SECAmb NEWS ISSUE 1 www.SECAmb.nhs.uk

OLYMPIC TORCH RELAY Read more on page 14 SECAmb NEWS FIRST EDITION - AUGUST 2012 OLYMPIC SPECIAL ✚ IN THE SPOTLIGHT WITH PAUL MANNING ✚ MAKE READY EDITORIAL CONTENTS CONTENTS EDITORIAL 14 CONTRIBUTORS Welcome to the first edition of the new staff magazine which will

Editor: Liz Spiers be brought to you every other month.

Assistant editor and writer: Clare Dyson It’s been a hectic few months bringing the magazine together,

Administrator: Gerda Murdoch planning and deciding its content, look and feel.

Reflections: Dave Wells We wanted to bring to you a magazine which not only provided

Journal Scan editor: Dr Jane Pateman interesting articles but also provoked discussion and debate. 9 Liz Spires 16 Photographer: Peter Cripps This is why there will be regular features such as the journal scan

Editorial Board: which will both support staff’s continual professional development and also encourage Cover image: CTL, Paul Everest and Nicola Brooks, Andy Collen, Barbara Tree, Matt debate on relevant topics within the emergency care field. Paramedic Practitioner, Jeannette Yeoell. England, Dave Wells, Warwick Avery, Craig Mortimer CONTENTS Photographer: Peter Cripps We will also bring to you peer reviewed articles written by our staff and, for the first time, SECAmb NEWS ISSUE 1 Readers’ Focus Group: be incorporating Reflections within the staff magazine which will be linked to a dedicated Mark Gregson, Sarah Wood, Phil Hamerton, Chris Blewett, Edward Jones, Karen Ramnauth, Roy section on the Staff Zone (www.secamb.nhs.uk/staff_zone/news/reflections.aspx) with NEWS & VIEWS REFLECTIONS FEATURES Nightingale, Jeffrey Overton, Nigel Sweet, Angela other Reflection articles for you to read. Rayner, Ellen Lawson, Hannah Rothstein, Mark With clinical audit such an important tool in ensuring that we are doing the very best by 3 Editorial 18 Case Study 12 Preparing for the Olympics Lamble, William Bellamy, Loraine Hurley, Jill MacKman our patients, every edition will feature information about up and coming audits as well as Awards Asthma Our Torch Carriers their findings. 4 News 19 Case Study Deployed to the Games Cat A Performance Non Conveyance Risk 16 Why HART? We also hope to bring you informative, in-depth features about Trust business as well as career features on individuals who work for the Trust. Changes to Cat A target 20 Case Study HART West Goes Live National Awards for Staff Girl’s Bravery Recognised Serving Best Interests 24 Test Your Knowledge But remember, this is your magazine, so if you have any suggestions about how we can of Patients Asthma make it even better, then I would be only too happy to hear from you. 6 In Focus 21 Case Study Letters, Board Highlights, Diary 25 Peer Review Have you got a great feature idea or have you been involved in an incident which other Hypothermic Risks Patient Assessment: 7 Reference staff could benefit from through a reflective article? And remember they don’t always 22 Case Study a reflective case study Journal Scan have to be about the bad jobs! Back Injury 26 Career Focus 8 Feature Analysis If you would like to get in touch, email me at [email protected]. 23 Case Study Paul Manning Interview Make Ready Review Diabetic Risks 27 How To Guide Enjoy! 9 Clinical Analysis Reflective Writing Clinical Audit 11 Feature Analysis Staff Survey

CONTACTING SECAmb NEWS Telephone: 07554 438376 Email: [email protected]

2 SECAmb NEWS ✚ ISSUE 1 3 NEWS & ANALYSIS NEWS NEWS & ANALYSIS Of the calls received, 264,500 were Category A calls and 424,200 were Surprised at having received the award, Darren Trust Reaches More Life- Category C calls. said: “They thought I’d done a fair bit, but I just think of it as me really.You’ve got to push However, a significant number of calls are now being handled more yourself.” Threatened Patients appropriately, with 26,100 calls in 2011/12 receiving telephone advice, Meanwhile Dave Fletcher was one of only five The Trust has again performed well against national performance stand- compared to 9,200 the previous year. ambulance personnel to receive the Queen’s ards, reaching more life-threatened patients than ever before. Chief Executive, Paul Sutton, said: “We realise that response time Medal. This medal, along with his AACE award, performance is only one dimension of performance and needs to be SECAmb was the second best performing ambulance trust nationally, both reflect his pioneering work around Pro- seen against clinical outcomes but it remains key to patient experience. From left to right, Dave Fletcher and Darren Foskett reaching 77.6 per cent of Category A calls within 8 minutes during tocol C, the resuscitation technique based on Therefore, it is still one of our key performance measures and so is an 2011/12. Only North East Ambulance Service did better, reaching 77.9 compressions only CPR, trialled by SECAmb. per cent within 8 minutes. outstanding achievement which outlines the excellent care patients in our region receive. With the introduction of NHS Pathways last year and Executive. Working alongside Consultant Cardiologist, The Trust also did well against the Cat A 19-minute standard, with 98.1 National Awards the recent announcement that we are the preferred bidder for the new Darren was recognised for his professional Professor Douglas Chamberlain – who per cent of patients requiring a transporting ambulance, receiving one NHS 111 service in our region, I’m confident that we have a sound foun- achievements which include re-writing the was instrumental in Protocol C – Dave has within 19 minutes. SECAmb was the third best performing Trust behind The year has seen two members of staff win dation to improve the service we provide even more in the future.” Bronze Commander course now used across helped support a dramatic increase in the only London and again, North East. prestigious national awards. the country. resuscitation survival rates across our region. Find out more: the performance of ambulance trusts for Darren Foskett and Dave Fletcher both The performance is testament to the hard work and commitment of Dave, who has now retired, said: “I’d like to 2011/12 and previous years is available to download at scooped awards for ‘outstanding service’ from He was also noted for his personal staff as the numbers of emergency calls continue to increase. Last year, pass on my thanks to everyone I’ve worked http://bit.ly/M9WkYT. the Association of Ambulance Chief Executives determination after being diagnosed with a the Trust received 688,700 calls compared to 653,900 the previous year. with at SECAmb and pay tribute to Professor (AACE), with Dave also receiving the Queen’s tumour on his left lung in December 2010. Chamberlain who has been a real inspiration Ambulance Service Medal. Undeterred by this potentially life-changing to me. The real award and privilege for me of For RED 1 calls, the clock start time remains the more 999 calls are being dealt with through It was the first time the AACE held national event, Darren returned to work just a few course is to read report after report of the lives Changes to same, but the target has increased from 75 per Hear and Treat. awards for outstanding service, with weeks after his operation to continue in his SECAmb staff have saved. One can ask of no cent to 80 per cent. In the letter to ambulance Head of Operational Planning, Rob Mason said: nominations received from each trust’s Chief team leader duties. more from any career!” Cat A Target chiefs, Director of Performance, Alan Hall, said: “These changes will help us focus on the most “This will ensure that patients who require serious life critical emergencies first, buying us The Department of Health recently wrote to emergency ambulance care will continue to a little time to determine the most appropriate ambulance chiefs in England calling on them to receive the most rapid response.” response for the remainder. provide trajectories for achieving 80 per cent of Make Ready has been shortlisted in the However for RED 2 calls, a new clock start “We are already seeing more patients being SECAmb joins Carbon RED 1 calls within 8 minutes from April 2013. Efficiency in Estates category and UHU in the time has been introduced to allow for a cared for over the phone or face-to-face with NEWS IN BRIEF Management Programme In June this year, the Department of Health more appropriate ambulance response to be Workforce Efficiency category. Paramedic Practitioners, and this is freeing up THE Trust is one of 24 public sector introduced changes in the way Category A calls considered based on the patient’s clinical need. Trust gets tweeting more time for crews to be available to respond Winners will be announced at an awards organisations taking action to reduce its should be handled. Category A calls were split You can now keep up-to-date with what’s For such calls, the clock will start when the to the most serious cases. It’s early days, but dinner on Tuesday, 25 September. carbon footprint and aiming to cut 25 per cent into two parts, RED 1 and RED 2, with the most happening in the Trust through Twitter. location and chief complaint or primary reason the changes seem to be having the desired off its energy bill over the next five years. critical patients being classed as RED 1. has been identified. effect.” Followers to our public account via 24/7 Paramedic Practitioner Taking part in the programme should result @SECAmbulance, are now enjoying Olympic Desk for all SECAmb EOCs Alongside these changes, the Department of The measures introduced in June this year are To find out more about the changes in large savings in terms of both money and updates to job vacancies tweets. And this Health also made changes to when the clock already having an impact. The Trust is seeing an go to: http://bit.ly/Mn2yTx. until March 2013. carbon for the Trust. starts for some RED emergencies. average of about 15 RED 1 calls per day and August we will be launching an internal A Paramedic Practitioner Desk is now twitter account. Available only to staff, it will Over the next 10 months we will be building available across the Trust, day and night, a framework to enable us to manage our be an extra way to let you know about all kind 24/7 until March 2013. of matters: alerts to changes in medicines, resources more efficiently and make these alerts to new instructions, REAP news, dates of To support operational staff, Paramedic savings. For more information, please contact Young Girl’s Bravery Recognised award ceremonies - anything that we think we Practitioners (PP) will be on hand in all SECAmb Environment Manager, Julia Brown: will be of use to you. Sign up at three EOCs. [email protected] Emergency call operator, Penny Schofield, presented a young girl with a @SECAmbstaff. Available over the phone, they can provide very special certificate at a school assembly recently. New Chairman for AACE Tweets won’t replace other forms of communication assistance to crews wanting advice on CHIEF Executive of West Midlands Ambulance Five-year-old Ellie Janes was presented with the certificate and gift at her but be another way to support it. whether a patient can be treated at home, or school in Pembury, Kent, after she made a 999 call for her mum, Nikki, whether onward referral is the better option. Service NHS Trust, Anthony Marsh, is the new who had suffered an allergic reaction having eaten a strawberry. SECAmb shortlisted twice in The PP desk can also be contacted if staff chairman of the Association of Ambulance Chief Executives. Penny said: “I remember Ellie was very calm and gave her address clearly HSJ Efficiency Awards would like assistance from another clinician in which is of course very important. Her mum should be very proud as THE Trust has been shortlisted twice for two their decision making process or simply to talk He took over the role from Peter Bradley, should Ellie. She was very brave.” national awards. through a decision made. Chief Executive of London Ambulance Service, on Wednesday, 1 August 2012, for a three- Her mother, Miss Janes, said: “I was really proud. I was really pleased for Make Ready and the Unit Hour Utilisation Call 0300 123 1833 (option 1). If the line is year term. her and happy she got the recognition she deserved. It was her moment (UHU) model have both been shortlisted for busy, leave your number and you will receive and she did it all, she deserved all the attention.” the HSJ Efficiency Awards. a call back.

