employed in a In addition, the program design ensures alignment professional internship year and to not have between clinical and theoretical content and achieved qualified/registered paramedic status. scope of practice of both disciplines. New health Data collection was via face-to-face semi- workforce models are vital to sustainability in a structured interviews. A thematic analysis of the rapidly evolving health care system and will interview transcripts using narrative inquiry has enable us to be responsive to the needs of the been employed. patients we care for. The Interprofessional Graduate Program challenges traditional notions Findings of graduate programs in both nursing and The excitement of gaining employment with an paramedicine and provides alternative experience ambulance service was equalled by fear. Once for graduates who are going to be future senior employed, paramedic interns encountered the clinicians. In this paper, the development and ‘reality shock' of full-time work. They were implementation of the Interprofessional Graduate confronted with the ambulance culture, and felt Program will be outlined and the preliminary the need to conform to this culture in order to be outcomes from the first six months of the program accepted by station colleagues and management. will be presented. Paramedic interns learned to cope with a range of challenging situations, and to deal with the reality of ambulance practice where not every case was an urgent life saving endeavour.

Paramedics Australasia 2011 Conference Abstracts

Conclusions Conclusion In the encounter phase of professional The question of whether intended clinical socialisation, the transition from university student placement learning outcomes can be feasibly met to paramedic intern can be a very difficult by increasingly the fidelity of simulations using experience. Interns felt the need to assimilate into SPs warrants further exploration. the culture to be accepted, and there was a perceived dissonance between the university and ambulance cultures. Educating Gibraltar: The challenges of bringing university education to Scott Stewart What is the undergraduate paramedic students’ perspective on the acceptability, Victoria University, Melbourne, Australia realism, and effectiveness of Simulated St Georges University of London, London, UK Patients? Objectives Matt Johnson, Leanne Boyd, Jade Sheen To provide a tiny, remote ambulance service with world standard education. Monash University, Victoria, Australia Background Methods This paper reports on a pilot study, exploring An overview of the challenges faced by the students’ views regarding the strengths and Gibraltarian Ambulance Service and innovative weaknesses of Simulated Patients (SPs) in an methods used to facilitate their university undergraduate paramedic degree. Research into participation. the theory practice gap of paramedic students has found less than 50 per cent of cases experienced Results during clinical placement lead to skill practice on a The Gibraltar service has limited scope of practice real patient. The goal of any clinical experience, and education. Its island like isolation, due to be it in a placement or a simulation, is to provide a political forces, means it faces challenges akin to context within which clinical concepts can be a remote small town. It has additional risks in brought together and practiced. Without genuine having large influxes of tourist via cruise ship, an student engagement – that is, with the students international airport near town and a busy acting only as observers – clinical placements shipping lane. Historically only BLS was may offer little more than face validity. This considered necessary due to the short transport represents a model of competence training that is times. The skill / education gap has now been increasingly being seen as unsustainable. An recognised. However traditional university alternative that may offer content validity is to attendance was not possible due to staffing and create a controlled situation that nonetheless geographic constraints. Tertiary education has offers an immersive experience where participants been commenced by burst, mixed mode delivery. are able to suspend disbelief leading them to This mixes visits by UK staff with an online speak and act as if the situation were real. The learning environment combining traditional text potential of simulations to enhance learning has based resources and links with ‘Wimba’ live class been recognised at a Federal level with Health room and interactive ‘Second Life’ scenarios. Workforce Australia (HWA) undertaking a $94M Assessment is a mix of face to face OSCE, Simulated Learning Environments (SLE) program. essays and online tests. The first year of delivery resulted in high student satisfaction and academic Method performance. Changes in practice and A cross-sectional survey of second year professional interaction have been noted. paramedic students. This study sought to explore the perceptions and reactions of paramedic Conclusions students to a Simulated Patients and views the Gibraltar provides a fascination microcosm of data through a qualitative lens. paramedic work. Hurdles have been overcome to enable tertiary level education for this remote Results British Overseas Territory. Positive changes are Students indicated that the scenarios with happening. Simulated Patients afforded a greater sense of reality than the use of peers and the results raise the potential for high fidelity scenarios using SPs to create a controlled, environment that may allow for learning goals previously attributed to clinical placements to be met within the academic curriculum.

The UK paramedic Education system: Learning’s of an Australian paramedic academics experiences teaching at St Georges University, London Scott Stewart Victoria University, Melbourne, Australia St Georges, University of London, London, UK Objectives To gain an understanding of the differences between the Australian and UK paramedic systems with a focus on education.

Methods An overview of the notable differences and learning’s gained from teaching at St Georges University London, and working with UK Paramedics for two years from the perspective of an Australian Paramedic Academic is presented.

Results Once the variances in jargon are stripped away, the most striking finding is the similarity of Anglo- American style Ambulance Services world wide. Patients, staff and problems faced are remarkably similar. The UK paramedic system has differences in registration, education, guidelines, drugs used, Paramedic practitioners and the frequent presence of medical doctors in the out of hospital environment. It also has recently adopted a Victorian style trauma system and intensive care paramedics. My personal insight is that the Australian system is world class. Australian Paramedics and their universities are well regarded internationally. The transition to teaching in the UK is significant but not prohibitively difficult. The art of teaching in different system is akin to learning a new language; the structure of the process becomes clear. For Australian paramedics wishing to work in the UK the task is well mapped but long and moderately expensive. For paramedic Academics the transition is slightly easier.

Conclusions The UK system is accessible and worthwhile for Australian paramedics and paramedic academics. The experience suggests an ethnological study of paramedics and lecturing staff that have made the transition from one region to another.

Paramedics Australasia 2011 Conference Abstracts

Conference Poster Abstracts The study identified a number of student concerns that could be used to inform improved future Logging onto a clinical focused course. teaching practice. Liz Thyer and Georgia Clarkson Victoria University, St Albans, Victoria, Australia The efficacy of a double degree program Objectives regarding student satisfaction: Our study aims to catalogue paramedic student perspectives of undergraduate students. expectations of distance education prior to Yelise Foon and Natasha Nemarich undertaking such a course and then again after completion of a year on distance education. We Charles Sturt University, Bathurst, Australia will also gather information regarding the Introduction alignment of these expectations with reality as Selected tertiary institutions offer the unique well as production of distance education material availability to study pre-hospital care and nursing and resources, student resources, age, gender as a combined program. Currently, Australia-wide, and location of students. Furthermore this four universities offer a Bachelor of Nursing in research aims to identify if there is any impact on combination with a Bachelor of Clinical Practice student grades by distance education. (or equivalent) – Charles Sturt University,

Queensland University of Technology, Australian Methods Catholic University and Monash University. Within The project employed a mix methodology quasi- Charles Sturt University the double degree is experimental design encompassing two offered over four years as an internal student. questionnaires and collation of student grades From course commencement to completion, (grade point averages - GPA's) pre and post students undergo dynamic shifts within their distance education experience. A pilot study was learning experiences, which may effect their conducted during the first year of the study and a perceived sense of worth when undertaking dual larger study is currently being undertaken. qualification study. Participants were third year students enrolled in the Bachelor of Health Science (Paramedic) at Hypothesis Victoria University completing components of their Current students have varying levels of study on-line. satisfaction depending on mitigating factors

influencing the course of their study in the double The two questionnaires utilised a Likert scale with degree program. additional directed open-ended questions.

Categorical data was analysed using frequency Objective: To assess the efficacy of the Bachelor distribution tables and determination of the mode of Nursing/Bachelor of Clinical Practice for each question whilst data collected from open- (Paramedic) combined degrees at Charles Sturt ended questions was subject to basic University (CSU) when considering the ethnographic analysis. satisfaction of current students and perceptions of Human ethics approval was obtained from Victoria differing grade subsets. University (HRETH 10/6).

