Clinical update - London Ambulance Service

Clinical update

O
Major trauma update
Post

Issue 34
Sharps update
Clinical
update
Page
1
ECG case study
2
Reflective essay
4
Care of detained
persons
Post partum
haemorrhage
7
Sept 2013
partum haemorrhage
CONTENTS
6
O
CARU focus
Adrenaline 1:1000
9
Coordinate My Care
11
Clinical equipment
messages
Have you seen?
MDB 127 Multiple ICD
activations
MDB 128 Suction units
MDB 129 ROLE by
paramedics
Hyperventilation – treat
with caution
A 999 call was made for a patient with ‘shortness of breath’ and categorised
as a C2. On arrival the crew was presented with an anxious 47-year-old
male complaining of shortness of breath and appeared to have a
significantly raised respiratory rate accompanied by pins and needles in his
hands and feet. The patient explained that his car had become stuck in a
muddy grass verge and that he had spent almost one hour pushing and
bouncing the car in an attempt to return it to the road. On further questioning
it became apparent that the onset of shortness of breath was quite sudden
during this strenuous activity. This was accompanied by ‘feeling faint’ and a
single episode of vomiting. The patient did not complain of any chest pain
and looked well perfused. The patient also complained of some ‘chest
tightness’ and a feeling of ‘a constriction in his throat’. These symptoms
commenced after the patient developed a rapid ventilation rate.
The patient’s observations were as follows:
Pulse 90 (weak and regular)
BP 165/104
Sats 100%
Respiration rate 28 to 32
BM 7.7
GCS 15
ECG rhythm strip showed sinus rhythm
The patient had no significant medical history and was not prescribed any
medications. A decision was made to acquire a 12 lead ECG in the patient’s
house before removal (see overleaf).
-1-
Clinical update
12 lead ECG taken
shortly after arrival of
the ambulance crew.
As you can see this patient’s ECG shows clear ST elevation in the inferior view. This signifies an acute inferior ST
elevation MI and probable occlusion of the right coronary artery (due to ST depression in aVL). A right sided ECG
(V4R) was also acquired which showed >0.5mm ST elevation indicating right ventricular infarction.
The patient was administered aspirin and GTN and a pre alert call placed to St George’s cath lab where the patient
underwent angioplasty.
This case study highlights the fact that myocardial infarctions do not always present with ‘typical’ signs and symptoms
and that hyperventilation should be treated with caution, particularly where other signs and symptoms are present.
Thanks to Fiona Scarlett, Complex Training Officer, St Helier, for submitting this case study.
Time for reflection
with the patient and taking a history. The responder
turned to me and stated that the call was not as given.
He went on to explain that the patient suffered with
COPD and was experiencing some breathing difficulties,
but he had also performed a FAST on the patient, who
appeared to show no facial drooping, arm weakness or
slurred speech. He then went on to talk more about the
breathing and began to auscultate the chest.
Registered paramedics have a responsibility to
undertake continued professional development (CPD)
to stay registered with the Health and Care
Professions Council (HCPC). As you are probably
aware, the HCPC randomly audit 2.5 per cent of
professionals from a particular profession every couple
of years. It is good practice to produce ‘reflective
pieces’ to demonstrate that you have learnt from cases
you have been involved in.
The following essay is based on Driscoll’s framework,
developed by John Driscoll in 1994, 2000 and 2007.
He took his time, but he did perfect it. It seems to be
based on a lot of whats.
Whilst this was happening, the son asked to speak to
me and told me he was very concerned about his
mother and although he could not pinpoint why, she just
wasn’t acting normally. I said we would assess her and
do the best for her. I went back over to the patient and
responder and was listening to the patient attempting to
have a conversation and answer the questions being
asked. The patient appeared to be stumbling over words
that were normally regarded as quite simple. The
responder finished the observations and whilst writing
out the LA4H asked if we were taking the patient to the
nearest A&E. I stated that based on my assessment so
far, the patient needed to go to the nearest HASU as I
felt, and my crewmate agreed, that the patient had failed
the FAST based on ‘word finding difficulties’.
On arrival at the HASU, we transferred the patient into
the resuscitation room and provided staff with a detailed
handover. I went off to book the patient in and then to
complete my paperwork. I went back into the
department to enquire after the patient just prior to
leaving, and the doctor informed me that the patient had
been experiencing a transient ischaemic attack (TIA).
What? I was working as part of a crew when we were
called to attend a 65-year-old female who had
suddenly become unwell. The presenting condition
was given as a ‘possible stroke’. On arrival, we entered
the location and were met by the son and husband on
scene and also the single responder who was talking
Analysis: So what?