4 SECAmb NEWS ✚ ISSUE 1 5 NEWS & ANALYSIS

NEWS & ANALYSIS IN FOCUS JOURNAL REVIEW

elcome to the first journal scan for SECAmb News. Letters Page Diary WThis article is provided by the Paramedic Science team at We are keen to share your opinions and views about the articles University of Greenwich. which feature in this magazine. Therefore, we very much Continued Professional Development Day – The one-day course is welcome your contributions but would ask that to be considered Medical 1, covering allergy, ECG and asthma. This is open to ECSWs The scan of journal features a summary of articles which are relevant to for publication, letters should be about the articles which have Wednesday, 22 August, Banstead emergency care. While some of these articles will be more applicable to appeared in previous editions and not general Trust business. Further details: Leane Stephens practice than others, they are primarily to provoke discussion and debate. While we will do our best to reproduce letters in their entirety, the editor reserves the right to edit the letters as necessary. Egham Royal Show – We’re sharing a stall with the Retirement We are interested in your views You can send your letters to [email protected] or Association at this busy event and will be recruiting public FT members and thoughts on these topics so write to Lewes Office, Friars Walk, Lewes, BN7 2XW. Saturday and Sunday, 25 and 26 August, Egham Further details: Isobel Allen why not write to the letters page were extracted that could easily be identified by the 9-1-1 [email protected] caller. Using various permutations of these RTC characteristics, a Chief Executive, Paul Sutton’s Continued Professional Development Day – The one-day course dispatch rule was developed to determine when an ambulance covers ECG and cardiac care. This is open to technicians Highlights to the Trust Board should respond to an RTC without lights and sirens: Tuesday, 28 August, Banstead Treating envenomation caused by fish sting In each edition we will feature snippets from Paul’s Further details: Leane Stephens Highlight Report to the public Trust Board meetings. You The review looks at the treatment which should be provided to those (1) the RTC does not occur on an interstate/highway (motorway or can view the full report in the Trust Board papers. stung by weever fish. The lesser weever fish is found around the dual carriageway), (2) the RTC involves more than one car. AND (3) Continued Professional Development Day – This one-day course coastline of the UK, particularly in the south and west of England. all patients are walking. They found this was 95.9% sensitive and A Regional Handover Policy has been agreed and circulated to all covers patient assessment. Open to paramedics and technicians. acute trusts, lead commissioners and Strategic Health Authority in our The spines on the fish’s first dorsal fin and gill covers release a poison 33.5% specific for patients who met trauma centre criteria, and region. It looks to introduce the dual handover button pressing. The Wednesday, 29 August, Banstead that can cause excruciating pain in anyone who stands on them. 97.7% sensitive and 32.5% specific for patients who required trauma implementation plans still need to be agreed with each acute trust, Further details: Leane Stephens Emergency staff should be aware, therefore, of the symptoms of lesser centre resources, i.e. it included almost all that needed transfer to with a phased implementation period is aimed to be fully rolled-out weever fish stings in patients who present with severe pain in the foot. an MTC but also many that did not, after on-scene assessment. from Quarter three 2012. The policy also outlines the escalation process Continued Professional Development Day – This one-day course Immersion of the foot in hot water is the most effective treatment. between the hospitals and SECAmb to minimise delays and improve covers trauma and medical scenarios. Open to all clinical grades. The applicability of the same criteria to the UK is of debate, patient care and experience. This will be implemented from July 2012. Friday, 31 August, Paddock Wood Make Ready Centre David Emerson (2012) Treating envenomation caused there is often a high degree of uncertainty about the quality of The contract for the Kent-wide PTS service from April 2013 Further details: Leane Stephens by fish sting Emergency Nurse 20, 3, 28-29 information received by passers-by in UK practice, and unlike the onwards, has opened for tender. SECAmb has successfully passed the US, English A and B roads have a higher degree of serious RTCs. first stage in the process, and will be submitting its tender proposal in Continued Professional Development Day – This one-day course D Isenberg1, D C Cone2, I G Stiell3 (2011) A simple three- August 2012. The outcome should be announced in October 2012. A simple three-step dispatch rule may covers resuscitation. Open to all clinical grades. step dispatch rule may reduce lights and sirens responses SECAmb visit US during July. A team of six visited three centres of reduce lights and sirens responses Tuesday, 4 September, Galleon House to motor vehicle crashes Emergency Medicine Journal excellence in pre-hospital care in the USA – the Maryland Institute Further details: Leane Stephens to motor vehicle crashes for Emergency Medical Services in Baltimore, Richmond Ambulance 2012;29:592-595 doi:10.1136/emermed-2011-200133 Authority in Virginia and MedStar Ambulance Services in Texas. The Lights and sirens have been shown to reduce response times minimally Trust’s Annual General Meeting – Displays about our work and aim of the trip was to learn more about high performance systems, in North America, but the rate of injuries among pre-hospital workers updates from Paul Sutton on what the Trust has accomplished this year. efficiencies as well as clinical treatment for trauma and cardiac arrest. is nearly 15 times higher among ambulances operating on lights and Paramedics’ ‘end of life’ decision Come along and meet members of the public and governors. Research and Development work continued to advance a sirens than those without. This study was to try to identify cases where making in palliative emergencies. Friday, 28 September, Venue to be confirmed number of research projects with a very successful research day a routine response was actually more appropriate. It was based on Further details: Isobel Allen This study was undertaken to determine paramedics’ understanding of and the continued recruitment of patients to the Atlantic trial. The the assumption that any patient who did not need transfer to a major their role in withholding or withdrawing resuscitation/EoL-treatment proposed large scale study of the use of oxygen in myocardial trauma centre (MTC), would have been appropriate for a routine infarction passed another stage of the path for funding. PRIDE 2012 – Join us in Brighton for the Pride Parade. A fun day out, all of palliative care patients when an advance directive is present. response, rather than lights and sirens, and so looked at predictors welcome regardless of sexuality. Delays in the LUCAS project have been resolved and the project of the need for transfer to an MTC based on the call information. Paramedics in Germany routinely treat palliative care patients at is now hoping to recruit patients in July, with St Peter’s, St Saturday, 1 September, Brighton the end-of-life (EoL). For this, they play a legally significant role Data was extracted from patient care reports (PCRs) of patients George’s and Ashford hospitals collaborating; it is hoped that Further details: Angela Rayner in EoL decision making in the outpatient emergency setting. Brighton will join later. Further discussion took place in respect transported by ambulance to a level I trauma centre (MTC equivalent) of introducing hypothermia using the RhinoChill device - this Please note that there are other CPD days running throughout September between July 2007 and 2008 with injuries sustained in RTCs. Christoph Wiese - Journal of Paramedic Practice, project is a joint collaboration with London Ambulance Service. and should you require further details, please contact Leane Stephens. Vol. 4, Iss. 7, 04 Jul 2012, pp 413 - 419 509 patients were included in the analysis. Five characteristics

6 SECAmb NEWS ✚ ISSUE 1 7 NEWS & ANALYSIS Establishing whether central reporting leads to improved performance the buildings themselves received little criticism, morale was low. was harder to measure as there are so many influences on performance. Linda said: “Feedback, through staff interviews and questionnaires, At the time of analysing data for the review, after an initial dip in suggested that the majority of staff supported Make Ready but the performance when the centres opened, the response time performance most notably negative comments were about the atmosphere of NEWS & ANALYSIS MAKE READY REVIEW had not significantly changed. Year to date figures compared to the the centres, the parking facilities at Paddock Wood and the quality same period the previous year showed an improving picture. However, of a number of the ambulance community response posts.” the number of Category A responses had increased by nearly 50 per The review found that the impact on staff has been significant and cent with no additional resource being put into the system other than one of the key challenges faced has been around business change, for the release of resources brought about by the Make Ready system. example changing roles and functions within the new Make Ready Linda said: “Staggered shift start and finish times help to improve System as well as understanding the impact of policies and procedures performance but at the time of the review these had not yet been on those working out of a central reporting Make Ready Centre. put in place at Paddock Wood. What we did find is that the balance Linda said: “Better understanding of the impact of business change in performance between urban and rural areas has improved.” would have ironed out a lot of the issues faced by staff, particularly the However, the report does highlight the impact of external huge change of culture moving from a familiar ambulance station into factors which cannot be underestimated. a huge Make Ready Centre and then being out at response posts.”