Methods Results A survey of current double degree students Responses to the pilot study indicated student felt enrolled in their first to fourth year of study will be online learning was appropriate for some conducted. The questions are specifically theoretical components of paramedic practice; designed to review individual motivation for however many students identified issues with their pursuing dual qualifications and factors within the time management, technological barriers and double degree program impacting student decreased engagement. Positive responses were satisfaction. These questions will be quantitative, elicited from students in relation to flexibility of displayed as graphical trends, as well as learning and ability to re-visit information as well qualitative, collated in themed data sets and as environmental savings. independently reviewed by a team of two

individuals. The sample size of the survey is 100 Conclusions students (n=100) across four different years. Initial anxieties regarding online learning were not realised and participants in the study largely Conclusion expressed positive overall online learning The projected timeline of this study will include the experiences where negatives were outweighed by st st open survey from July 1 - July 31 , 2011. From positive feedback. st th August 1 – 15 , the data will be collated and st analysed, and a completion date of 31 of August. Concurrently, an independent party will review the data for bias.

Pain assessment and pain management Tabletop Exercises for Paramedic Incident practices of ambulance officers in Command Training Auckland. Christopher R. Foerster Sarah Werner1 and Jane Koziol-McLain2 James Cook University, Townsville, QLD, 1St John, Auckland, New Zealand Australia 2AUT University, Auckland, New Zealand Lambton EMS, Lambton County, Ontario, Canada Background Pain is a common complaint of many patients in Background the prehospital setting. Pain prevalence is Paramedics and supervisors have an important unknown in Auckland, New Zealand. Little is command role in coordinating the medical known about how ambulance officers assess and response to multiple casualty incidents (MCIs). treat pain. Ambulance officers have more options Tabletop exercises are an effective and than previously to treat pain, but actual practice is economical disaster exercise format that are unknown. commonly used to prepare upper level emergency management personnel for their decision-making Objectives role in disasters. An adapted version of this This study sought to establish the prevalence of exercise style may be useful for preparing patients reporting pain, characteristics of pain paramedics for their front-line command role in assessment, including pain scores and OPQRST, MCIs. and treatment of pain using pharmacological and non-pharmacological interventions. Relationship Objectives between qualification and pain assessment The objective of this project was to investigate the practices was sought. Data gathered will provide a feasibility of developing and delivering a tabletop baseline for future research. exercise for paramedics.

Methods Methods Patient report forms were randomly selected over A tabletop exercise for paramedics was a 7-day period (n=371) in September 2010. Data developed around a scenario of a suicide abstracted included presence of pain, pain bombing at a sports stadium during an event. The assessments documented including OPQRST and response was divided into three modules with the pain scores, pharmacological and non- exercise taking place over two hours including the pharmacologic treatment of pain documented. introduction and debriefing. The author facilitated Descriptive statistics were used to analyse the two pilot tests of the program with different data. Deceased patients, patient transfer patients, ambulance services, one with front-line and accidental personal alarm activation cases paramedics participating and one with paramedic were excluded from analysis. managers and supervisors.

Results Results Pain was reported in 49% of eligible patients; the The tabletop exercise format was readily adapted most common location being chest pain. Initial to the needs of paramedics. After the initial pain scores were documented in 20% of patients exercise development, delivery required only in pain. Time (50%) followed by Onset (39%) were limited resources. Exercise materials were most frequently reported pain assessments. Low minimal, allowing for the exercise to be as mobile rates of analgesia administration were reported for as the facilitator. Participants rated the exercise those reporting pain (paracetamol 19%, positively, saying that they found it useful to be EntonoxTM 16%). Intravenous morphine was able to discuss these decisions in a low stress administered to 8% of patients reporting pain, environment. The primary limitation of this study is mean dose 7.5mg ± 5.7. Analgesia refusal was that it sought to examine only the feasibility of this noted in 6% of patients. Non-pharmacological type of training for paramedics and not its efficacy. treatment of pain was very poorly documented, positioning (4%), followed by splinting (3%). Conclusions Conclusions: Assessment of pain is poorly The results from these pilot tests suggest that documented. Low rates of analgesia tabletop exercises can be adapted to train administration are present. Non-pharmacological paramedics for their front-line command role and treatment of pain appears undervalued. Further that delivery requires only minimal resources. research opportunities exist about the patient's Having demonstrated the feasibility, further desire for analgesia, and pain assessment in research is warranted to evaluate the efficacy of paediatric and cognitively impaired patients. this type of training for paramedics.

Paramedics Australasia 2011 Conference Abstracts

Quality of Life of Young Adult Out-of address some of the possible reasons that Hospital Cardiac Arrest Survivors organisations and individuals fail to really "get" Conor Deasy, Janet Bray, Karen Smith, bullying and harassment when it happens to Stephen Bernard, Peter Cameron others (or when they are perpetrators), and yet, can easily recognise it when it happens to them or DEPM, Monash University to those close to them. Alfred Hospital, Melbourne, Australia Ambulance Victoria, Melbourne, Australia Background Prehospital acupressure by paramedics Amongst patients suffering out of-hospital cardiac for management of acute pain: a arrest (OHCA), young adults represent a minority. systematic review of randomised However, these victims suffer the catastrophe controlled trials. when they are in a very active phase of life and Paul Simpson, Ric Thomas, Jason Bendall have a long life expectancy. Little is known on the Ambulance Research Institute, Ambulance quality of life of these survivors. There is no consensus about which particular dimensions Service of New South Wales, Sydney, Australia should be included in quality of life studies, as well Objective as for the instruments that should be used. Pharmacological analgesia is not always available Victorian Ambulance Cardiac Arrest Registry has in the prehospital setting, leading to consideration commenced collecting quality of life data using of non-pharmacological alternatives. Acupressure SF-12, EQ-5D and GOSE on OHCAs. has been studied in several European ambulance services and may be an effective intervention Aims when performed by paramedics. The objective of To assess the Quality of Life in young adults who this study was to conduct a systematic review of survive OHCA in Victoria. the literature to determine the effectiveness of acupressure for acute pain when performed by Methodology paramedics in the prehospital setting. The Victorian Ambulance Cardiac Arrest Registry (VACAR) records will be used to identify cases of Methods OHCA that occurred between 2003 AND 2008 in A systematic search of MEDLINE, EMBASE, the 16-39 year old age group. CINAHL and the Cochrane Library databases was Survivors will receive a telephone questionnaire to conducted to identify prehospital randomised establish their quality of life post cardiac arrest controlled trials comparing paramedic-performed using SF-12, EQ-5D and GOSE. acupressure to ‘sham' acupressure for management of acute pain. Potentially relevant Results articles were systematically assessed for eligibility We will present characteristics of young adult against a priori inclusion criteria, and for quality OHCAs. We will describe the quality of life and validity using recognised methods as outcomes and relate them to the characteristics of recommended by the Cochrane Collaboration. the cardiac arrest. We will describe the quality of life tools, their performance, training, policy and Results procedure around telephone follow up as pertains The search identified three small prospective to this patient group as well as the challenges randomised controlled trials that met the inclusion encountered. criteria, with a total of 62 patients receiving acupressure and 56 receiving ‘sham' treatments. All three compared paramedic-performed ‘real' Bullying and Harassment acupressure with ‘sham' acupressure using a in Paramedicine - One Person's Journey visual analog scale (VAS) to measure pain Allison Ballard reduction and all were methodologically robust in design. One study used auricular acupressure University of Canberra, Canberra, Australia for acute hip fractures in older patients, one used Australian National University, Canberra, acupressure at the Baihui/Hegu points in patients Australia with radial fractures, while the third used auricular University of South Australia, Adelaide, acupressure for fractures and soft tissue injuries. Australia All three studies reported statistically significant differences in post-intervention VAS pain scores This paper will outline a case study/studies in favouring ‘real' acupressure. Insufficient data was bullying and harassment within different Australian available in the published papers to allow meta- ambulance services and will address areas such analysis. as the adverse impacts on career, health and wellbeing, peers, service provision, the