It can sometimes be quite easy to be led by other
clinicians at scene. The single responder believed the
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Clinical update
patient was not experiencing a stroke and believed
that she should be transported to the nearest
emergency department. I could see how he arrived at
this decision as assessment of the face revealed no
facial droop. On assessment of the arms, they did not
drift and whilst conversing with the patient, there was
no evidence of slurring of words and yes, she was
struggling to find certain words but her medical history
also included a recent onset of dementia, so could this
not have also caused her word finding difficulties?
The history of the onset of symptoms, together with
the observations and PMH all assisted with my clinical
decision making. The son was also a large factor in
assisting me with the impression as he was so sure
that his mother was sounding suddenly different and
her use of words on occasion, was not right.
This highlighted to me the importance of making my
own clinical decisions based upon my own history and
findings.
Now what?
What have I learned from this experience?

It is beneficial to gain input from other clinicians at
scene, but if you are taking responsibility for that
patient’s care and treatment, think about all that is
in front of you and form your own clinical
decisions.

Increase knowledge as to how different types of
strokes, depending on where they occur in the
brain can present. They are not always clear cut.

Always listen to relatives or friends at scene: they
know the patient much more than you do and they
will assist you in making the right decision.

I felt that, if the patient had not been experiencing
a stroke, I could totally justify and quantify my
thought processes in reaching the decision I had
made.
Thank you to Rachel Phillips, Complex Training Officer,
Greenwich, for providing this article.
IMPORTANT NOTICE
Safeguarding and Careline
Major trauma updates
Use of the major trauma triage tool
Staff are reminded that in line with the new major trauma
triage tool, if a patient does not trigger the tool but the staff
on scene still have clinical concerns for the patient, and
suspect they have a major traumatic injury, the case
should be discussed with the trauma paramedic on the
HEMS desk in EOC. This should be undertaken before the
patient is transferred to a major trauma centre (MTC).
The importance of documenting respiratory
rate
One of the earliest physiological changes that occurs in
response to haemorrhage is an increase in the patient’s
respiratory rate. It is therefore vital that an accurate
respiratory rate is measured in all trauma patients. This
allows an assessment under ‘step one’ of the trauma tool
and consideration given to the most appropriate
destination. A number of cases have been identified
through audit were the respiratory rate has assumed to be
normal and recorded as such. However, on review, there is
a high likelihood that patients presenting with such major
injuries would present with an abnormal respiratory rate.
On scene times
There has been a marked improvement in the length of ‘on
scene’ times for penetrating trauma over the last 12
months. However, the most recent major trauma audit
shows that the average on scene time for penetrating
trauma is now 19 minutes which is a four minute increase
from the previous report of 15 minutes. Staff are
encouraged to ensure that the absolute minimum length of
time is spent on scene with patients who have suffered
penetrating trauma. The target on scene times for a
patient with a penetrating wound is less than five
minutes.
Mark Faulkner, Paramedic Advisor to the London Trauma Office
Asthma in children
When attending children with asthma who appear to
improve after initial nebulisation, it is recommended they
are still conveyed to hospital as there is a risk of
subsequent deterioration. In those circumstances when
parents decline to go to the emergency department
(ED), you should strongly advise they see a GP that
day. Ensure you document your advice on the PRF.
If the child’s parent(s) or
main carer are not on
scene eg child at school –
make all attempts to speak
with the parent / next of kin
to explain the child is being
taken to the ED as the
safest option. You should
not leave the child in care
of non-clinical staff.
Reminder:
When attending a patient who has alerted us through
Careline, before leaving scene you should ACTIVATE THE
ALARM AGAIN and briefly inform Careline about what has
happened to the patient and where you are taking them / or
if you are leaving them at home. This is important as it
reduces the number of calls made to EOC after the patient
is conveyed and ensures continuity of their home care
packages.
-3-
Clinical update
The care of detained persons
Over the last few years the Service has been criticised
in a number of forums including Her Majesty’s
Coroner’s Courts, in relation to the care provided to
detained persons when working alongside the police
service. There is no doubt that this group of patients
can be challenging for ambulance staff to manage, but
the overriding principle is that ambulance staff must
maintain primacy for care of the patient, ensuring that
the patient’s clinical needs are assessed and met until
direct handover to an appropriate clinician. The fact the
patient is being detained by the police does not negate
the ambulance clinician’s duty of care to the patient.
the police of the clinical dangers of restraint.
(Joint Royal Colleges Ambulance Liaison Committee
National Clinical Guidelines (2013) (pages 94
and
200)
and
via
the
following
link
http://thepulse/patients/11473369194948.html).
Although detainees are monitored within police custody
suites, the level and type of monitoring does not equate
to the level of monitoring that would occur in an
Emergency Department environment. Patients with
clinical needs such as any reduced level of
consciousness (even if it is due to alcohol), head
injuries or other acute medical needs should never be
discharged to the care of a custody suite. Furthermore,
patients must not be left in care of the police without
having completed a full patient assessment and
indicating that there is no acute medical need. If this
assessment has not been possible due to the agitated
or combative nature of the patient, it is vital that the
patient is conveyed to hospital for further medical
assessment.