Linda said: “It is difficult to unpick the impacts the move to a With the review completed, a group has been set up to central reporting Make Ready combined with the opening of implement actions to iron out the issues highlighted at Paddock the new Tunbridge Wells Hospital at Pembury has had overall. Wood and Ashford as well as to ensure that the approach to Some impacts on transports and handovers at Pembury are implementing the next Make Ready Centres is different. clear but have been managed well, not least thanks to the Engagement work has already begun with a business case workshop efforts and commitment of crews working in that area.” for the development of the Brighton Make Ready Centre, held last Despite there being a one per cent reduction in the number of month. Further staff and stakeholder engagement events are set patients taken to hospitals run by the Maidstone and Tunbridge to take place soon for Brighton, Polegate and Tongham. Rotas Wells Acute Trust, there was an 18 per cent (the equivalent of for Brighton Dispatch Desk are already being looked at and all Linda Wood one ambulance lost to the system per day in each area) increase future ambulance community response posts will be signed off in turnaround delays during January and February 2012. by Clinical Operations before they become operational. It was three months in the the Make Ready function and the operational change to As part of this review, mileage was also considered. It found that, while Chief Executive, Paul Sutton, said: “This was a very comprehensive review central reporting needed to be measurable - where there was some crews have experienced significant increases in their shift mileage, and I’m satisfied that the findings justify the Trust’s position to continue undertaking but now the Make evidence of before and after the system being in place.” there was no evidence to suggest there was an overall increase in with its plans to develop further Make Ready Centres across the region. the average number of miles per response. Fuel taken from pumps at Ready Review is complete, Liz As a result, in looking at whether benefits were realised, “I’m also pleased to see that the report has recognised Paddock Wood and Ashford has also fallen from 838 litres in November the review focused on five key elements: that in future centres greater importance will be placed on Spiers met with Linda Wood, who 2011 to 696 litres year to date (time of the report being compiled). Category Element ensuring that the central reporting model will be adapted to led the review, to find out more. Asset Critical failures for vehicles and equipment A key aspect of the review also looked at the impact central reporting take account of varying and local needs and that more effort had on staff. As a result, the review sought the opinions of staff about will be taken to engage staff early on in the process.” Following the development of the Trust’s first central reporting Performance the move to central reporting. It found that while the structure of Make Ready Centres in Ashford and Paddock Wood, the Clinical Infection control & response times Trust Board requested a review earlier this year. Performance Economic Unit hour utilisation, lost unit hours, fleet & Service Developments Programme Manager, Linda Wood, said: “It Performance stock costs, logistics, estate costs was a huge but worthwhile exercise and I’m confident that this Staff Impact Premises and Facilities, Culture and process will ensure that we learn lessons moving forward.” Management, Morale and Communications, Vacancies, Sickness The report, accepted by the Board recently, found that the concept Environmental BREEAM standard and carbon footprint of Make Ready works and is widely supported, but also found that Impact there are issues with central reporting which need to be addressed. Linda said: “The evidence showed that fundamentally, there The Review specifically looked at the operational effectiveness is nothing wrong with the concept of Make Ready. of the two centres. This included whether the centres delivered the services they set out to, and whether the benefits of Make “It provides staff with a clean and fully stocked ambulance or car. Ready detailed in the business cases were realised. Evidence shows that it reduces vehicle and equipment failure rates, improves the cleanliness of vehicles and reduces stock wastage.” Linda said: “In undertaking this review, the success of both

8 SECAmb NEWS ✚ ISSUE 1 9 NEWS & ANALYSIS AN INTRODUCTION

NEWS & ANALYSIS TO CLINICAL AUDIT STAFF SURVEY Measuring our clinical performance is vital The Trust is looking to take a new approach if we want to ensure world class outcomes for our patients. to tackling the issues brought to attention SECAmb has a team dedicated to undertaking clinical audit to enable Post Return of Spontaneous Circulation Care audit: from the staff survey. the Trust to monitor and review its standards of clinical care, using a Clinical Audit Lead: Andy Hitt, Critical Care Paramedic. consistent and well-grounded methodology. The findings are used to Specialist Group: Jez Loseby, Critical Care Paramedic. The 2011 staff survey again showed that more aspects – all of which link to organisational develop new standards, take account of new clinical interventions as they Hydrocortisone audit: work needs to be done in key areas to improve development and a key reason for Pam Fricker’s are introduced and, most importantly, stimulate improvements in the Clinical Audit Lead: Adam Ormrod, Critical Care Paramedic. the way we do things in SECAmb to support involvement in taking this agenda forward. quality of patient care and outcomes. IV paracetamol audit: staff in their working environment. There are three key themes that Pam and Of course the key tool that helps us to report on how well we deliver Clinical Audit Lead: Michael Carter, Critical Care Paramedic. Taking on the challenge to address some of the colleagues in other ambulance trusts are clinical care to patients is the information entered on to the patient’s Specialist Group: Richard Simmons, Paramedic Practitioner. key issues is the Trust’s Head of Learning and looking at: clinical record. If it’s not written down we have no choice but to report Alcohol re-audit: Clinical Audit Lead: Andrea McLean, Clinical Team Development, Pam Fricker. Leadership – This involves working with senior that it didn’t happen. We need staff to be as thorough as possible in Leader. capturing the care they give to patients otherwise it’s really difficult to She said: “There was genuine disappointment managers to develop better communications Specialist Group: Lisa Masey, Paramedic. evidence good, and continually improving, treatment. that the results of the staff survey were no between managers and staff so that everyone is Amiodarone re-audit: Clinical Audit Lead: Luke Wheeler, Paramedic. better and in some cases worse than they were clear about the organisation’s goals and objectives. We have two programmes of work that enable us to do this and what compared to the previous year. Values - Staff feeling valued and made to feel and how we audit is described below: In the next publication, we will be sharing Michael Carter’s experience “However, during 2011, we went through the they are taken seriously. of being the clinical lead into an audit on the use of IV paracetamol. Michael will explain how the exercise and findings may inform changes workforce review and some of the training Staff involvement – Not only staff feeling Clinical Audit Plan or improvements in the pain relief given to patients, as well as what he that should have taken place was delayed. It is listened to but being actively involved in Each year an annual plan of audit topics is compiled, chosen from a learnt as part of his own professional development in the process. We underway now, so hopefully things will begin to the decision making process; using their variety of sources including reviewing National Institute for Clinical will also be introducing you to the team behind clinical audits. improve. That’s not to say there isn’t more that skills, knowledge and expertise to shape the Pam Fricker Excellence (NICE), National Service Frameworks (NSFs), local priorities and needs to be done.” organisation. risks, and staff suggestions. Moving forwards we will also be engaging working practices and procedures. Clinical Indicators In previous years, action plans have been drawn Pam said: “The majority of ambulance trusts have with patients, the public and colleagues in the wider health economy. up and efforts to tackle individual elements While not within Pam’s remit, it is also hoped The Trust’s clinical audit programme also includes the collating and performed poorly in these three areas. There are arising from the results have been the focus. that the Trust’s Inclusion Strategy and the newly Each audit has a registered clinician as the lead who steers the audit reporting on national performance audits which all ambulance trusts in some high flyers and so through the national This year the Trust is looking at broad themes. shaped Foundation Council will also assist as and sets the primary aims and standards against which the audit will be England have to submit data for. work we will also be looking at best practice. this will start to address issues regarding staff carried out. Pam said: “We know that nationally ambulance These are the Clinical Outcome Indicators (COIs) introduced by the “However, there are already quite a few things involvement and engagement. trusts do not perform well in the NHS staff On occasion, a specialist group can also be set up to ensure the Department of Health after the Category B response standard was happening within SECAmb that will hopefully survey, and we have met with London To assist in improving engagement at a local level, broadest and deepest knowledge and scrutiny of the topic in question. abolished last year: address some of these issues. Recommendations and/or lessons learned from the audits are taken back Ambulance Service to look at this in more detail some training around communications skills will “From the autumn onwards, we will start to through the organisation for implementation through joint working at • Outcome from cardiac arrest - ROSC and consider the key themes on a national level.” be provided to line managers in the autumn. look more closely at what it means to work in senior management level. • Outcomes from Acute ST-elevation myocardial infarction (STEMI) Pam said: “This will be a good start but we Outcome from cardiac arrest - STD Chief Executive of London Ambulance Service, SECAmb by holding a number of pilot events. • will also need to be really looking at what is Audit topics for 2012-2013 are: Outcomes from Stroke for Ambulance Patients Peter Bradley, has voiced concerns about the These will involve working with staff to see • happening at a local level. It’s not just about Transportation in cardiac arrest: lack of significant improvement in the results of where the organisation has come from, where it and Clinical Performance Indicators (CPIs) which are submitted nationally providing more training; it is about being able Clinical Audit Lead: Dave Hawkins, Critical Care Paramedic. the staff survey and has asked for resources to is going, the key milestones and challenges, and twice a year to benchmark ambulance trusts on other priority conditions, to put things into practice, and developing Specialist Group: Danny Dixon, Technician, Sean Chapman; Technician. look at this. looking at what it means to work in SECAmb and to drive forward improvement programmes in those areas. skills on a day to day basis through feedback, Care provided by voluntary and private ambulance services The hope is that Pam’s work on a national level to achieve those milestones and rise to those Hypoglycaemia coaching and experience. Clinical Audit Lead: Craig Dickenson, Paramedic. • will help to shape a strategy to improve things challenges.” Asthma Major Trauma Decision Tree audit: • for all ambulance trusts, as well as for SECAmb. “I really hope that with this work and some Febrile convulsion (pilot in 2012) Some of the L&D Organisational Development Clinical Audit Lead: Adam Heywood; Critical Care Paramedic. • of the specific things which have taken Trauma (pilot in 2012) One key area that the staff survey focuses on team are also doing diagnostic work. They are Specialist Group: Luke Wheeler, Paramedic. • place around training already, we will see an is learning and development, in particular shadowing a number of staff within a range of Outcomes and performance from the clinical audit plans and indicator improvement in next year’s survey.” Airway Management audit: relevant training and career progression. Staff roles at Paddock Wood Make Ready Centre. The Clinical Audit Lead: Dave Hawkins; Critical Care Paramedic. reporting will be shared in future publications. Anyone with an interest in involvement and engagement, and wanting to aim is to see what works and doesn’t in areas To view the Trust’s full staff survey results for any of the indicators is encouraged to approach the clinical audit team to Specialist Group: John Bayliss, Paramedic. 2011 visit: http://bit.ly/OcvECv find out how to become involved in driving improvement in these areas. work within the organisation are also important such as communications between staff, and