"profession", and health organisations. It will also

Conclusion inclusion in the meta-analysis. The meta-analysis Paramedic-performed acupressure is an effective of 206 patients showed that ‘real' acupressure non-pharmacological intervention that provides produced a final VAS score about 30mm lower clinically meaningful reductions in acute pain. than ‘sham' acupressure (31 mm; 95%CI 25mm to Acupressure could be a useful addition to the 37mm; p<0.0001). scope of practice of paramedics, particularly those unable to administer analgesics, and non- Conclusion ambulance first aid providers. Paramedic-performed acupressure is an effective non-pharmacological intervention that reduces acute anxiety. Acupressure could be easily Prehospital acupressure by paramedics implemented into paramedics' scope of practice. for managing acute anxiety: Systematic review and meta-analysis of randomised controlled trials. Prophylactic metoclopramide for patients Paul Simpson, Ric Thomas, Jason Bendall receiving intravenous morphine in the emergency setting: A systematic review Ambulance Research Institute, Ambulance and meta-analysis of randomised Service of New South Wales, Sydney, NSW, controlled trials. Australia Paul Simpson, Jason Bendall, Paul Middleton Objective Ambulance Research Institute, Ambulance Paramedics commonly encounter patients Service of New South Wales, Sydney, NSW, experiencing acute anxiety. Anxiety secondary to acute pain is often indirectly managed through Australia administration of opioids or other analgesic Objective agents; however, for acute anxiety of non-pain The objective of this study was to conduct a origin, or painful conditions when pharmacological systematic review and meta-analysis of analgesia is not available, paramedics have few randomised controlled trials, comparing anxiolytic avenues other than simple metoclopramide to placebo, for preventing reassurance. Acupressure has been proposed in vomiting in patients who have received several European studies to be a simple, effective intravenous morphine for acute pain in the and safe option that could easily be added to emergency setting, and to determine the level of paramedics' scope of practice. The aim of this evidence supporting the use of prophylactic systematic review was to determine the metoclopramide in this population. effectiveness of acupressure for reducing acute anxiety when performed by paramedics in the Methods prehospital setting. Comprehensive systematic electronic searches were conducted of MEDLINE, EMBASE, and the Methods Cochrane Library for randomised controlled trials A systematic literature search of MEDLINE, addressing the clinical question. Reference lists of EMBASE, CINAHL and the Cochrane Library was identified articles were hand-searched. Studies conducted to identify prehospital randomised meeting the inclusion criteria were assessed for controlled trials comparing paramedic-performed validity and bias using Cochrane methodology. acupressure to sham acupressure for Methodologically appropriate clinical trials were management of anxiety. Identified studies were included in the meta-analysis using Revman 5.2 assessed for eligibility against a priori inclusion software to provide a pooled estimate of effect criteria, and for quality and validity using expressed as odds ratio (OR) with 95% recognised methods. A fixed-effect model meta- confidence interval (CI). analysis of methodologically homogenous studies was conducted using Revman 5.1 to provide a Results summary statistic for mean difference in final Three randomised controlled trials fulfilled the (post-treatment) 100mm visual analogue scale search criteria. All three studies were included in (VAS) value. the final meta-analysis totalling 595 patients. The incidence of vomiting was 2% and 3% for Results metoclopramide and placebo respectively. The The search identified five eligible studies meta-analysis demonstrated an overall result of comparing ‘real' acupressure with ‘sham' no difference between metoclopramide and acupressure, all of which were methodologically placebo for the primary outcome of vomiting (OR robust in design. All studies reported significantly 0.72; 95% CI 0.11-4.58; p=0.73) with no evidence lower post-treatment anxiety scores in the ‘real' of heterogeneity (p=0.13). acupressure groups. Four studies reported sufficient detail allowing extraction of data for Paramedics Australasia 2011 Conference Abstracts

Conclusion Results The incidence of vomiting following administration For the 500 cases included, 76% were classified of intravenous morphine is very low. There was as ‘falls' by the CAD system, with53% receiving little evidence that routine prophylactic an urgent response. The mean age was 83 (±7), administration of metoclopramide following the and 64% were female. Falls happened at home in administration of intravenous morphine for acute 54% of cases, with 18% occurring in residential pain management in the emergency setting is care. A simple trip (24%) and loss of balance clinically beneficial. Routine metoclopramide (32%) were the most common reasons for falling. administration may expose patients to a risk of Almost 30% of patients spent more than 30 harm which is not justifiable given a lack of minutes on the floor prior to ambulance arrival, evidence of benefit. and 78% sustained a new injury. Almost half had never called for falls previously, while 15% had called within the last 4 weeks. The overall non- The ‘CATCH' study: A preliminary analysis transport rate was 26% with no statistically describing the epidemiology of 500 significant difference between day and night (24% prospectively collected cases involving v 32%; p=0.07). older fallers attended to by paramedics. Paul Simpson1, Jason Bendall1, Jillian Conclusion 1 ,2 3 ,5 Ambulance responses to older fallers generally Patterson , Anne Tiedemann , Paul involve females living at home, and one in four Middleton1 ,6, Jacqueline Close3 ,4 results in non-transport. Future research should 1Ambulance Research Institute, Ambulance focus on safe management of non-transported Service of New South Wales, Sydney, NSW, fallers and strategies to optimise the dispatch Australia process to ensure an appropriate response 2New South Wales Department of Health, New priority. South Wales, Australia 3Neuroscience Research Australia, Randwick, Proposed studies of Prehospital Sepsis New South Wales, Australia Care 4Prince of Wales Clinical School, University of Richard Thomas New South Wales, Sydney, New South Wales, Ambulance Research Institute, Rozelle, NSW, Australia Australia 5The George Institute for Global Health, Sydney, New South Wales, Australia, Background 6University of Sydney, Sydney, New South Sepsis is responsible for the deaths of thousands Wales, Australia of Australians annually and leaves many others dependent on high-level hospital care for long Objective periods. The human and financial cost is Older patients who have fall constitute a significant yet reducible. Sepsis describes a significant proportion of ambulance emergency number of conditions that originate in an infective responses. The ‘CATCH' study is a large, on- source, progressing to organ and systemic going prospective descriptive study that aims to cardiovascular failure. Little is described about describe the epidemiology of 1500 older fallers prehospital recognition and care of community aged 65 years or more who were attended by acquired sepsis. Paramedic capacity to identify paramedics in New South Wales, Australia. The sepsis has not been described in the literature aim of this preliminary analysis is to describe the though in-hospital recognition is known to be epidemiology of the first 500 cases enrolled in the difficult. A suite of in-hospital interventions are CATCH study. described that reduce mortality and morbidity, and time-to-care is a critical feature in the Methods management of sepsis. Researchers have begun We selected the first 500 cases from the to examine the potential role of prehospital care to prospective CATCH study database for a achieve similar mortality and morbidity reductions preliminary analysis. A tailored data collection as have been observed with the contemporary tool has been completed for all eligible older prehospital care of AMI, stroke, and trauma fallers, providing falls-specific data not routinely patients. captured in ambulance clinical records. This data was linked ambulance clinical records and Methods computer aided dispatch (CAD) data. Analysis A series of studies are proposed to bridge the was conducted using SAS 9.2 to produce knowledge gap and explore potential morbidity descriptive statistics and compare proportions. and mortality reductions through prehospital intervention. The first study, already underway, is an epidemiological review of close to 3 million cases in NSW to describe the prehospital