Acute behavioural disturbance / excited delirium
These are conditions where a patient’s behaviour is
significantly altered and often displaying one or more
of the following:
o
o
o
o
No patient with an acute clinical need should be
discharged from the ambulance service on the
assumption that they will be seen by clinical staff within
the custody suite such as a forensic medical examiner
(FME) or custody nurse. This is because the availability
of such staff cannot be guaranteed by either you, or the
arresting officer.
It is understood that when dealing with agitated
patients, actions can occur quickly, therefore it is
imperative that a clear plan is developed with the police
to ensure all personnel on scene (both police and
ambulance) understand the clinical needs of the
patient. Ambulance clinicians must act as the patient’s
advocate to ensure that these clinical needs are met.
Acutely bizarre or aggressive behaviour
Impaired thinking
Disorientation
Paranoia or hallucinations
These patients may have a history of illicit drug use
(such as cocaine) and / or psychiatric illness. Acute
behavioural disturbance / excited delirium carries a
significant mortality risk and during restraint these
patients require careful monitoring to ensure their
safety.
Head injuries
Head injuries require careful monitoring and often
require a CT scan to investigate the scope of their
injuries.
The above areas must underpin our practice when
working with police colleagues but are especially
relevant in the following four groups of high risk
patients:
Alcohol and / or drug intoxication
These can cause significant medical harm, including
reduced level of consciousness and associated
airway or respiratory compromise. Furthermore,
intoxication can mask signs and symptoms of serious
underlying illness or injury. These patients need a full
and thorough clinical assessment to determine the
most appropriate place of care, if this assessment is
not possible, conveyance to hospital is mandatory.
Patients being actively retained by the police
Restraint is fundamentally dangerous and should only
be carried out as a last resort. A person in the prone
position or whose chest expansion is impaired is at an
increased risk of positional or restraint asphyxia. Where
a patient is being restrained, staff should carefully
monitor the patient’s airway and breathing and where
necessary act in the patient’s best interest and remind
All staff are asked to re-familiarise themselves with
the DVD “Death in Police Custody and LAS Medical
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Clinical update
Advice”. This DVD was jointly produced by the Service
and Metropolitan Police Service and highlights these
important issues. They were widely distributed in 2011
to complex training teams and the training centres. If
further copies are required please contact David
Whitmore via the Medical Directorate at Waterloo HQ.
When caring for people who are detained aged under
18, staff must clearly demonstrate that they have
considered any safeguarding issues and err on the side
of caution by completing a LA279 / LA280. In the very
rare situation it is not considered necessary, those
reasons must be very clearly documented on the PRF.
All clinical staff are reminded that when working with
the police, and indeed other people who are not
registered health care professionals, primacy of care
for the clinical condition of the patient rests with
Service clinicians until direct handover to an
appropriate clinician. This is ultimately the
responsibility of the most senior Service clinical
member of staff on scene who must take the lead, in
most cases this will be the paramedic, but in the
absence of a paramedic primacy of care would then
fall to the most clinically qualified member of Service
staff, (be that EMTs, A&E support staff or indeed PTS).
Primacy of care is detailed in the policy: TP 03 –
Statement of Duties to Patients, and also an article in
the December 2011 Clinical Update, both of which can
be accessed via the pulse on the following links:
http://thepulse/uploaded_files/Trust%20Policy%20and%20Procedures
/2012-09-18_tp003_statement_of_duties_to_patients_v4.1.pdf
http://thepulse/uploaded_files/Clinical%20Update/clinical_update_dec
_2011.pdf
David Whitmore, Senior Clinical Advisor to the Medical Director.
The medical care of people who have self-harmed
Deliberate self harm (DSH) is a complex issue for health professionals both in primary and secondary care. It is
especially pertinent for frontline staff. Self-harm accounts for a significant proportion of emergency calls. Calls
originate from those who have harmed themselves and, more often, from concerned family or friends. The
severity of such incidents ranges from minor physical injuries to life-threatening conditions. Sometimes staff
may need to initiate treatment before a patient who has self-harmed reaches the emergency department. This is
particularly likely if the person has taken an overdose. JRCALC guidelines provide definitive advice and
guidance to ambulance staff, including the use of naloxone in suspected opioid poisoning. Consideration should
be given to others in the home (ie children and adults at risk) who may be affected by the illness and a LA279 /
280 must be completed.
Clinical practice recommendations
•
Unless the patient’s clinical condition requires urgent treatment that should not be delayed, staff should
record relevant information about their home environment, social and family support network, and history
leading to self-harm, as well as the patient’s initial emotional state and level of distress. This information
should be passed to hospital staff and a safeguarding referral made as necessary.