10 SECAmb NEWS ✚ ISSUE 1 11 IT’S ALL IN THE FEATURE

FEATURE PREPARATION

100 days before the Olympic Games began, SECAmb staff, along with the London Ambulance Service and LOCOG (official organisers of the Games), held a conference at a windy, deserted football stadium in Crawley. Amongst complex flow charts and PowerPoint presentations, we asked SECAmb staff if they felt prepared for the games; ‘As much as we can be, knowing what we know…’ was the general response. This is, of course, much of the principle on which SECAmb operates on a regular basis, as it deals with public events and the general unpredictability of life. There is always the unknown. The difference with the Olympics is the scale of the unknown - visitor numbers, operational disruption and potential terrorism being the major considerations. Alongside this, there’s the considerable pressure of the eyes of the world being upon us. Consequently, planning was taken to an entirely new level, with an Olympics working group in place at SECAmb since 2009.

Most preparation was for the events that crossed our area: the Torch Relay, the men’s and women’s Road Cycling Race, and the Time Trial. In many ways, these events were harder to prepare for than the Jon Amos Peter Radoux stadium ones, particularly considering that the stadiums were built over a seven-year period when there was just a seven-hour leeway Throughout the Games, the control hub in London will communicate to set up for the cycling events. Then there’s the disruption they “Usually you have to have a margin of chance where you trust the past at 50k an hour and between 600,000 and 1.2 million spectators with SECAmb through a similar hub of our own - Mission Control - based bring to a local area; the impact on operations and the security risk. knowledge and experience of the emergency services to handle watching them go by. We had to create access points along the route, in our Banstead office. Staffed with a representative from emergency Not forgetting additional potential factors of sunny day spectators a situation well - otherwise you’d spend 24/7 in meetings.” and plan alternative routes. The Road Race covers a big area - I did one lap of it in the car and was worn out.” Peter Radoux said. resilience, communications, an administrator, and a senior manager,“ getting dehydrated in the sun whilst drinking too much. New Year’s Eve, the World Cup, as well as the Olympics in Sydney It’s a single point of access for us, helping with the flow of information,’ and Vancouver were all used as planning models. And last summer During the cycling events, Peter was sat in the Olympics control room For the average, non-Olympic event, responsible parties – police, explains Jon. ‘And if anything major does happen, we’ll be able to a dry run of the Road Cycling Race was held. Senior Operations in London, in close proximity of all the other emergency services local authorities, event planners – meet up around a table and come take the external pressure, taking the heat off staff on the ground.” up with a plan. When it comes to Olympic preparation, there’s an Manager, Peter Radoux, oversaw the operational aspect of the representatives. This was to ensure that information was easily shared Hopefully they won’t have to. So far, all has gone according to plan - average of 30 to 40 meetings with external partners a month. cycling events. His main objective was to ensure that our regular with strategic decisions quickly made. The dry run highlighted how service ran as normally as possible – the area of Surrey that the Road useful this was when a fire started just before the race. “Normally during the men’s Road Cycle Race, approximately 70 calls were handled “The level of detail was intense – fine points were escalated up to Races go through gets an average of 60 to 70 999 calls a day. we wouldn’t know about this at the same time as the fire service. well by SECAmb and St John Ambulance. With the majority of the cabinet meetings,” said Contingency Planning Manager, Jon Amos, But being immediately aware means we know how we might be Games yet to happen, the only safe thing to predict is that the Olympic “We weren’t worried about the athletes, they’ve got their own medics, who has overseen the Olympics planning along with Dave Wells impacted,” said Peter. The increased contact with other agencies has stadiums will be a lot more packed than the one back in Crawley. and there’s St John Ambulance for the crowd - it’s about how we and others from Contingency Planning and Resilience Department. also given all involved a greater understanding of each other’s work. access the nursing home in an emergency when there are cyclists going

12 SECAmb NEWS ✚ ISSUE 1 13 CARRYING Deployed to FEATURE

FEATURE THE TORCH the Olympics

Due to their inspirational work, two Along with ambulance personnel Kieran Cambell Andrew Hartley of our staff along with one of our from across the country, 28 SECAmb

Community First Responders, had a staff will support the London Despite the expectations, and the fact that he will be spending day they’ll never forget when they took Ambulance Service (LAS) during five weeks away from home throughout the games, Kieran is more enthusiastic than nervous about the deployment. part in the Olympic Torch Relay. the Games. Here’s two of them: “Working and living alongside ambulance colleagues and visitors from Hastings Paramedic Practitioner, Jeannette Yeoell and Clinical Team Kieran Cambell around the world, in spectacular venues, will be a great experience. I’m Leader, Paul Everest, both carried the Torch through Bexhill on 17 July, Just one year after graduating as a paramedic, Kieran is taking part really looking forward to being part of the greatest show on earth!” while Horsham CFR, Andrew Clark, did his run in Weymouth on 13 July. in potentially the event of his career. All is going according to plan. * Anyone interested in learning more about Autonomic Dysreflexia can “It sounds a bit of a cliché, but ever since the winning bid was announced Jeannette was chosen for her heroic actions when in November 2009, she now access the Olympic e-learning packages at www.secamblive.nhs.uk in July 2007 it was an ambition of mine to be involved in the Olympics broke down the door of a burning house in St Leonard’s on Sea to rescue - it’s what gave me the kick-start to apply for my paramedic degree.” Andrew Hartley an elderly woman who had been badly burnt. It took two months after applying for the role to find out that he’d Usually based in the classroom as a Learning and Development Paul was selected for his dedication to share his love of judo with those been successful. Since then, Kieran’s put substantial training under Manager, Andrew Hartley will be spending the Olympics and Paralympics less able; he runs his own club, Westerleigh Judokwai, and for the last ten his belt; a week’s intensive classroom training with LAS, four days at period inside the Games park as a Venue Commander where he’ll years has been Team GB’s judo coach for people with special needs and Operation Amber in the Olympic Park and completion of an e-learning oversee SECAmb staff supporting the LOCOG medical teams. learning difficulties. package based around the games.* On top of this, he also spent five Paul Everest, Jeannette Yeoell, Andrew Clark “It’ll be a very different role from the day job, and that’s one of the Meanwhile, Andrew has volunteered for St John Ambulance for an days of operational work within central London as part of SECAmb’s reasons I volunteered,’ he says, ‘along with that, it’s a once in a lifetime impressive 25 years and spent two years as one of our CFRs. mutual aid deployment for the Queen’s Diamond Jubilee. experience and a good opportunity to work with colleagues from “I feel well prepped,” he says, “and I think the training ambulance trusts up and down the country. Already I’ve heard a lot Jeannette Yeoell Paul Everest Andrew Clark will continue to be useful throughout my career.” more about their services and they’ve been asking about ours – there’s During the Paralympics, there’s a high likelihood that clinicians will go to a strong interest in our Foundation Trust status and Protocol C.” I got my outfit and instructions by special It was unbelievable, phenomenal - words can’t I don’t think anyone would ever have expected to venues where there are several people with spinal cord injuries; athletes, It hasn’t been entirely new territory all the way though, with Andrew delivery a few weeks before, so I knew what describe it. I’d been watching it on the TV in the be nominated out of the thousands put forward so spectators and games workforce members. “So we learnt how to recognise spending a week in a classroom to prepare for his role, along with I was wearing on the day. But in every other lead up but it wasn’t until I did it that I had any just being selected was a fantastic feeling Autonomic Dysreflexia, a potentially life-threatening medical emergency several days on-site. He and other managers learnt about security respect, it was all a complete surprise. idea of what it would be like. I was stunned by Doing the run itself was incredible. People waved that occurs most often in spinal cord injured patients. This is not something issues, rules surrounding anti-doping, details of where the athletes the public response. I was met at the starting point by my colleagues flags and banners and the cheers kept on coming. we would be likely to have much day to day contact with normally, but will be treated if they have an emergency - essentially it was “all the Lisa and Nicole who’d managed to park the I had some initial nerves, but they soon There was one moment when someone came into the new knowledge is invaluable for this deployment.” explained Kieran. logistical things that we’ll need to know when we are up in London.” ambulance right at the point where most of my disappeared thanks to the crowd’s atmosphere. the cordon waving their own homemade torch, Meanwhile during the four days of Operation Amber, Kieran and SECAmb Along with Andrew, there will be two other SECAmb managers joining family were waiting. My dad had the best view People were calling my name, taking my photo, but they quickly got bumped out the way. colleagues joined other ambulance trusts in working with the LAS to LAS. Together they will act as the point of contact for the welfare and though, as I started right outside his flat. He and I spotted a dozen or so colleagues. I think I Back at the hotel it was more photos and practise how clinicians would be deployed into venues during Games time. operations of the other SECAmb staff – almost right round the clock. was sitting on the balcony so I gave him a wave missed a few which is a shame, but it all went people wanting my autograph. Looking back on “The aerial photos you see of the Olympic Park at Stratford “Life in the Olympic village is very long - there will be a fair few 22- and could see he was in tears. so quickly. it now that was quite bizarre... But it was great, make it look quite compact, but in reality it’s huge, with a hour day periods. Athletes can be warming up at 4.30 in the morning Then I was off. I’ll never forget being number Later on in the evening, I went to a restaurant everyone saying congratulations and well done. substantial road network around the perimeter.” and even before that, the security checks will be happening. And then 118 and receiving the torch from Eddie Izzard with friends where the torch got a lot of the TV coverage can keep us up – due to the time difference, getting Since then I’ve already done three school visits Kieran also recognises that he will be playing an ambassadorial role during who gave me three kisses! The crowd were interest. It’s now got a hectic line up of school events out at peak time in North America means a late night for us.” with the torch - some of the kids hold it up and the Games. As the other clinicians on site from LOCOG wear a generic amazing. By the end I had my arm right up trips and brownie packs. kiss it like a football trophy. It’s been a really LOCOG uniform, he and his colleagues will be the only uniformed medics Andrew joined PTS in 1994 where he stayed for one year before becoming in the air carrying the torch because I was so It was brilliant to also have the opportunity good opportunity to talk to the kids about why on site. “During Operation Amber we had people coming up to us having a technician, paramedic and then CTL. He’s now been teaching for six elated. It was a complete buzz! to raise awareness of the Judo club I work for, I was nominated, and what it means to be a walked past several doctors, nurses and first aiders because of our obviously years, a role he really enjoys and hasn’t looked back from. So it might be I have run several marathons in my time, but 300 Westerleigh Judokwai. In fact, the only thing I Community First Responder. recognisable uniform. Alongside requiring medical assistance, they were a change of scene going back to operational work but he says, “I think metres carrying the torch took my breath away. wish is that it could have gone on for longer! also interested in the ambulance service and the NHS as a whole.” it’s like riding a bike – it will all come flooding back to me,” he says.