The Official Journal of Paramedics Australasia © 2013 Australasian Journal of Prehospital Care: 2013;10(2) incidence of sepsis including frequency, Conclusions distribution, and mortality. The second will The paramedic's ability to gather information, examine the capacity of paramedics to identify problem-solve and select a course of septic patients and validate an assessment tool. A management are of particular importance in time- third study is a randomized trial that will compare and resource-limited settings; two situations standard care versus high-volume fluid common in the rural pre-hospital environment. administration. A fourth and final study will look at The paramedic's experience level and the prehospital antibiotics for sepsis. presence of stressors will affect cognitive demands, in turn affecting the decisions made Results and patient outcome. This is more significant in These proposed studies will advise who is septic, rural areas due to decreased resource availability when and where; if paramedics can identify them; and increased travel time to appropriate care. and if increased prehospital fluid volumes and Future research needs to be undertaken in the antibiotics will reduce mortality and morbidity. pre-hospital setting to ensure optimal paramedic clinical decision making processes are identified Conclusions and taught in order to provide best patient care. Studies that improve the understanding of sepsis and identify interventions that can begin at the earliest time, during the prehospital period, may Alternate Care Facility Triage lead to reductions in mortality, morbidity Christopher R. Foerster1 ,2, Adam Perper3, and health care costs. Bethany Cummings4, Steven J. Parrillo5, Erik S. Glassman6

1 Paramedic Decision Making: Issues in Lambton EMS, Lambton County, Ontario, Canada Rural Settings 2 Kate Kloot Cleverley James Cook University, Townsville, QLD, Australia Ambulance Victoria, Warrnambool, Australia 3Hackensack University Medical Center, Deakin University, Centre for Rural Emergency Hackensack, NJ, U.S.A. Medicine, Warrnambool, Australia 4Department of Emergency Medicine, Background Winchester Medical Center, Winchester, VA, Clinical decision-making plays an important role in U.S.A. 5 the pre-hospital healthcare environment. It allows Department of Emergency Medicine, Einstein paramedics to gather and process information, Hospital Elkins Park, Philadelphia, PA, U.S.A. 6 problem-solve and choose a treatment course for Strasburg Rescue Squad, Strasburg, VA, USA their patient. Despite guideline and protocol use, Background patient management still requires some form of Despite implementation of surge capacity plans, judgement regarding the patient's condition. mass casualty incidents will tax the resources of Whilst significant research has been undertaken surrounding healthcare facilities. Lower acuity into nursing and general medical decision-making patients can deplete resources both on scene and processes, very little has examined the problem- in emergency departments. Current prehospital solving methods utilised by paramedics. triage schemes prioritise patients for transport, but

do not identify patients who can be safely Discussion transported to Alternate Care Facilities (ACFs) to Decision making efficacy is dependent on clinician ease the burden on the traditional points of entry. experience level and the presence of stressors

(e.g. time pressure or noisy environments), as Objectives they change cognition demands. Increased The objectives of this project were to identify experience allows clinicians to use heuristics patient populations that can be safely transported (cognitive shortcuts) and better identify relevant directly to ACFs and to develop an algorithm for cues in busy or stressful environments, but use by field providers making this determination. stressors are often increased in rural areas due to distance and resource limitations. The seriously Methods injured or unwell patient often has a combination Past mass casualty incidents were considered to of complex medical problems, a greater risk of determine which patient populations could be death, and is more likely to rapidly deteriorate transported directly to ACFs. Patient populations during transport due to longer transport times. Not were sought that required minimal care but may only are there increased cognitive demands needlessly utilise resources at a traditional point based on the patient's condition, but issues such of entry and on scene. An algorithm was then as patient history location, resource availability, developed for use by field providers to determine paramedic skill set, and patient/family transfer patients’ suitability for transport to an ACF. requests are all factors needing consideration. Paramedics Australasia 2011 Conference Abstracts

Results intended and observed learning outcomes, Four primary patient populations were identified teaching and learning activities and standards- who could be eligible for transport to alternate based assessment. care facilities. After activation by the Incident Commander, patients who are classified by the Constructive alignment appears to offer traditional triage scheme as walking wounded, curriculum designers and professional worried well, or requiring delayed urgent care accreditation bodies the necessary theoretical would be considered for inclusion. Specific groups framework to ensure the consistent who may be eligible are those with isolated soft implementation of graduate attributes. Evidence tissue injuries, isolated orthopedic injuries, indicates that simply adding graduate attributes or isolated mental health issues, or multiple minor psychomotor skills on an ad-hoc basis or as a injuries or illness. Precise implementation of this bolt-on to existing courses does not provide the algorithm is dependent on local resources, contextualised learning processes required. legislation and regulations. This initial work now Additionally, undertaking course mapping requires validation in a full-scale exercise. exercises has been likened to a ‘tick and flick' approach and in isolation is ineffective in ensuring Conclusions that espoused graduate attributes are Transport to ACFs can direct a specific patient experienced and demonstrated by students. population away from traditional points of entry to This paper will provide examples of how enhance existing surge capacity plans. The constructive alignment has been used by cognate algorithm presented in this research can be used and non-cognate disciplines, providing the as a basis for local protocols for field providers to paramedic discipline with a roadmap in its urgent determine which patients should be transported to need of curricula coherence. ACFs.

Transition to tertiary education: Curricula Coherence: Is Constructive Preliminary findings from first year Alignment a potential solution in paramedic students paramedic education? Brett Williams and Fiona Newton Brian Sengstock1 and Brett Williams2 Monash University, Melbourne, Australia 1University of the Sunshine Coast, Queensland, Objectives Australia 2 As part of its 20/40 agenda, the Australian Monash University, Melbourne, Australia Commonwealth government has proposed that Universities around the world are experiencing 40% of 25 - 34 year olds will complete a significant challenges as they position themselves Bachelor's level qualification by 2020. This target in competitive knowledge-based economies. On is now placing greater emphasis on transitional a national scale, these challenges, possible issues to tertiary education. While a number of solutions, and potential roadmaps have been studies have established the importance of outlined in the Building University Diversity and positive transition experiences as a foundation for the Bradley Reports which examined the retention, to our knowledge, no such studies have approval, registration, and flexibility issues relating examined this aspect from a paramedic to the Australian Higher Education sector. These perspective. The aim of this study was to survey challenges are having a major impact on those paramedic students as they make their transition involved in paramedic education and training. into first year tertiary studies at a large Australian As the number of Australian paramedic programs University. continues to grow, it is timely that academics, policymakers and educators consider the Method implications of not having national curricula A cross-sectional study consisting of a paper- standards or agreed upon graduate attributes. based questionnaire (115 items) using a convenience sample of first year undergraduate Currently, no national curricula conformity, paramedic students. Student self-directedness standardisation, or graduate attributes exists, was assessed using a unipolar 5-point Likert scale which suggests that Higher Education institutions (1=Strongly Agree to 5=Strongly Disagree), while and industry are uncertain if graduates are confidence in a number of information technology meeting their respective needs. Thus, an and assignment preparation skills were measured - opportunity for curricula renewal, informed by using a 7-point bipolar Likert scale (ranging from + curriculum design theory is now available for 3 to 3). those involved in paramedic education and training. One such theory is Constructive Alignment. Constructive alignment is a curriculum design theory that aligns graduate attributes,