•
When attending a patient who has self-harmed, urgently establish the likely physical risk, and the person’s
emotional and mental state, in an atmosphere of respect and understanding.
•
If a patient who has self-harmed is refusing further treatment, staff should assess mental capacity and
provide information about the potential consequences of not receiving treatment when attempting to gain
valid consent.
•
If a patient lacks the capacity to consent to treatment (whether for medical or mental health reasons) then
treatment needs to be delivered in the best interests of that individual.
•
In cases of self-poisoning, ambulance staff should obtain all substances and / or medications found at the
scene of an emergency call, whether thought to be involved in the overdose or not, and pass these to staff
upon arrival at hospital. The patient, where possible should be conveyed expeditiously to the nearest
emergency department.
•
In cases where, following an act of self-injury, the patient does not require hospital treatment, staff should
consider, having taken full account of the patient’s preferences, taking the patient to an alternative
appropriate service, such as a specialist mental health service. The decision to do so should be taken jointly
between ambulance staff, the patient and the receiving service.
Kudakwashe Dimbi, Mental Health Clinical Advisor
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Clinical update
Post partum haemorrhage (PPH) clarification: Further advice
and guidance on the management of PPH
attempting fundal massage (JRCALC 2013). (This
is following a JRCALC evidence review which has
suggested that performing fundal massage when the
placenta is still in situ may encourage partial
placental separation and therefore could increase
bleeding).
Most births attended by frontline staff are normal with
little intervention required. As the placenta is stripped
away from the uterus with powerful contractions, a
natural expulsion of the placenta usually follows with no
necessary intervention. It is important not to interfere
with the uterus during this third stage of placental
expulsion as this can cause further maternal life
threatening complications including post partum
haemorrhage (PPH).
Additional guidance
Please note: if syntometrine administration is
delayed / unavailable or maternal condition has
not stabilised, irrespective of whether the
placenta HAS or HAS NOT delivered, then the
only available treatment option is to attempt
fundal massage to control bleeding (Consultant
midwife’s advice 31/7/2013). The Service does not
at this time administer misoprostol due to the
availability and superior effect of syntometrine but
remains under review.
Most significant bleeding arises from the uterine blood
vessels that have nourished and oxygenated the
placental bed. If the uterus is NOT contracted (ie
relaxed) it cannot stem blood loss. Significant bleeding
is defined as an estimated blood loss of 500 mls
(or more) or any signs of maternal haemodynamic
compromise (blood loss may NOT be apparent as the
uterus fills with accumulated blood). In addition, for a
number of women, blood volume loss of less than
500 mls may significantly impact on maternal wellbeing.
Clinical care following completion of the
third stage and particularly after any PPH
event
This guidance is concerned with a PPH immediately
following birth (‘primary’ = within 24 hours) but the
principles that remain applicable including syntometrine
use may also be followed for a later PPH (secondary =
after 24 hours). Large bore IV access is required for a
PPH and as a precaution, where there is a delay in
placental expulsion. The availability of large bore IV
access ensures early initiation of fluid administration
where a clinical need exists. A relaxed uterus (atoney)
is the most common cause for a PPH. The
administration of syntometrine is the most effective
treatment in maintaining a contracted uterus and
preventing blood loss (JRCALC 2013).
Maternal observations must be acquired and
recorded regularly. Once the placenta has
delivered the uterus should be periodically assessed
to ensure that it remains firm and contracted (hard
and palpable). PV blood loss should be inspected
and recorded. Prompt transfer to the nearest
maternity unit is required following any PPH event.
Assessment of mother’s and infant’s wellbeing must
be repeated regularly following birth and particularly
where PPH has occurred.
The use of fundal massage as an intervention
for a PPH requires further research
Dr Andrew Lingen-Stallard, Consultant Midwife
What does duty of care mean?
Whilst fundal massage is known to be effective, it has
the potential to harm and worsen outcome for some
women. Current evidence maintains that if the placenta
remains in situ, fundal massage for PPH is not optimal
treatment.
Previous editions of the Clinical Update have
highlighted the importance of withholding CPR / ALS
from end of life care (EoLC) patients in the terminal
stage of their illness where it is clearly inappropriate
and futile.
If there is significant bleeding following the birth of
the baby, and the placenta HAS delivered, fundal
massage should be undertaken in the first instance
to aid the uterus to contract. This should be
followed by the administration of syntometrine to
maintain a contracted uterus (see administration and
contra-indications in PPH and syntometrine JRCALC
2013 guidelines).