14 SECAmb NEWS ✚ ISSUE 1 15 FEATURE

FEATURE HART

As the Trust’s second HART base goes live, Clare Dyson finds out more about this specialist team. Seven years ago, when paramedics tried to reach passengers injured in London’s 7/7 bombings, they were held back by the extreme conditions. Shortly after, the government called for all ambulance trusts in England and Wales to have ambulance staff that were trained and equipped to From left to right, Ian Stringer, Martin Warren enter situations that would otherwise be too dangerous – this is how HART came about. The basis on which HART was founded and GETTING THE GATWICK BASE READY From left to right, Ian Stringer(Para), Dan Shelverton(Tech), its name, the Hazardous Area Response Daryll Lonsdale(Team Leader), Martin Warren(Para), Ian Rooney(Para). The new base at Gatwick is a temporary one, although it will be in Team, clearly reflects the nature of work. use for at least two years. Managing to secure a site just five minutes But this doesn’t mean that HART deals with from the runway was a coup as the operational requirements headline incidents alone - the skills and A HART team’s strength in numbers can also be used to take the team leader on the day’s weather and wind directions. This will give are to respond to incidents at the airport in 30 minutes. equipment the teams have can support clinical operations on a daily basis. pressure off road crews in more day to day incidents. Dan Shelverton them the indications of how a smoke/chemical plume may develop. recalls a recent job where a lady with a broken leg had been on the The rest of the shift will either be spent on jobs, or in training. After securing the site, the next challenge was getting To find out more about what HART can and does do, we went along to floor in her bedroom all day. Daryll said: “Because of the nature it ready in time for the Olympics within a tight time the new base – HART West – situated just five minutes from the runway Before joining HART, paramedics undergo intensive training; a of her break and the surroundings, it was a very tricky extraction. scale – the legal details for the site were only finalised in at Gatwick. It opened on Monday 2, July and comes two years after HART two-day civil responders course, a two-week breathing apparatus Due to our equipment, and the number of us, we were able to get February, with the main contractors appointed in April. East went live in Ashford. Team Leade,r Daryll Lonsdale, explains, “Most course, a three-week incident response course on a military site, her downstairs without the crew having to do difficult lifting. Often trusts only have one HART team but because of our three main transport a three-week urban search and rescue course and a four-day “As it is a temporary base the fitting out of the site was more crews are in a position where they just have to cope, but we can give hubs; Gatwick, Dover Docks and the Channel Tunnel, we were required inland water operation course. Keeping this knowledge fresh is complex - additional project planning was required to ensure hands on help, sometimes simply by our strength in numbers.” to have two. And this one needed to be ready in time for the Olympics.” paramount. This may mean going to a nearby fire station to practise that the installations and equipment were both operationally All shifts start with the team seeing which vehicle they are assigned interdisciplinary skills, terrorist attack training at Gatwick, or going fit for purpose yet easily transferrable to the permanent base,” Along with Daryll were five other members of his HART team to. There are ten different types of HART vehicles, each housing a to a derelict nursing home to practise skills in the pitch black. explained Leonard Lewis, HART Project Manager for the job. on duty that day. One of the core features of HART is that it is different kit. The equipment – from cars to breathing apparatus – is not made up of teams of six; there are seven teams based at Gatwick. Water based skills are particularly important as SECAmb has so much The fitting out of the premises included significant changes quickly summarised, but essentially prepares them for many hazardous Brought together in their training, the teams may end up working coastline. The recent flooding saw the HART’s skills put to the test during to the electrical supply, creating a shower block, Breathing eventualities; breathing apparatus and safety gear to go into areas of side by side for the next ten years. Having strength in numbers is a 36-hour stint at Worthing when the teams from Ashford helped Apparatus (BA) maintenance and cleaning facilities, drainage smoke or chemical poisoning, equipment for working at height, ropes crucial as it gives them the human resource to tackle situations the fire and rescue service reach people in need of medical care. and waste. And ensuring that all IT was functioning well for for safety in water, and vehicles that can cross practically any terrain. of mass casualties – triaging is one of their strengths. both the base and the vehicles was, of course, crucial. Alongside the HART training, each team then spends every seventh The Polaris 6x6 is one vehicle that the team are keen to highlight. The Gatwick crew put this into action on their very first night, when week on the road to ensure their clinical skills stay fresh. It was a definite case of all hands on deck as David Dunton of “It can get over pretty much any terrain. If there’s a biking or horse called to a fire at a block of flats in Surrey. “Using our CO monitor, Avinny Consultant Engineers, the fit out contract administrator riding incident on the Downs for example, we’d be able to reach the It’s a big change for the team we met at Gatwick, who, we were able to quickly triage 13 patients, testing their carbon says. “There was a lot of good team work going and everyone patient without the need for an air ambulance, or having to carry apart from Daryll, were all new to HART. But so far, so good; monoxide levels. Four were sent to hospital but the others didn’t came together to achieve the Go-Live on 2 July; including the the patient in difficult circumstances,” explains Ian Stringer. “I’m enjoying having a new challenge, and it’s great to need to go. This meant we were able to stop nine ambulances coming project team consultants and contractors, HART, estates, IT, be working as part of a team,” says Martin Warren. out to take all the patients to hospital for testing,” says Daryll. After checking their assigned equipment, the team are briefed by the security, finance and senior management within SECAmb.”