Results uncomplicated myocardial infarction was Twenty-four students participated in the study associated with a non-significant increased risk of (40% response rate). The median age was 23 mortality (risk ratio 2.0, 95% CI 0.8 to 10.3, years, the majority of students were female n=17 p=0.08), and a greater aminotransferase level (70%). The median ATAR score was 90.0. (p=0.05) when compared with room air. When Students responded positively to self- guided by pulse oximetry, severe hypoxaemia directedness, for example, ‘I want to learn new (SpO2 < 80%) was less frequent in myocardial information' (M=1.25, SD=0.44), and ‘I am infarction patients treated with oxygen (4% vs. responsible for my own decisions' (M=1.45, 35%, p<0.05). SD=0.58). Students lacked confidence in being able to find resources from library databases: Conclusion ‘Ability to narrow search using Boolean terms' There is no empirical evidence to support the (M=0.87, SD=1.82), ‘Ability to broaden search routine use of oxygen therapy for ACS. Limited using truncations' (M=0.52, SD=2.04), and evidence suggests that oxygen therapy limits ‘Download a full text article from a database' hypoxaemia within 24 hours of onset of (M=0.47, SD=2.06). myocardial infarction; however it may also lead to an increase in mortality. Conclusion This information will provide teaching staff with important data that will be used to facilitate the The emergency ambulance workload design of future transition programs. It is during the early recovery periods from the anticipated that the data will also facilitate staff in Christchurch earthquakes. making improvements in teaching and learning Bronwyn Tunnage1 and Mark Deoki2 within the paramedic program. 1 AUT University, Auckland, New Zealand 2St John New Zealand, Auckland, New Zealand Oxygen therapy in Acute Coronary Objectives Syndromes: Are we doing more harm than An earthquake measuring 7.1 in magnitude struck good? the city of Christchurch on 4 September 2010 1 2 2 Jennifer Melvin , Ziad Nehme , Brett Williams causing widespread damage. Aftershocks 1The University of Notre Dame, Perth, Australia continued for months followed by a 6.3 magnitude 2 earthquake on 22 February 2011 which resulted in Monash University, Melbourne, Australia multiple fatalities and major damage. At a time Objectives when businesses and organisations had great Administration of oxygen therapy for patients difficulty maintaining their usual activity, continuity suffering acute coronary syndrome (ACS) has for of provision of pre-hospital emergency health care many years taken a leading role in paramedic was critical. Many of the local population were clinical practice guidelines. However, this practice bereaved or recovering from injury as well as is based on a false premise of benefit rather than living with considerable social and economic reflecting evidence-based practice. We conducted disruption. The literature reports that increased a review of the literature to determine whether incidence of cardiac and psychological disorders normobaric oxygen therapy is an effective have been observed for months after treatment for ACS. earthquakes.

Methods This study quantifies the emergency ambulance A literature review was undertaken using the workload and performance in the months following electronic databases PubMed, Ovid Medline, the Canterbury earthquakes. It establishes the CINAHL Plus and the Cochrane Library from their change in demand for ambulance responses commencement to the end of May 2011. overall, and by priority response categories, and Keywords used in the search included; acute the change in response time key performance coronary syndrome, myocardial infarction, heart indicators (KPI), compared to previous years. attack, MI, AMI, heart infarct, angina, coronary syndrome, coronary thrombosis, and oxygen. Methods Clinical trials only were eligible for inclusion if they A retrospective analysis was undertaken of measured the effect of normobaric oxygen response data from the St John Ambulance therapy on patients suffering ACS. Service in the Christchurch region from January 2008 to May 2011. Statistical significance was Findings established by Chi-squared testing. Of the initial 4765 articles, 66 potential studies were identified after screening title and abstract. From these, 2 clinical trials met the eligibility criteria. The use of high flow oxygen therapy in Paramedics Australasia 2011 Conference Abstracts

Results Methods After the September 2010 earthquake, overall The training has been developed through the demand increased by 14% compared to the same recognition of international principles and the months in 2009. However, in the months after the guidance from leading world experts and the February 2011 earthquake, a decrease in overall relevant federal bodies. It has been tailored for a demand from the previous year was observed; the variety of audiences and has now been adopted only instance in the entire 2008-2011 period that by National AusMAT State and Territory groups this phenomenon was observed. Change in as mandatory training for AusMAT personnel. The demand varied by category of priority response. course includes, convoy driving, negotiation, Response time KPIs were adversely affected by security awareness, weapons awareness, both earthquakes. controlled road blocks and personal survival. The courses run for a period of 3-4 days and Conclusions incorporates a “deployment” into the field to All ambulance providers need disaster plans to ensure candidates “self select’ when exposed to ensure continuity of service provision after a major reality of austere environments. catastrophic event. In Christchurch the demand for, and performance of, emergency ambulances during the recovery period was influenced by The Effectiveness of Airway Management factors including evacuation of the population from in the Pre Hospital Treatment of Traumatic the affected region and functionality of the Brain Injury infrastructure. Joseph Cuthbertson

St John Ambulance WA Inc, WA, Australia Australian Medical Assistance Teams Objectives

(AUSMAT) the Paramedic perspective There is concern over mortality and the potential Abigail Trewin and Ian Norton for secondary brain injury in the head-injured National Critical Care and Trauma Response patient. The use of advanced airway management Centre, Darwin, Northern Territory, Australia and rapid sequence intubation (RSI) in the pre hospital treatment of patients with Traumatic Brain Background Injury (TBI) is controversial. Currently in St John AUSMAT (Australian Medical Assistance Team) is Ambulance Service Australia (WA) Inc. three a civilian medical team responding to a disaster forms of pre hospital treatment are utilized to with the purposes of rendering emergency manage the airway of the adult head-injured medical care. The National Critical Care and patient. If attended by on-road paramedic staff, Trauma Response Centre was established by the basic airway management is utilized unless the Federal Government in response to the patient is unconscious and areflexic, in which 2002/2005 Bali Bombings and 2004 Asian case advanced airway management utilizing Tsunami. The NCCTRC is funded to provide, a endotracheal intubation or laryngeal mask level one AUSMAT, Training and Disaster insertion is authorised. In the critical care response equipment under the direction of the paramedic setting, the severely head-injured Australian Health Protection Committee. The patient can be managed utilizing paramedic NCCTRC provided the majority of AusMAT initiated rapid sequence intubation techniques and personnel to the Pakistan response in 2010. The on-going sedation, paralysis and ventilation. NCCTRC AusMAT training program includes a There is a lack of data evaluating the risk and broad spectrum of health professionals and outcomes involved with these techniques when provides training to participants from across each utilised to treat head-injured patients by state and territory. It prepares responders for the paramedics from the Western Australian austere environments of a disaster zone, working ambulance service. In this study we provide an with limited resources while meeting key SPHERE updated evaluation of outcomes associated with outcomes. each procedure.

Objective Methods A core focus has been ensuring paramedics and The research framework will be that of a other key emergency services personnel are not retrospective, observational study of patients overlooked in the selection of a team suitable for transported and treated between January 2004 response. Creating opportunity for paramedics to and January 2009 in Western Australia. As the be included and recognised for their key attributes designated state trauma centre, all major trauma is fundamental in ensuring the creation of relevant patients are transported to Royal Perth Hospital, teams. Ensuring Paramedics understand the key where a trauma registry records assessment and attributes for AusMAT deployment and how to treatment details for all admitted patients. All engage in the relevant training is essential in patients admitted to Royal Perth Hospital trauma ensuring this health profession is not overlooked. unit with a head abbreviated injury scale > 3

The Official Journal of Paramedics Australasia © 2013 Australasian Journal of Prehospital Care: 2013;10(2) transported and treated pre hospital by St John to mitigate attrition of knowledge and skill. The St Ambulance WA paramedics from January 2004 to John Internship Model is am evolving robust January 2009 will be included. Hospital records of method for further developing the talents of patient outcomes will be matched with pre hospital graduates. records.