The BMJ has recently published an article about
dying and the complications which can arise when a
patient’s resuscitation status is not clear. It highlights
the distress often caused to relatives where CPR is
inappropriately applied and provides a balanced and
thoughtful view. Click on the below link to access this
highly recommended read:
http://blogs.bmj.com/bmj/2013/05/17/david-lock-what-doesduty-of-care-mean/
If there is significant bleeding following the delivery
of the baby, and the placenta HAS NOT been
delivered, crews should move straight to the
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Clinical update
Clinical Audit and Research focus
Adrenaline 1:1000 – who, when, how and when not?
Anaphylaxis: Sudden onset and rapid progression of:
Adrenaline 1:1000 is still being misused in the Service,
despite reminders in the Clinical Update, posters on
stations and a review of training slides. CARU’s recent
re-audit of adrenaline 1:1000 showed:
•
When adrenaline was given, 99 per cent of
patients received it via the correct route.
However...
• 18 per cent of patients should not have received
adrenaline
• 12 per cent of patients given it received the
incorrect dose
Adrenaline has some potentially dangerous side effects
including cardiac arrhythmias, hypertension (risking
cerebral haemorrhage), pulmonary oedema and angina.
As with all drugs, there is a risk:benefit ratio to using
adrenaline, with the risk of the side effects of the drug
balanced against the benefit to the patient. As long as it
is used appropriately, these benefits outweigh the
potential risks. By administering adrenaline when it is
not indicated or required, your patient is getting all the
potential risks without sufficient benefit. Before giving
this drug with potentially serious side effects, always
remember: think who? when? how? And when not?
Who?
Adrenaline 1:1000 is
indicated for the treatment
of life-threatening and
near fatal asthma, and
the treatment of
anaphylactic reactions.
•
Airway and/or breathing problems
o Dyspnoea
o Hoarseness
o Stridor
o Wheeze
o Throat / chest tightness
•
And/or circulation problems
o Hypotension
o Syncope
o Pronounced tachycardia
•
And/or skin problems
o Erythema
o Urticaria
o Mucosal changes
How?
Adrenaline 1:1000 MUST ONLY be given
intramuscularly (IM). Under no circumstances
should it be given intravenously (IV).
•
Adults and children 12 years and over - 500 mcg
(0.5 ml of 1 milligram in 1ml) intramuscularly (IM)
•
Children 6 years to 11 years - 300 mcg (0.3 ml of
1 milligram in 1 ml) intramuscularly (IM)
•
Children 5 years and under - 150 mcg (0.15 ml
of 1 milligram in 1 ml) intramuscularly (IM)
If there is no improvement in the patient’s condition, a
further dose of adrenaline can be given after five
minutes, with further doses every five minutes if
necessary.
In cases of anaphylaxis in patients taking tricyclic
amitriptyline,
imipramine,
antidepressants
(eg
dosulepin) administer half doses.
When not!
When?
Life-threatening asthma: any one of the following in a
patient with severe asthma –
• Altered conscious level
• Exhaustion
• Arrhythmia
• Hypotension
• Cyanosis
• Silent chest
• Poor respiratory effort
• PEF < 33% best or predicted
• SpO2 <92%
Near fatal asthma: Patient requiring mechanical
ventilation with raised inflation pressures.
•
Adrenaline is NOT indicated for COPD – Ensure
you know the signs and symptoms and relevant
medical/social history to differentiate COPD and
asthma.
•
Adrenaline is NOT indicated for asthma attacks
which are moderate or acute severe in nature –
Ensure your patient has a life-threatening or near
fatal asthma attack.
•
Adrenaline is NOT indicated for other causes of
DIB (eg chest infections, acute cardiogenic
pulmonary oedema (ACPO) - ensure your patient
is having a life-threatening or near fatal asthma
attack.
•
Adrenaline is NOT indicated for minor allergic
reactions but rather for systemic anaphylaxis.
The full clinical audit can be found on the X:Drive here: X:\Clinical Audit
& Research Unit\Clinical Audit Reports\Adrenaline re-audit
-7-
Clinical update
CARU focus
learning disability. Frequently individuals are able to
demonstrate that they are capable of safeguarding
their own interests and have the capacity to consent
to treatment. However, in an emergency situation
there may be a number of other factors that warrant
safeguarding by professionals, eg an older adult may
live independently with minimal support but, on
developing an infection may become more vulnerable.