16 SECAmb NEWS ✚ ISSUE 1 17 REFLECTIONS REFLECTIONS CASE STUDY: Welcome to the new look Reflections which will appear in every edition of the magazine. Alongside these articles you can review REFLECTIONS other reflection articles on a dedicated section of the Staff Zone (www.secamb.nhs.uk/staff_zone/news/reflections.aspx) NON - CONVEYANCE RISK We welcome your contributions to Reflections, turn to the ‘how to guide’ section page 27 of the magazine to find out more on how to write a reflective piece. A 40-year-old man was experiencing chest pains with associated • Where possible, carry out the primary observation at the patient’s sweating. Without his knowledge, his partner called for an location ambulance. CASE STUDY: ASTHMA ATTACK • Record all actions and observations that you do at the scene and A 17-year-old girl was enjoying New Year’s Eve celebrations rate on 14 upon the crew’s arrival, Salbutamol and Atrovent via oxygen A double technician crew attended the emergency. When explore all areas of referral with friends at a pub when she became unwell. An may have helped. they arrived they walked the patient down two flights of stairs If a patient is left at home, consideration must be made of a asthma sufferer and also anaphylaxis, she became short of to the ambulance to carry out an assessment. A basic set of • An incorrect dosage of adrenaline was administered, although in this case further health care professional referral such as a GP or paramedic breath when friends decided to call for an ambulance. observations were completed but no ECG was carried out it would not have had a detrimental effect on the patient. practitioner. because, according to the crew, the patient appeared unwilling The crew attending the emergency received a to be treated. All staff should have received a personal issue of a Safe Non-Conveyance message through the MDT that they were attending Learning Points Guide. This is an insert to the JRCALC Clinical Practice Guidelines (2006) a patient suffering an asthma attack. After discussions with the crew, the patient left the ambulance Nationally, asthma still claims the lives of about 2,000 people each year. Pocket Guide. If you have not received your copy then contact your COM. and returned to his flat. No referral was made to another When they arrived, just after midnight, noisy celebrations were It is a common life-threatening condition and its severity is often not healthcare professional and while a non-conveyance form was in full swing. They managed to find the young lady who was recognised (JRCALC 2006). signed by the patient’s partner, the crew failed to fully explain the RED FLAGS sitting on a garden wall struggling for breath. Observations Asthmatic patients can deteriorate very quickly and prompt diagnosis and implications of the form. were recorded and a respiratory rate of 14, a pulse of 56 treatment is crucial to a successful outcome. – Chest Pain and a GCS of 11 were recorded. During the course of the Shortly after the patient returned to his flat, he collapsed and – assessment, friends informed staff about the patient’s pre- While vital to obtain a medical history, it is also important to take into again his partner called for an ambulance. On arrival of the ––Sweating / Pale existing conditions and staff were handed an epi-pen. account other evidence available. second attending crew, the man was in full cardiac arrest. Despite ––Family Concern for patient extensive efforts of those who attended, the patient sadly died. (family know their own better than we ever will) Oxygen therapy was provided to the patient before she was • Take note of the MDT notes transferred to the ambulance which was parked close to • Absence of chest sounds is a good indication of an asthma attack so A coroner’s inquest was highly critical of the observations the garden where further assessment and treatment could always look to see if chest sound is present recorded on the patient report form and the lack of be undertaken in a more fitting environment. However, communication with the patient’s partner about the significance oxygen therapy had little impact and shortly after arriving • A pulse rate in decline is a good indication that a patient is of the non-conveyance form she was signing. at the ambulance, the patient went into respiratory arrest. de-compensating Key Considerations Once the crew recognised this, the girl was ventilated with • Where possible nebulise straight away – do not wait until the a BVM and a decision was made by the paramedic on scene patient is in the ambulance. Delays in this treatment will increase The dismissive nature of the patient may have prevented the crew to treat her for anaphylaxis and administered adrenaline the patient’s chance of going into respiratory arrest from carrying out the necessary assessments but this should not have 1:1000 (IM). However, the patient’s condition continued to prevented them from advising him to attend hospital given the symptoms Initially oxygen therapy and a beta 2 antagonist (Salbutamol) should deteriorate and she went into full cardiac arrest. CPR was • that he was displaying. started immediately and attempts to intubate were made. be administered The care and treatment this patient received fell below the standards However, breath sounds were not detected and so the patient If you are attending a patient who has suffered either a respiratory • expected. There are many aspects to take into consideration such as was extubated. En route to hospital, CPR and treatment or cardiac arrest, it is possible to nebulise bronchodilators using a the Mental Capacity Act, Scope of Practice JRCALC guidelines and best continued. An I.O. was placed for drugs, a laryngeal mask was BVM, including when the patient is intubated. The manual of Clinical practice. inserted and adrenaline and atropine were administered. Paramedic Practice states: Unfortunately the treatment was unsuccessful and Learning Points ‘The nebuliser should be connected to the patient sadly died of an asthma attack. the oxygen supply as normal and then Every patient left at home must be advised of any risk to them and the connected via a ‘T’ piece to the catheter Key Considerations relevant paperwork completed to support both the patient and the crew. mount after the bag-value ventilator or Therefore ensure the following: Any child with severe breathing difficulties is not only distressing for the mechanical ventilator. It is essential that the nebuliser is maintained in an upright It is vitally important that paperwork is completed child and family but can be a stressful time for the attending crew. • position to ensure that sufficient gas If a patient is not conveyed, a non-conveyance form must be In a noisy environment, the crew were led to believe the young lady was passes through the drug to aerosolise it’ • completed and a copy left at the scene by staff whose scope of suffering from anaphylactic shock after they were handed an Epi-pen. practice requires them to do so However, clues to the underlying problem were when the patient was RED FLAGS All available medical examinations must be done and at least two intubated, chest sounds were absent which should have been considered • sets of observations need to be recorded in conjunction with the information from the MDT. The patient’s declining ––GCS 11 pulse rate of 56 per minute would have also been another indicator the patient was ‘de-compensating.’ ––Decreasing Respiratory Rate ––Decreasing Pulse Rate The young lady’s symptoms may have been managed if she has been nebulised in the garden soon after the crew arrived. With a respiratory ––Difficulty in Breathing ––Silent Chest

18 SECAmb NEWS ✚ ISSUE 1 19 REFLECTIONS CASE STUDY: CASE STUDY:

REFLECTIONS SERVING THE BEST INTERESTS OF PATIENTS HYPOTHERMIC RISKS

A three-year-old child with Down’s syndrome was on a Learning Points A member of the public called for an ambulance expressing Learning Points flight returning to Gatwick with his parents, when he concern for the welfare of man in his 20s or 30s lying on a park became unwell. The young boy had been treated abroad This case highlights how important your initial assessment, clinical bench on a cold, rainy autumn evening. Hypothermia can quickly become a life-threatening condition for bronchitis and been on antibiotics. En route home, the decision and communication skills are. It is important to take account of and if exposed to cold weather for an extensive period, the body A single responder was sent to the emergency and on his arrival boy had become breathless and lost consciousness for a the following: begins to shut down and the heart will start to slow as it uses all he found the man unresponsive and possibly intoxicated. its energy to maintain a core temperature. This can lead the patient period. An ambulance and single responder were sent to the • Clinical observations in this case showed a child was time critical emergency and met the family as they arrived at the airport. A transporting ambulance was requested and while this to become confused, aggressive, drowsy and difficult to move. ‘Just’ an unwell child could be in fact a child ‘compensating’. • was being arranged, the single responder undertook basic Therefore such patients, regardless of their circumstances, A primary assessment was undertaken on board the aircraft It is well documented that children compensate observations of the patient. should be treated in a timely and respectful manner. and the crew found the child was conscious, pale and had an effectively during illness but ‘crash’ very quickly increased respiratory rate of 60 per minute with an SPO2 of 79 Wearing light summer clothing, his temperature was recorded as • Primary observations should be undertaken per cent. Once the assessment was completed, the child and • Ambulance crews should always take patients directly to 35°C degrees confirming that the man was suffering from mild parents transferred to the ambulance where the technician the nearest A&E unless a specific pathway is in place hypothermia. • Efforts to warm a patient should be done quickly took the lead and assessed the patient who was nebulized and • Good communication is ‘key’ to making the correct While the single responder awaited the arrival of the ambulance, • Secondary observations should be undertaken to ensure given oxygen. This lead to improvements in the child’s condition decision. Keep patient relatives or carers informed and a blanket was provided to the patient but no other efforts were that efforts to warm a patient are working despite the fact, according to the PCR, he had a respiratory be clear in communications with colleagues made to support or treat the patient. rate of over 40 per minute with sub-sternal recession. • Always treat patients with respect and objectively • In similar situations senior clinicians must lead and ensure that When an ambulance arrived no further observations were The decision was taken that the child should go to A&E, an • Be aware that your actions could be being watched or recorded their decision is the right one based on the patient’s clinical undertaken and little care or respect for the patient was 11-minute journey from the airport. However the parents, presentation at the time and the full extent of available information provided, to the extent it concerned a CCTV operator who was • You have a duty of care keen to have the child treated at their local hospital where observing the situation from the Police Control Centre as it was they had direct access to the children’s ward, placed pressure taking place. on the crew to take them there, more than an hour away. RED FLAGS RED FLAGS A request for police presence was made due to concerns raised However, despite the patient clearly being time-critical, the crew by the crews regarding the aggressive nature of the patient, ––Poor weather conditions decided to take the child to his local hospital. The technician ––Respiratory Rate 40-60 per minute despite evidence on the CCTV footage, which showed that the – Evidence of alcohol consumption attended the patient while the paramedic drove. While en – – Low SPO2 patient had not been aggressive to the crew. route, an ASHICE was passed and a response back from the – ––Patient unable to communicate intended receiving hospital was to take the child to the nearest ––Sub Sternal Recession The man was finally moved on to a trolley in an undignified A&E based on the clinical observations given. Unfortunately, ––Previous Medical History manner, transferred to the ambulance and taken to hospital. communications between the crew and control were limited and not all of the hospital’s response was passed to the paramedic. Key Considerations Once at hospital, hospital staff raised concerns about the We are often faced with patients who are under the influence distance travelled with such a time critical patient. Thankfully, that can become aggressive when efforts are made to help them. the child made a full recovery post transfer to London. However, every effort should be taken to ensure that we do not let Key Considerations preconceptions of previous incidents cloud our judgement or dedicate the way we treat all other patients found in similar situations. It Judgements were clouded by the slight improvement of the is important to treat all patients with dignity and respect. child, post initial treatment. Pressure from the parents and the fact the child was already on treatment whilst on holiday may also contributed to the wrong decision being made. Decision making can be very challenging for a crew dealing with sick children. In this case the parents knew the child’s medical condition well and believed that he could be treated more effectively in his local hospital where his case notes were. However, the parents were unaware of just how sick their child was at the time. If the parents had been more fully informed of their child’s condition they may have been able to understand the need to attend the nearest A&E. Effective communication is imperative with any type of incident.