Results A Partnership Model for Prehospital Pending Education Paul Burke1 ,2, Dianne Inglis1, Caitlin Walker1, Conclusions Rod Crole1, Jeff Kenneally1 Pending 1 Ambulance Victoria, Melbourne, Victoria, Australia 2 Paramedic graduate destination and Monash University, Melbourne, Victoria, internship in New Zealand. Australia 1 2 Paul Davey and Tim Bradley Objectives 1AUT University, Auckland, New Zealand This presentation highlights the benefits for 2St John, Auckland, New Zealand establishing a pre-hospital educational program involving partnerships between pre-hospital Introduction providers, tertiary institutions, and other Higher education is preparing Paramedic healthcare and emergency service providers. graduates for employment in ambulance services and equipping employed working Paramedics for Methods advances in scope of practice. AUT University An educational program titled Clinical Grand and the Order of St John have worked closely to Rounds was established, based on the traditional ensure that the degree graduate is road ready. concept of medical grand rounds, with the There is nothing so practical as good theory and collaboration of Ambulance Victoria and a number nothing so theoretically interesting as good of external stakeholders from universities and practice (Barrows, 1992). hospitals in Melbourne. The collaboration is in line with the Australian Learning and Teaching Objectives Council 2009 report into Paramedic education To examine paramedic graduate destination and (1). Evaluation of the program has consisted of the internship model in New Zealand. questionnaires distributed at each session.

Methods Results A critical review of the Order of St John internship The evaluation done to date only reflects the first programme was undertaken using surveys (n=55). presentation, and was overwhelmingly positive. The respondents indicated on a 4 point scale an Findings and Conclusions average of 3.69 for improved understanding of the The AUT, University degree was established in topic. The likelihood of attending another Grand 2002. Clinical placement hours of a minimum of Rounds session was rated at an average of 3.90. 1080 hours over three years provide essential The cost in time of organising and presenting the links between theory and practice. Advanced life session was not calculated. The financial costs support competencies are embedded in year were negligible as most resources were provided three of the degree. A four step internship model by the partner organizations in exchange for a was designed in 2007 for pre-employment variety of benefits from their involvement in the graduates entering the ambulance service. This program. programme established six monthly goals, workshops, and assessment requirements for Conclusions increasing scopes of practice. Challenging AV's Clinical Grand Rounds provides a model for assessments and applying for increased scope of a pre-hospital education program which can be practice was optional but encouraged. Some implemented at low-cost, and will help to foster graduates displayed potential to progress but lost understanding and relationships between pre- confidence over time. Attrition of advanced life hospital providers, hospitals, tertiary institutions support knowledge and skill was observed in and other emergency services. This presentation some graduates due to the optional nature of the will discuss the short and long term benefits of the programme. New graduates require induction and program. on going structured support to operate effectively before taking on increased levels of clinical responsibility. The optional element for challenging clinical standards assessment for increased scope for practice should be removed Paramedics Australasia 2011 Conference Abstracts

UK and Victorian, Acute Pain Guidelines Preparedness of International paramedic Compared academics to teach Evidence Based Scott Stewart1 and Paul Burke2 Practice 1 Scott Stewart and Elizabeth Thyer Victoria University, Melbourne, Australia 2 St Georges, University of London, London, UK Victoria University, Melbourne, Australia Objectives Objectives To compare the effectiveness of different To evaluate the literature regarding preparedness analgesia guidelines used by two "World Class" of paramedic academics to teach Evidence Based ambulance services to suggest optimal treatment Practice (EBP). regimes. Methods Methods A literature review was undertaken using Medline, The guidelines for acute pain management of UK OVID, EMBASE and Cochrane Library databases Ambulance Service Clinical Practice Guidelines with MeSH subject headings: ambulance 2006 and Ambulance Victoria, Australia Clinical paramedic, EMS, EMT, education, Evidence Guidelines 2010 are presented in summary form. based practice, paramedic, prehospital, and out- The available outcome measures are then of-hospital. The literature centred on medicine, compared psychology, nursing, and allied health, but no literature on preparedness of paramedic Results academics to teach EBP was found. The management of acute pain by out of hospital providers is one of the highest priorities after Results reducing morbidity and mortality. Historically EBP is benchmarked best practice in most health oligoanalgesia and under treatment have been disciplines (Dawes, et al., 2005; De Smedt, Buyl, widely reported. Under treated pain has many & Nyssen, 2006; Tippett, Clark, Woods, & adverse effects including, reduced patient FitGerald, 2003) and paramedics have also satisfaction, reduced patient compliance and the recently embraced EBP (Jensen, Petrie, & development of pain syndromes. Recently the Travers, 2009). Despite an increase in activity in guidelines of many ambulance services have recent years, paramedic research lags behind been widened to increase the scope of analgesia other health disciplines (Tippett, et al., 2003) with improved availability of opiates and novel which impacts its application to EBP in both analgesics Australia and internationally (Bledsoe, 2003; Centre for Prehospital Research, 2008; Sayre, Recently a number of other analgesics have White, Brown 2002). become available to UK ambulance staff, including Paracetamol , Ibuprofen and Morphine The move to higher education for paramedics is Sulphate in addition to Nitrous Oxide. Victoria relatively recent, making appropriate staffing of shares the option of Morphine but has degrees problematic. Some paramedic Methoxyflurane, Fentanyl and has trialled academics were not educated at a higher Ketamine. education level and/or have limited research experience (O'Meara, 2006) and this increases Lack of knowledge has been suggested as a key the complexity of transitioning into, and issue in ineffective pain management. This has developing in, academia. Compounding this is been addressed by the increasing move to Higher the difficulty in maintaining clinical competency Education for Paramedic Staff. concurrent with teaching and research (Centre for Prehospital Research, 2008; Pointon & Williams, Children however are not as well catered for 2008). The importance of this is highlighted as particularly with basic providers and antiemetic EBP is seen to be most successful when it relates availability. to real clinical decisions and is integrated with other knowledge, clinical expertise and patient Conclusions circumstances (Straus, et al., 2011) raising Adequate education would enable all ambulance questions of paramedic academic preparedness teams to have adequate assessment and to teach EBP. treatment options available to them. A lack of published data prevents the use of outcomes to Conclusions evaluate the effectiveness of these regimes. A To competently teach EBP, the paramedic Combination of the two guidelines would appear academic needs to understand the EBP process, to be closer to the optimal solution. This would be able to evaluate the quality of evidence, apply provide options for managing the diverse evidence to the out-of-hospital setting and deliver problems and situations encountered. Paediatric this to students utilising sound pedagogy. analgesia is particularly in need of improvement.