NEW free-to-access research resource launched by
the National Institute of Health Research (NIHR)
Five ‘open access’ journals are now available from the
NIHR Journals Library. Whereas journal articles
typically include a summary of the study methods and
findings, reports published in these journals go one step
further by including the study protocol, a full report of
the findings, and a scientific summary. The journal
reports are free to view and download and can be
accessed via the link below:
People living with a learning disability or autism have
heightened vulnerability for many reasons, and
improving their empowerment and their access to
advocacy can go some way to limiting this. Often it is
not the condition itself that causes vulnerability so
much as the disabling effect of the dependence on
care and a consequent restriction in choice that
disempowers people. Staff should do all they can to
involve patients in the decision making process.
http://www.journalslibrary.nihr.ac.uk/
Safeguarding people who have
autism or a learning disability
Safeguarding systems and collective responsibility are
at the forefront of protection, but an issue that
concerns staff is that they, as individuals, may need to
blow the whistle on abuse. It is common for staff to
have misgivings about what will happen to them if
they raise concerns. They may also be anxious about
making a mistake and getting a colleague into trouble
if the concerns turn out to be unfounded. The Public
Interest Disclosure Act (1998) affords legal protection
to the informer and a system of support across
private, public and voluntary sectors. If staff witness or
have concerns about a member of staff they have a
professional responsibility to report it.
People living with learning disabilities and / or autism
have the right to live a life free from abuse and neglect.
They also have the right to be treated equally and with
absolute respect from ambulance staff.
Respecting and understanding choice plays an important
role in safeguarding adults and children. Listening to
individuals’ preferences about their treatment and what
makes them feel comfortable and safe, is key.
Ambulance staff should think carefully and wisely about
how individuals make choices and consider any
limitations they may have with regard to choice making
and consent. Listen to carers who know the person and
work together to ensure that the patient’s wishes are
respected.
The
Service
has
a
professional responsibility
to ensure the safety of
people we engage with.
History informs us that
people
with
learning
disabilities and / or autism
are at particular risk of
abuse. Tragic cases such
as the death of Steven
Hoskins
in
Cornwall
Tips for staff when communicating with people
with a learning disability or autism
People living with a learning disability have difficulties
with receiving, processing and communicating
information. People living with autism have issues
with social interaction and communication, this
creates challenges for staff assessing and treating
patients.
highlight the need to protect adults at risk from those who
wish to harm them. Ambulance staff should always
consider if there are any safeguarding concerns when
attending an incident, but should have a heightened
awareness of possible safeguarding issues when dealing
with ‘at risk’ groups.
Every day people with a disability are subjected to hate
crimes such as being assaulted, shouted at and spat at.
The motivation for this type of crime is often the
perpetrators’ negative prejudice. There is evidence that
the long term effects of these experiences increase
anxiety and fear of going out.
Staff should be mindful that vulnerability should not be
assumed to be inevitable part of living with autism or a
•
Be aware that some people may need a lot of reassurance
before they allow you into their ‘personal space’.
•
Gather as much information as you can from family and
support networks. Find out the best way of engaging with the
patient so that they feel comfortable talking to you.
•
Use unambiguous language, be as straight forward as
possible.
•
Give patients time to process information
•
Be calm and clear and make sure they understand what has
been said.
•
Break down questions to one at a time.
•
Don’t make assumptions - people with autism and learning
disability are all individuals.
•
Remember that these patients may also have additional
difficulties such as ADHD, dyslexia or dyspraxia, depression
and anxiety.
•
Overall slow your assessment down where condition allows.
Alan Taylor, Head of Safeguarding Adults.
-8-
Clinical update
EOLC: How can ‘Coordinate My Care’ (CMC) assist me?
Emergency calls to palliative care / end of life care
(EoLC) patients can often cause problems for the
attending staff because of difficulties in finding essential
information quickly in the patient notes, and / or finding
medications in the house. Without information to guide
management, knowing the patient’s preferred wishes,
or contact details to obtain specialist help, the patient
may be inappropriately conveyed to the emergency
department (ED). This lack of information has
unfortunately led to inappropriate resuscitation
attempts, and / or the unnecessary involvement of the
Police Service and HM Coroner. Staff are encouraged
to read the Clinical Update article FAQs: DNA-CPRs
http://thepulse/uploaded_files/Clinical%20Update/clinica
l_update_june_2013_thepulse.pdf
In an effort to reduce such occurrences, the Service
started holding paper-based records for end of life care
patients from approximately 2005. Since 2010 / 2011
that changed to an electronic register and is now called
Coordinate My Care (CMC). CMC enables the Service
to access such patient records at the point of 999 call.
Although not every patient is yet ‘flagged’, this is the
intention within the near future.
At the time of issuing this bulletin, some 7,000 patients
are known to the Service. CMC is populated by GPs /
palliative care teams and district nurse teams to ensure
that crucial information can be provided to an
ambulance crew before they arrive on scene via a short
message on the MDT, which is of particular importance
when giving DNAR-CPR status. CMC information is
also available to staff after their arrival if required via the
clinical hub.
The clinical hub advisors in the control room are able to
access CMC records and provide information regarding
the patient to the ambulance crew. Once the crew is onscene, and have assessed the patient, they can contact
the clinical hub and obtain further details, discuss the
situation and use the information held on CMC to make
decisions regarding treatment, referral or conveyance.