20 SECAmb NEWS ✚ ISSUE 1 21 REFLECTIONS CASE STUDY: CASE STUDY:

REFLECTIONS BACK INJURY DIABETIC RISKS

An elderly woman had been suffering from a chest complaint Learning Points for a few days when she called for an ambulance. It is well documented that the risk of coronary artery disease The lady, an insulin dependent diabetic, had been to her GP a few is a major complication for patients with diabetes. Diabetic days earlier, treated for a chest infection and prescribed penicillin. patients also have a significantly increase risk of a silent MI. Since treatment, she has been suffering from diarrhoea, Particular attention should be taken into account: had started to vomit and had increasing become short of breath. The crew who attend the lady, while finding her • When assessing a patient, take account of the entire alert, noted this information down on the patient report patient’s previous and current medical history form and also recorded that a left bundle branch block • Abnormal ECG readings should provide crews with strong and a first degree heart block which were present on the evidence to insist on transporting a patient to hospital or ECG reading that they took. She was nebulised and her to seek further clarification from a senior paramedic respiratory rate dropped from 24 to 22 beats per minute. A man, in his 60s, was involved in a road traffic collision after Learning Points • Diabetic conditions should have been taken into consideration when his car aquaplaned across a road at approximately 40 mph, However, on this occasion, the crew stated the patient treating a patient’s presenting complaint, particularly in the elderly before travelling up an embankment and hitting a tree. Road traffic collisions, falls and sports injuries are the most common declined to attend hospital. As a result, the patient causes of spinal injury so a high index of suspension must be considered. was advised to call 999 again should her condition • Before a non-conveyance form is completed by a patient A 999 call was made and a paramedic and emergency deteriorate and show her ECG reading to her GP. or a relative explain fully the significance of it care support worker attended the emergency. JRCALC recognise that with neck and back trauma, injury most frequently occurs at junctions of fixed sections of the spine. Hence, fractures are Three hours later, the elderly lady’s daughter called for • Ensure that it is properly documented whether a patient is When they arrived, the man was still in the car but was more common in the lower cervical region where the cervical and an ambulance after the patient suffered a fit. A second refusing to go to hospital or, you are recommending the patient conscious and talking. They noticed that the front of the vehicle thoracic spine meet C5, 6, 7 T1 and the thoracic lumber junction T12-L1. crew was sent to the lady’s home and documented that does not need to go to hospital and document this on the PCR. had been badly damaged and as a result had prevented the The Joint Royal Colleges Ambulance Liaison Committeei (JRCALC) the lady was alert but with a presenting complaint of • Always follow-up with a call to another healthcare man from getting out of the car. He had been wearing his being sick with a recent history of suffering a fit. seat belt and the airbag was deployed during the collision. looks at evidence for not immobilising a patient with neck and professional such as a GP or a paramedic practitioner or back trauma. It states that if ALL the following criteria can They were informed that a previous crew had attended to the The crew undertook primary and secondary surveys of the patient be met then significant spinal injury can be excluded. However, lady and had picked up changes in the ECG reading. However, during which he complained of left-sided lower back pain. in extremes of age, this can lead to a few being missed. the crew failed to take account of the fit and left the patient in RED FLAGS The patient’s spine was palpated by the paramedic prior • Normal mental status the care of the daughter, who signed a non-conveyance form to the patient being asked to move himself across and in the belief that there was no need for her mother to attend ––Diabetic No neurological deficit get out of the passenger side of the vehicle, during • hospital as there was nothing seriously wrong with her. ––Shortness of Breath which he complained of slight discomfort to his lower • No spinal pain or tenderness The following day, a third ambulance was sent to the elderly – ECG Changes back. With the exception of moderate hypertension, no – • No evidence of intoxication lady’s address and she was admitted to hospital where ––Vomiting other significant injuries or illnesses were detected. she suffered an MI and sadly died several days later. – Fitting The patient was again assessed in the ambulance and the • No evidence of an extremity fracture – Key Considerations decision was made to discharge the patient with advice. It is recommended that determining the mechanism of injury Once home, the patient had a sleep and awoke with severe it is important to understand the forces involved and where It may be the diagnosis of another healthcare professional was lower and central back pain. After self-presenting at A&E, he there is the possibility of spinal injury, manual immobilisation incorrectly taken at face value and obscured the crew’s assessment was admitted post-scan with an anterior column fracture of T12 should be commenced at the earliest opportunity. of the patient. It is important when treating a patient to take account of an entire previous and current medical history. and posturing bulging of the L4/5 disc. He remained in hospital i Joint Royal College of Ambulance Liaison Committee for a number of weeks and in a back brace for three months. (2006)Trauma Emergencies Neck and Back Trauma The signs and symptoms of this patient should have prompted the crew to transport the patient to A&E. Key Considerations RED FLAGS The non-conveyance form can all too easily be misinterpreted The fact the patient seemed able, with only minor discomfort, by patients and relatives and it is of the utmost importance to to self-extricate himself from the vehicle obviously led the crew ––Back pain ensure all parties concerned fully understand the significance to believe the patient had not suffered any serious injury. of the form. Informed consent is a patient’s right. – Mechanism of injury However, the speed of the collision and the extent of the – damage to a vehicle should have been taken into consideration ––Damage to vehicle and airbags deployed when thinking about the most appropriate course of action for the patient – things are not always as they seem.

ECG reading showing a a left bundle branch block

22 SECAmb NEWS ✚ ISSUE 1 23 CONTINUED PROFESSIONAL DEVELOPMENT FEATURE

FEATURE TEST YOUR KNOWLEDGE (Number One) PEER REVIEW

The Test Your Knowledge questionnaire, In each edition we will be featuring senior clinicians to be reviewed. If it has been published, please cite the name and date of publication so that appropriate permission can be which has been designed for all grades of an article written by a member of staff obtained to reproduce it. clinicians, will help you keep up to date with which has either been reviewed by a the latest subject knowledge. This means Keep an eye out on future editions where we will be providing you with a group of senior clinicians within the guide on how to write a peer review paper. it can be used towards your Continued Trust, or which has appeared within a Professional Development. peer review journal. In this first edition, we will be featuring an article written by Critical Care Paramedic, Andy Hitt. This article appeared in the Journal of Paramedic If you would like to submit an article for this section - the article Practice on 18 December, 2009. Here is the abstract, introduction and can be previously published or unpublished - please send your overview - to read the entire paper, go to www.secamb.nhs.uk/staff_zone/ work to [email protected]. my_secamb/learning_and_development/peer_review.aspx Asthma If the article has not been published, it will be passed anonymously to 1. Asthma is one of the most common medical conditions that kills up to 2,000 people a year? a) TRUE  Patient assessment: a reflective case study b) FALSE 

At a glance, the journey from ailment to treatment appears to take a 2. Salbutamol is a ß2 Antagonist? 7. An acute asthmatic patient will present on auscultation with an; Abstract straightforward, logical path: history; examination; diagnosis; treatment. a) TRUE  a) Expiratory wheeze  The three ‘C’s of physical assessment—capacity, consent and Health professionals have used this path for centuries; some discovering b) FALSE  b) An inspiratory wheeze  communication— could be compared to the ‘ABCs’ of resuscitation; short cuts along the way, placing their faith in the physical signs c) A combination of both  without all three you will make very little, if any, progress. But do we promising to lead them to diagnosis. Others are more wary; concerned 3. A patient presenting with any one of the following symptoms d) None of the above  give these aspects the attention they deserve, especially in time critical that some physical signs may be misleading and highly subjective, they could be deemed as having ACUTE severe asthma? situations? This case study is based on a 76-year-old female who allow their history taking skills to guide them for most of the journey. a) PEF 33-50% best or predicted  presented at Accident and Emergency (A&E) with central chest pain, Today, in a world of waiting lists and litigation some argue that we should b) respiratory rate ≥25/min  8. Patients with atopy usually present with the “allergic triad” diarrhoea and vomiting, productive cough and pyrexia. The aims of this let technology do the leg work (Wipf et al, 1999)—ultrasound, chest c) heart rate ≥110/min  These are; case study are to discuss the impact of 21st century legislation on patient X-rays, magnetic resonance imaging (MRI) and computed tomography d) inability to complete sentences in one breath  a) Atopic dermatitis  assessment, demonstrate the importance of objective, structured history (CT)—why use a stethoscope? e) All of the above  b) Allergic rhinitis  taken and investigate the subjective nature of physical examination. c) Allergic asthma  This case study will: In a world of waiting lists and litigation some argue that we should 4. Inhaled ß2 agonists are the first line treatment for d) All of the above  • Discuss the impact of 21st century legislation on patient assessment let technology do the leg work— ultrasound, chest x-rays, magnetic acute asthma? • Demonstrate the importance of objective, structured history taking resonance imaging (MRI) and computed tomography (CT)—why use a a) TRUE  9. Lower airway obstruction in asthma patients is caused by; • Investigate the subjective nature of eliciting physical signs, present stethoscope? b) FALSE  a) Swelling of the mucosal lining cells  the evidence and formulate conclusions. Key words b) Spasm and constriction of the bronchial muscles  Overview • Capacity • Consent • Communication • Kappa (K) 5. Adrenaline 1 - 1:000 should be administered IM/SC for patients c) Increased production of the bronchial mucus  • Auscultation This case study is based on a 76-year-old female who presented at with life threatening asthma not responding to a ß2 agonist? d) All of the above  Accident and Emergency (A&E) with central chest pain, diarrhoea a) TRUE  Accepted for publication 1 December 2009 and vomiting, productive cough and pyrexia. She initially contacted b) FALSE  10. The most common precipitant of anaphylaxis is? her general practitioner (GP) who, based on a verbal assessment by author, a critical care paramedic (CCP), was asked to assess the patient a) Insect Stings  telephone, advised her to call an ambulance and attend A&E for further and report his findings to the A&E Consultant. 6. A silent chest in an asthmatic patient would indicate; b) Food  assessment. Reluctantly, the patient agreed to accompany the ambulance a) An improving patient  c) Medications  The Caldicott Committee (Department of Health (DH), 1997: 6) states that: crew to hospital. The paramedic’s handover and patient report form b) A pulse rate >120  d) Animal fur  ‘maintaining the confidentiality of patient information is fundamental to (PRF) indicated a preliminary diagnosis of chest infection complicated by c) A pre terminal sign  the relationship between patients and healthcare professionals and is an chest pain of either pleuritic or musculoskeletal origin. The patient was d) A peak flow reading of above 300  Answers in next edition integral part of the ethics of the healthcare professions’ and, as such, all haemodynamically stable and fully alert at the time of handover. The patient identifiable information has been removed from the text.