How effective are first responder End-tidal CO2 monitoring via LMA by programs in Australia? Advanced Care Paramedics in the out-of- Stephen Burgess and Malcolm Boyle hospital setting Kristi Browne Monash University, Frankston, Victoria, Australia The University of the Sunshine Coast, Sunshine Coast, QLD, Australia Objectives Early access to defibrillation for cardiac arrest Objectives patients is highlighted in the seminal paper The object of this review is to determine whether describing the "chain of survival" concept. The End-tidal CO2 monitoring (EtCO2) would be of use of fire fighters as "first responders" to acute benefit for Advanced Care Paramedics through a incidents, especially cardiac arrests, commenced Laryngeal Mask Airway (LMA). The focus is in the mid 1980s in North America. The objective placed specifically on Queensland, as currently of the study was to identify Australian first Capnography is only indicated for use in the responder programs and report their effect on Queensland Ambulance Service by Intensive survival rate from cardiac arrest. Care Paramedics. Whilst Capnography is mandatory for the confirmation of Endotracheal Methods tube placement, it has significantly broader uses A literature search was conducted using medical which needed to be examined in greater depth. electronic databases, MEDLINE CINHAL, and EMBASE with the databases searched from their Methods beginning until the end of May 2011. References Studies on the benefits and limitations of from retrieved articles were reviewed. Keywords Capnography (ranging between the years 1997 included prehospital, out of hospital, first aid, and and 2011) were examined and graded according variations of first responder. Articles were to the NHMRC guidelines for grading evidence. included if they reported on Australian first This analysis specifically focused on the evidence responder programs and their outcomes, including base, risk of bias, consistency, clinical impact, survival to discharge from hospital. Articles were applicability and how generalised the studies excluded if they were not written in English and were. were hospital based. Results Results Capnography has consistently predicted return of There were 430 articles located by the search with spontaneous circulation in cardiac arrest, and can seven articles met the inclusion criteria. Two also be used to gauge the efficacy of CPR. In articles were excluded as they did not report cases with major trauma causing poor tissue survival outcomes. A study at the MCG and perfusion & haemodynamic instability, ventilating Shrine of Remembrance involving St John according to EtCO2 measurements can lead to Ambulance Australia realised 71.4% (n=20) hypoventilation, however these changes are survivors over five years, the Hatzolah program predictable and can be accommodated for by realised 26% (n=5) survivors over eight years. A targeting EtCO2 levels between 25-30 mmHg. In study involving QANTAS aircraft and terminals all other cases for patients over 10kg, EtCO2 over five and a half years realised 22% (n=6) levels correlate to arterial blood gases, and EtCO2 survivors in aircraft and 24% (n=4) in terminals. In levels between 35-45mmHg should be targeted to two studies, a pilot study and a 12 month prevent hypoventilation or hyperventilation. evaluation involving the Metropolitan Fire and Emergency Services Board first responders, there Conclusions was 4% (n=6) and 7.2% (n=31) survivors over two There is a strong evidence base to support the one year periods. Higher survival rates were routine use of Capnography in the out-of-hospital associated with decreased response times to setting with an LMA, particularly in cases of defibrillation. cardiac arrest. EtCO2 monitoring is not a skill which requires extensive training or equipment. Conclusions Introducing capnography for ACP's on a state- The results of this study suggest the survival from wide scale is feasible, and has a low cost to high out of hospital cardiac arrest attended by first benefit ratio. responders is, in some studies, comparable with international studies.

Paramedics Australasia 2011 Conference Abstracts

Gender differences in emergency ‘000' Problem based learning in the Ambulance calls and ambulance response for acute Service of New South Wales: Xtream2 - myocardial infarction (AMI) patients. Outdoor simulation that supports Linda Coventry1, Judith Finn1 ,2, Ian Jacobs1 ,2 workplace learning and collaboration in 1The University of Western Australia, Perth, training with front line agencies and Western Australia, Australia university undergraduates. 2St John Ambulance (Western Australia), Perth, Sharon White Western Australia, Australia University of Tasmania, Sydney, Australia Objectives Introduction Minimising time from the onset of symptoms to The ASNSW conducts activities that provide definitive medical treatment is an important goal points for paramedics to maintain their Certificate for the prehospital management of patients with to Practice. Participation in Certificate to Practice acute myocardial infarction (AMI). Recognition of activities is voluntary and student centred. the potential AMI during the ‘000' call is required Xtream2 activities that involve an informal self- to ensure appropriate prioritisation of ambulance reflective approach to clinically focused problem response. Our study sought to compare the based scenarios. This is supported by a characteristics of ‘000' calls and dispatcher summative assessment. The summative response in men and women with confirmed AMI. assessment is based on comparisons of the self- reflection by the participant and compared to the Methods summative assessment for the scenario that is Perth Emergency Department discharge data was completed by the ambulance educator. used to identify AMI patients who arrived by Collaboration with emergency services and ambulance between Jan 1 2008 and Oct 31 2009. paramedic undergraduates from University of The ‘000' call to St John Ambulance (Western Tasmania has shown successes in building Australia) was transcribed to identify demographic stronger relationships, value adding to training, characteristics of the caller, the patient, presenting enhancing the understanding of other roles and symptoms and dispatcher priority response. breaking down barriers. Differences between men and women were analysed using univariable and age-adjusted Objectives multivariable techniques. Self-reported time from Investigate interagency collaboration in training of onset of symptoms to the ‘000' call was analysed problem based learning in macro simulation. for a sub-set of patients (n=861). Participation in the activity and survey was voluntary and not subject to ethics approval and Results was considered as feedback. During the study period a total of 3,329 AMI patients presented to Perth EDs: 2,100 via Method ambulance. After pre-defined exclusions, 1,681 Surveys were undertaken in order to provide emergency (‘000') calls were analysed: 621 feedback for refinement of the program using an (36.9%) of the patients were women. Women action research model. Completion of the survey were older than men (mean age 77.6 vs 69.1 was voluntary. years, p<0.001); less likely to report chest pain (54% vs 69%; OR = 0.54; 95% CI 0.44 - 0.67) and Results more likely to report vomiting (7.4% vs 4.9%; OR Paramedics suggested a more formal approach to = 1.55; 95% CI 1.03 - 2.34), even after adjustment clinical assessment at the patient's side. State for age. Women were less likely than men to be Emergency Service, Rural Fire Service workers allocated a priority one (lights and sirens) were surveyed. Both of these groups agree that ambulance (p<0.001), even for patients with chest collaboration in training would be beneficial to pain. Women delayed longer than men in calling patients and agencies. for help (median 104 vs 60 mins, p=0.006). Conclusions Conclusions Indicate the paramedics are focused on the Ambulance dispatch officers (and paramedics) development of clinical skills sets in macro need to be aware of the potential gender simulation and the development of clinical differences in AMI presentation, in order to ensure contingencies. Furthermore, paramedics are more the appropriate prehospital response. likely to agree to assessments when treating patients and they want a more assessment of clinical skills sets in clinical practice settings that are less formal.