Feedback from staff is positive; CMC is now accessed
on average four times a day by the Clinical Hub
assisting crews on scene with EOLC patients. This
figure is expected to grow as the CMC expansion
continues. Ambulance crews, who are not experts in
EoLC, report satisfaction concerning the amount of
information now available to them, assisting with
complex decision making.
The introduction of CMC represented a significant
advance towards greater integration between the
Service and other services that provide definitive EoLC,
and is expected to reduce the frequency of unnecessary
conveyance to EDs and unnecessary and distressing
resuscitation attempts. Combined with further EoLC
education for Service clinicians, this will improve patient
experience, quality of care provision and help to ensure
that an individual’s needs and wishes are met at the
initial point of contact.
David Whitmore, Senior Clinical Advisor to the Medical Director.
Sharps update
The UK adopted the EU Council Directive 2010/32 /EU in
May 2013 to protect health workers from diseases
through new regulations on the prevention of sharps
injuries in the hospital and healthcare sector.
There is the potential of contracting a blood borne virus
such as HIV or Hepatitis C through a contaminated
sharps injury. Employers and employees need to ensure
that the new regulations are applied without exception in
the workplace so that they are not putting workers and
patients at risk. Preventing the unnecessary use of
sharps, using safer sharps and disposing of them safely
will all help to dramatically reduce that risk.
The new regulations require healthcare employers and
employees to:
The Service places a ‘flag’ on a patient’s address once
they are entered on to CMC. Thus, should an
emergency call be made at any point from this address
then the ‘flag’ is activated indicating to control room
staff, clinical hub staff, and the responding ambulance
crew(s) via their MDT, that a CMC record is held for a
palliative care / EoLC patient.
•
Avoid the unnecessary use of sharps
•
Use safer sharps, incorporating protection mechanisms
•
Prevent the recapping of needles
•
Use secure containers for safe disposal of medical sharps
•
Provide health and safety information and training for staff
The majority of sharps injuries are preventable with the
provision of effective training, safer working procedures
and safety-engineered medical devices that shield or
retract the needle / sharp after use.
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Clinical update
What to do if you receive a sharps injury?
GTN and
inferior STEMI
Advice can be sought from the following document at
(The pulse Home> Clinical > Infection Prevention and
Control > Training Workbook > body fluid exposure
Staff are reminded that
patients who present with
an inferior STEMI +/- ST
elevation in V4R should
still be administered GTN
provided
the
blood
pressure is >90mmHg. It is
only when the patient is
hypotensive should GTN
be withheld (or used with
caution if the systolic blood
pressure is just above
90mmHg).
What has the Service reviewed and
implemented with regards to the legislation?
•
Recognised that not all Service sharps are
currently safe
•
Tried, tested, purchased and provided, with staff
approval, safer needles and other safer medical
instruments (razors)
•
Staff training is being provided in the use of IM/SC
safer needles as part of the current CSR 2013 skills
update package.
Drug dose error in JRCALC 2013
guidelines
A drug dose error within the 2013 JRCALC clinical
guidelines has been brought to our attention. On page 327
of the large reference version the initial IM dose of naloxone
at birth is correctly listed as 40 mcgs, but the volume is
incorrect by a factor of 5. It currently reads as 0.5ml but
should read 0.1ml. The page for age and pocket book
entries are correctly printed.
New Medicina IM/sub
cut retractable needle
Harry Day, Safety and Risk Department.
When is a care home not a care home?
Sometimes we are called to establishments which appear on
first impressions to be some kind of care facility. Levels of
support and care available can vary enormously depending on
the kind of scheme encountered. Here is a brief outline to
remind staff of some of the expressions used to describe
facilities. Fuller details can be found in an article in the Clinical
Update no 25 (June 2011).
PRF completion: Past medical history
and medications
Many of the patients that we see are on multiple
chronic medications, some of which are more relevant than
others. Writing ‘see list’ or ‘various’ in the medications
section of the PRF is not helpful if the list or medicines
go missing.
Answer: When it’s a:
Hostel: Providing emergency or temporary accommodation to
homeless people and usually offering minimal levels of support.
It is advisable to look at the medicines that the
patient is on, and, if there are many, work out which
are the most important and relevant to the presenting
complaint.
Supported housing: Usually refers to schemes where elderly
or other people at risk live independently with access to ‘floating’
support staff who may not be on the premises.
Sheltered housing: Usually refers to housing schemes which
offer a modest degree of support to the people who live there.
The support will usually be provided by on-scene staff during
‘office hours’ and access to an alarm system at other times.
Examples of ‘essential’ medicines include:
•
Housing with extra care: Schemes where tenants have access
to an on-site care team providing personal care packages and
emergency cover, often to a fairly intensive level. However, this
does not count as ‘residential care’.