24 SECAmb NEWS ✚ ISSUE 1 25 CAREER FOCUS FEATURE

FEATURE Paul Manning, HOW TO GUIDE – Reflective Writing Patient Transport Service With every edition we will provide a guide Description: It is important to include where the incident took place, Operations Manager who was there, the context of the incident, the part you and others played on how to undertake your role better. In this in the incident, the age and condition of the patient, your treatment and edition we will be providing a guide on how what was the result. to write a reflective article. Feelings: Think about what your thoughts were when you arrived at the incident, how this made you feel, the impact of other people on What was your first job? The aim of Reflections is to encourage reflective learning through the publication of articles with clear implications of practice. your thoughts and feelings during the incident, your thoughts about the When I left school at 18, I knew I wanted to outcome and your thoughts about it now. join the ambulance service, and so applied for We welcome your contributions and one of the best ways to understand the Patient Transport Service. I passed all the how to write articles is to read a selection from this magazine. Evaluation: This is about considering the positive and negatives of what tests with flying colours and thought I was in took place during the incident so what worked well and what could have Your reasons for contributing may be to share knowledge, practices and but then at some point during my recruitment worked better. Think about what was good about the experience and better understanding. Whatever your reasons, it would be advisable to process the entrance age went up to 21. That what was not as good. contact the editorial team at [email protected] and we can discuss was a bit of a disappointment but it didn’t to be a fairly relaxed and casual element to How much hard work was the tendering your ideas and provide further advice on how to compile your piece. Analysis: This is about making sense of what took place. Think about the put me off. I spent the intervening three years factors which affected the outcome; what helped and what hindered it, PTS whereas now it is very business focused. process, and how do you switch off? And remember writing a piece for Reflections does go towards your working at the National Blood Service. why it happened and how it happened. It has to be. For the past few years, any willing There have been some long days - getting home What did you think of PTS when Continued Professional Development. provider has been able to tender for the work at 10.30 or 11.00 for several nights in a row Conclusion: Think about what you could have done. What might have you finally joined? – this has seen the NHS competing within a hasn’t been unusual. Running is my switch-off been the alternative actions or approaches; were there things you could I loved it. I guess my initial aim on joining PTS What is Reflection? swamped market. East Midlands Ambulance - it’s a fantastic stress release. And I’ve recently have done differently even if things went well, could negative events had been to eventually become a paramedic Service, for example, has just lost all their PTS got a power kite so am planning to start kite Reflecting is about looking back on a particular incident or event that been avoided and could positive events have been more effective. but I found that PTS really suited me; it has a services to private providers. Alongside this, surfing. Otherwise, I love being about people went well or in some cases, not so well. The process of reflection should very social side to it which I love. Action: Think about what you would do next time. Consider what you the patient experience of the health service and could talk for England, but it is important to allow you to provide a written account about the incident or event in a would do if you encountered this situation again; how would you increase Do you get to know the patients well? has changed; patients have more choice over have some down time too. Generally, I suppose structured way that allows learning to take place. the likelihood of similar positive outcome or minimise the likelihood of a Yes, and with some of the patients, you may be which hospitals they go to, which increases the I just try and balance it all out. The HPC require evidence that learning has taken place and one effective negative outcome. What do we need and might learn from this. the only person they’ve seen in a month, so you competitive aspect. What’s the best and hardest way is to provide reflective accounts of your experiences in practice. become friends. I stop and catch up with people How did SECAmb get the PTS part about working in PTS? Reflections is about recapturing experiences by uncovering and exploring around town that I used to transport years ago. Submissions Guide contract for Surrey and Sussex? The hardest part is the fact that there are lots thoughts, feelings and behaviour. Reflection has been described by Schon In fact I think this social side of the role is part Your article should be no longer than 500 words. Articles should It has been a challenging time which has taken of patients that need to get home and so it can (1993) as a valid method of maintaining professional development in of the reason that many people stay in PTS for be readable so use straightforward language and avoid jargon and us along a new journey. We have made some be frustrating when that doesn’t happen for practice. It is important all healthcare professionals utilise reflection to so long – I can’t think of anyone that’s resigned abbreviations. They should be submitted as a single text file in a plain massive changes to PTS which put us in the whatever reason. The best bit is again, probably challenge their practice so that the detrimental effects of ritualistic non within the last 18 months. font with as few changes in style as possible. Where acronyms are best possible place to win the new contracts. the social side of things. evidenced based practice can be erased from patient care. How did you become an Fortunately, we have some brilliant staff who used, they should be written first in full and then appear in brackets, for What’s next - will you stick with PTS? To assist you as a practitioner,there are several structured models of Operations Manager? have understood the reason for those changes example: Community First Responder (CFR). Articles should be referenced I recently got sponsorship to do a degree in reflection you may come across. Although a framework of reflection is not After a few years in PTS at Horsham, I became and have really helped us with the journey so far. appropriately and is the responsibility of the author. Illustrations and public service business management which essential, it can provide a useful starting point. Gibbs (1988) experiential images are welcomed. Authors should provide their full name, job title, the Team Leader there. I soon realised that I An important part of the hard work has been was brilliant. However, I was the only student learning cycle involves reflection as a basic guide and provides a enjoyed managing people and that I’d probably base and telephone contact number. Articles will be acknowledge put into building relationships with hospitals, left on the course so after the first year the framework that is used widely in educational settings. Gibbs guides before being reviewed by subject experts and considered for publication. found my vocation – again, it’s the social side ensuring that we’re aware of any performance course was stopped. But I am hoping that I can the reader to reflect in order to learn from experience in a debriefing of the role that appeals to me. From that role I If approved, the editorial team reserve the right to edit the piece for issues/potential problems. We realised that continue my studies in the future - I love feeling sequence, which asks the reader to reflect on feelings, evaluate the publication. became Team Leader at Crawley and from there, we need to work with PCTs to do a great job like I’m progressing and getting better at what experience, analyse the situation and develop an action plan. This model I moved into my current role. and be a market leader in the provision of References: I do. Other than that, I used to have an idea is particularly useful for contributing to a change in practice, as the cycle Gibbs G (1988) Learning and doing: A guide to teaching and learning Throughout your 10 years in PTS services and ultimately the PCTs are the about becoming a pilot but I don’t think that’s can be used after the action plan has been implemented to aid reflection methods. Oxford Further Education Unit, Oxford. PTS, how have things changed? commissioners for the PTS contracts. This has going to happen anymore. I have thought about on the changed practice. There have been massive changes. There used helped to contribute to our success. teaching though, so maybe one day…

26 SECAmb NEWS ✚ ISSUE 1 27 COMPETITION As this is the first issue of SECAmb News, we wanted to mark it by giving you the opportunity to take part in an exciting competition. There will be two prizes: A 3M Littmann Master Cardiology Stethoscope, Brass Edition – which will get engraved with your name. Or A coffee machine, to the same value, for your workplace. First though, you have to answer what we hope is a tricky - but not impossible - question.

Which UK peacetime major incident in the 20th century records the earliest UK use of pre hospital IV fluids?

To apply, please write send the answer to [email protected], stating which prize you are after - clearly only those with a use of a stethoscope in their work at SECAmb should apply for that prize. All answers must be received by August 31. The correct answers will be placed into a hat (or a comparative methodology), with the winner picked at random. The money for these prizes has been gratefully received from SECAmb’s Charitable Trust Fund.

IN THE NEXT EDITION – October 2012

✚ NHS 111 With SECAmb announced as the preferred bidder for the new non-emergency medical calls across the region, we will look at what impact this will have on the Trust and its vision to be a single point of access for emergency care for patients in the region. We will also look at how the organisation is planning for the new service when it joins forces with Harmoni to provide the service during the Spring of next year.

ALSO TO BE FEATURED REGULARS ✚ IBIS – what impact the service is having on ✚ Reflections reducing admissions ✚ In focus – View from the Board, Letters, ✚ Electronic Patient Report Forms – looking at Journal Scan the trials taking place in electronic patient report forms

CONTACT SECAmb NEWS: [email protected]