SES and RFS volunteer workers enjoy the Are acute stroke patients identified by participation and collaboration in training, paramedics transported to appropriate suggesting a breakdown of organisational walls stroke thrombolysis centres? and improving teamwork at scenes. Collaboration Janet Bray1 ,2, Kelly Coughlan3, Ian Mosley2, Bill in training and assessment for front line agencies Barger1, Chris Bladin2 ,3 and undergraduate students requires investigation from a multi disciplinary research perspective. 1Ambulance Victoria, Melbourne, Australia 2Monash University, Melbourne, Australia 3Box Hill Hospital, Melbourne, Australia From the back of the ambulance to the Objective courtroom: Educating paramedic students Current Ambulance Victoria (AV) clinical practice in the law guidelines instruct paramedics to transport Brian Sengstock patients they identify as acute strokes (< six University of the Sunshine Coast, Sippy Downs, hours) with positive Melbourne Ambulance Stroke Australia Screen (MASS) criteria to the nearest thrombolysis stroke centres (TSC). The aim of this Traditionally paramedics were trained using an study is to determine if this practice is followed. apprenticeship model in the vocational education sector, by State Ambulance Authorities, with a Methods focus on competency based training in clinical Over a six month period, metropolitan and rural skills. In recent times paramedic education has cases with a primary assessment of stroke < six transitioned to the higher education sector as a hours were examined. Cases not transported to pre-employment degree qualification. Paramedics TSCs were reviewed for thrombolysis eligibility are often fearful of the law, adopting the age old and reason for destination. analogy that lawyers are "ambulance chasers", rather than seeing the law as an ally to the Results practice of their profession. The delivery of legal For the six month study period, paramedics knowledge through lectures and tutorials alone identified 1451 and 471 cases as acute stroke in does not allow paramedic students the opportunity metropolitan and rural areas, respectively. The to engage with the law in the context of their majority of metropolitan cases were transported to future profession. An innovative approach to the TSCs (n= 1285, 88%), but only 65% (n= 305) of teaching of law to paramedic students through the rural cases; a further 3% (n=47) of metropolitan use of simulation in conjunction with more cases and 9% (n=43) of rural cases were traditional approaches to teaching such as transported to a hospital with a stroke unit, but not lectorials, case discussions and workshops, offering thrombolysis. However, the majority of allows the paramedic students the opportunity to acute strokes transported elsewhere were engage not only with their clinical knowledge, but ineligible for thrombolysis; only 24 (of 164) also with the law and legal process. metropolitan cases and 43 (of 166) rural cases were considered eligible from available Despite ambulance services becoming more documentation. Most of these rural cases aggressive with a variety of new approaches to occurred in the Grampian and Loddon Mallee reducing errors which may result in litigation, regions, where transport to the nearest TSC is > evidence based paramedic practice and root 60 minutes. The most common reason for choice cause analysis for unexpected patient outcomes of destination in those not transported to a TSC cannot fully alleviate the risk of litigation. that were MASS positive was "closest public ED" Paramedics are human and humans by their very (metropolitan 41% and rural 65%). Other reasons nature are imperfect and make mistakes. Through included: closest ED on bypass, clinical guideline, fully integrating a litigation matter from the service patient or guardian choice, and patient history at of the statement of claim and defence, through to destination. trial and ultimately judgment, into the course, students are provided with a unique opportunity to Conclusion participate in the pre-trial and trial elements of a The majority of acute strokes identified by litigation matter. This unique approach allows paramedics in metropolitan regions are participants to experience the factual and legal transported to stroke thrombolysis centres. components of a matter, without having to endure Recent developments (commencement of part- the stress, cost and uncertainty of an actual time TSCs, telemedicine and "ship & drip" litigation. The simulation culminates with protocols) in the Grampians and Loddon Mallee participants engaging in a mock trial. regions will improve access to stroke thrombolysis in these areas.

Paramedics Australasia 2011 Conference Abstracts

Determinants of ambulance usage in rural Extending Care - Meeting the needs of populations during serious health modern healthcare emergencies Jeffrey Andrew Buck Reed and Jason Bendall Ambulance Service NSW, NSW, Australia Ambulance Research Institute, Sydney, NSW, Objectives Australia The NSW Extended Care Paramedic (ECP) Background program was developed in collaboration with key Ambulance utilization rates in high acuity patients stakeholders including NSW Health, Area Health have been shown to be lower in rural areas than Services, Hospitals, Divisions of General Practice in urban areas. There is strong anecdotal and Ambulance, each contributing to the design of evidence that rural populations view ambulance a program aimed at safely reducing Emergency services differently than urban users. Department presentations for suitable sub acute Objectives: The objective of this study was to "000" contacts. determine the rationale for decision making in rural people who experience serious health A 10 week intensive education program based at emergencies. Sydney University, Clinical School for Medicine at Nepean Hospital, with further 12 month clinical Methods and on-going education program to meet the Results of a previous study into numbers of requirements of a qualified Extended Care patients presenting to rural and urban emergency Paramedic. departments was combined with an expansive literature search focusing on both the The ECP program commenced operations in phenomenon of rural ambulance usage and Sydney West in 2007 with the introduction of first decision making paradigms employed by those group of 12 ECPs in a proof of concept phase. experiencing health emergencies. In 2008 a second course was conducted for a further 5 positions as a regional proof of concept Findings in the Mid North coast of NSW and 5 relief Adjusted to population sizes, rural people have a positions. There are now 58 ECP's in NSW. lower usage of ambulance in serious medical emergencies than their urban counterparts. Methods Literature suggests that the choice may be due to The primary measurable outcome was non differences in the way rural people view transport rate. Other measurable outcomes emergencies and unscheduled events, and their included patient outcomes, patient satisfaction connection to their community. Rural people tend and external evaluation of cost effectiveness. to have a higher degree of self-determination. All patients left at home were followed attempted Their problem solving approaches appear to be to be followed up, this had received ethics more aligned to operating in situations with lower approval. Questions assessed patient satisfaction; levels of external assistance and they are more follow up care and any re-presentation to likely to be action-oriented. The review indicated ambulance or hospital. that rural populations have a strong sense of being "appropriate users" of ambulance and that Results they may have a very high standard of what As of April 2011, ECP's had responded to 37,000 constitutes "appropriate". It was also found that cases of all priority types. More than 17,000 of many rural people have a low level of interaction these cases requiring no further ambulance with ambulance and a poor understanding of the resources. capacity of ambulance services to assist in health emergencies. Non-transport rates ranged from 38% to 60%, compared with 22% by standard care vehicles Conclusions A "very satisfied" response was recorded 97% of Rural people who experience health emergencies call backs. make decisions about service access based on a wide range of experiential, cultural and other ED transport avoidance saved an average of $308 factors. This may impact upon the likelihood of per patient with additional savings for the wider some rural residents utilising ambulance services health system. at times of serious health emergencies. Conclusions The ECP program in NSW has been demonstrated to be cost effective, safe and have favourable clinical outcomes. It has a high rate of patient satisfaction and contributes to the

Oxygen for the emergency treatment of acute coronary syndromes - A benefit more presumed than proven Suzanne R Davies1 and Paul M Middleton1 1Ambulance Research Institute, Ambulance Service of NSW, Sydney, NSW, Australia 2Ambulance Research Institute, Ambulance Service of NSW, Sydney, NSW, Australia Objective In 2009, over 90,000 Australians were either hospitalised or died from an acute coronary syndrome (ACS), at a cost of $18 billion dollars to the economy. Early, evidence-based emergency care of these patients is critical; approximately one third of deaths will occur in the first hour, one half in the first day. Current prehospital care for patients with suspected ACS aims to maximise the delivery of oxygenated haemoglobin to the myocardium and to slow the pathological process. Treatment consists of salicylic acid, nitrate, morphine and high-flow supplemental oxygen.

Methods The authors undertook a review of the literature, to describe and evaluate the current evidence for the routine use of high-flow oxygen in the prehospital management of patients with an ACS. Current international and national prehospital practices and guidelines were also examined.

Result No robust evidence for the routine use of untitrated supplemental oxygen in the emergency management of patients with an ACS was identified. The ubiquitous use of supplemental oxygen for ACS has instead been based on two biologically plausible assumptions: (1) that increasing the concentration of oxygen in the blood will also increase the delivery of oxygen to ischaemic myocardium, and (2) that a high concentration of oxygen in the blood (hyperoxia) has no harmful effects. Neither assumption has been supported by clinical evidence.

Conclusion There is insufficient evidence to support the routine use of oxygen in the treatment of the normoxic patient suffering an ACS. The use of oxygen for these patients may increase the possibility of an acute myocardial infarct, increase infarct size and possibly increase the risk of mortality. There is a widespread and urgent call for adequately powered, randomised controlled trials investigating the early use of oxygen therapy in ACS, measuring important clinical outcomes and performed in the context of widespread use of reperfusion techniques.