Warfarin
•
Anti-hypertensives
•
Steroids
Less important medicines include:
So when is it a ‘care home’?
Answer: When it’s a nursing home registered to provide
nursing care and required to have qualified nursing staff on duty
24/7.
•
Dietary or mineral supplements such as, thiamine
or calcium,
•
Over the counter medicines such as paracetamol.
Important negative findings are also helpful – for example
writing ‘not on Warfarin’ in an elderly faller evidences that a
risk-assessment has been made.
Or:
Answer- When it’s a residential home providing personal care
without any formal nursing provision although the managers will
often be qualified nurses.
Neil Thomson, Assistant Medical Director, East.
Clive Palmer, Social Work Liaison Officer
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Clinical update
Clinical equipment important messages
Pelvic splint
The Prometheus Pelvic Splint has been in use for over a year and we have received very positive feedback from
both operational staff, trauma teams and pelvic surgeons within the major trauma centres.
Staff are reminded of the following in reference to the Prometheus Pelvic Splint:
The middle of the splint should be positioned at the level of the greater trochanter (see red arrow below in Fig 1),
if it is positioned too high (at the level of the iliac crest) this can cause the IC joint to widen and potentially
worsening any haemorrhage in the case of a fracture. Accurate positioning is vital (see Fig 2).
Fig 1
Fig 2
The pelvic splint should only ever be applied directly
over skin. It is simply pointless to apply over clothing as
the splint will need to be released to remove the clothing
at hospital and the tamponade effect of the splint will be
lost.
The pelvic splint should always be cut to size and not
folded over (as in Fig 3). This allows for more accurate
placement.
Staff are reminded that the application of a pelvic splint
denotes a suspected fracture of the pelvis and as such
the patient triggers the major trauma tool and should be
conveyed to a major trauma centre.
Fig 3
Clinical equipment failures in practice
If staff experience the failure of a piece of clinical equipment, it is important that the equipment is retained and
submitted with an LA52 to the complex management team. If contaminated, the equipment should be placed
into a sealed bag. Isolation of equipment that fails enables prompt and detailed examination to be completed to
identify why a failure may have occurred (and if there is a requirement for wider alerting of a problem). Any batch
number should be recorded on the LA52. Complex management teams should contact Safety and Risk to
determine exactly what action needs to be taken concerning the failed equipment.
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Clinical update
Bag, valve mask (BVM)
Occasionally during transit or resuscitation the connector which contains the blue ‘duck bill’ valve (just above where
the bag connects to the mask) may work itself loose. The same valve can simply be replaced and the connector
screwed back together. This takes approx three seconds to resolve. This is a known issue with multiple brands of
BVM and the service is working with the supplier to resolve it. It is recommended that you check that this connection
is tight when you first start to use the BVM.
Bags
A work stream as been commenced to review both the response and paramedic bags. This group contains
representation from the Medical Directorate, Safety and Risk and operations along with a number of Staffside
representatives. The group’s initial meeting discussed an outline specification which has been submitted to
manufacturers and we are currently reviewing the responses. From this we hope to be able to identify a number of
products to trial in the near future.
When did you last check your bag?
All staff who carry personal issue clinical equipment are reminded that it their responsibility to undertake regular
checks to ensure that all stock is within date. Clinical equipment should be stored within its original sealed
packaging.
Leaving oxygen and Entonox cylinders at hospital
All oxygen and Entonox cylinders are now asset tracked by BOC (the Service’s supplier of medical gases). BOC
has advised the Service that approximately 500 cylinders are being left at hospitals every month, incurring a cost to
the Service of circa £74,000 per year in extra rental charges. Most of the Service’s cylinders are at least ¾ full when
collected from hospitals by BOC. Once cylinders are collected, they are automatically emptied, cleaned and refilled
irrespective of how much oxygen remains in the cylinder. This incurs significant unnecessary expense to the
Service.
It is extremely important that crews do not leave oxygen or Entonox cylinders at hospital.
Mark Faulkner, Clinical Advisor to the Procurement Department
Controlled drugs (CDs) reminder: Legible entries in the CD register
All staff are reminded that is an absolute requirement of controlled drugs legislation, (and Service policy), that they
are required to print and sign their name in the CD register. The printed element must be legible and must be at
least the full surname and initials of the person making the entry. During a recent audit of CD registers the printed
name was only legible in 30 per cent of entries in some CD registers. Whilst other CD registers showed better
compliance, there was only one CD register that showed absolute legibility for all entries. Compliance will be reaudited in the near future and staff who fail to legibly print their name will be open to censure by the Service.
David Whitmore, Senior Clinical Advisor to the Medical Director
Edited by Jo Nevett, Clinical Advisor to the Medical Director
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