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Latest Articles
Volume 15, Issue 10: Ehlers-Danlos syndrome – just a joint issue or a much bigger problem?
October
You’re feeling exhausted after a hectic night shift but before you can take a break the next call comes in – a 23 year old woman with knee pain. On arrival you find Samira with a dislocated patella, she tells you she has Ehlers-Danlos syndrome, what do you know about this condition?
CPD benefit
Ehlers-Danlos syndrome (EDS) is thought to affect 1 in 5000 to 1 in 100,000 people, although it is
is often under-recognised and under-diagnosed. A major component of EDS is joint hypermobility abnormalities but it can affect not just the ligaments, but also the skin, internal organs and, in some cases, blood vessels. This article provides guidance on best practice when providing acute care for patients with EDS in the pre-hospital setting. This includes the best way to manage the patient’s pain and safely transfer them to hospital, enabling you to provide these patients with tailored care for a
complex life-long condition.
Volume 15, Issue 9: Under pressure – the weight of crush syndrome in the pre-hospital setting
September
You are returning to base when you receive a message from dispatch: ‘Forklift accident, male patient trapped’. A ‘major trauma’ with an ETHANE requested at your earliest convenience. Feeling apprehensive you start to run through the best practice guidelines with your colleague …
CPD benefit
Crush Syndrome (CS) manifests as systemic harm caused by the crushing or pressure-induced injury to muscle cells. It is multifaceted and can cause a number of secondary, potentially life-threatening conditions, such as compartment syndrome, hyperkalaemia, hypocalcaemia, metabolic acidosis, shock and acute kidney injury (AKI). This article discusses these conditions and gives guidance on best practice for assessing the patient at the scene, including recognising the need for early activation of other assets, such as fire and rescue, tech rescue and HART. There is also advice on the management of patients in the pre-hospital setting, ensuring you quickly recognise the resources required and appropriately monitor your patient throughout, enabling you to provide the best possible care for this complex condition.
Volume 15, Issue 8: Delirium – A confusing condition
August
It’s a hot sunny bank holiday, you are just about to take a well-earned break when a call comes in for an 80-year-old male who is acutely confused. On arrival the patient’s daughter mentions that this level of confusion is completely out of character, you start your assessment but there are so many differentials to consider…
CPD benefit
Delirium is a term used to describe an acute deterioration in mental functioning over hours or days. It is a very common medical emergency, particularly in older people, which can lead to misdiagnosis of dementia. This article discusses the aetiology and pathophysiology of delirium including the combination of pre-existing risk factors and precipitating factors that increase the likelihood of a patient developing delirium. There is also guidance on how to assess and diagnose patients in the pre-hospital setting using screening tools such as 4AT and the PINCHME mnemonic. There is useful advice on good practice in pre-hospital management, such as considering alternatives to hospital admission, that will enable you to provide the best possible care for patients presenting with this complex, multifactorial condition.
Volume 15, Issue 7: Bleeding in early pregnancy – why am I bleeding?
July
It’s early on a nightshift when a call comes in for a 32-year-old female with vaginal (PV) bleeding. When you arrive you find Laura and her partner, she is nine weeks pregnant and fears she is losing her baby. After your assessment you think that she is likely experiencing a miscarriage – how you will proceed?
CPD benefit
Any bleeding from the genital tract during pregnancy is of concern and in early pregnancy may indicate miscarriage or an ectopic pregnancy. This article discusses vaginal bleeding in pregnancy including risk factors, the definition and symptoms of miscarriage as well as possible complications. There is advice on how to make a differential diagnosis, taking into consideration other pregnancy-related conditions that can cause bleeding and advise on using the pre-hospital maternity decision tool in assessment. There is also guidance on how to manage fetal tissue if a miscarriage takes place and how to manage and treat the mother. This will enable you to provide the best possible patient-centred care, recognising that a miscarriage can be both a medical emergency and an emotional crisis.
Volume 15, Issue 6: Child sexual exploitation – the signs that cannot be ignored
June
Close to the end of your shift you receive a call to attend a 14-year-old female with suicidal thoughts, on arrival you find a well presented young girl whose mother discloses some concerns alerting you to the possibility of child sexual exploitation – who do you inform and how?
CPD benefit
Child sexual exploitation (CSE) is a type of sexual abuse where the victims are children and the perpetrator takes advantage of them for their own benefit. It is becoming increasingly prevalent through many forms of modern technology and social media, which can be used as tools to gain access to and groom young people. This article provides guidance on how to recognise CSE, including a table of indicators and risk factors. It also outlines safeguarding guidelines and how they apply to pre-hospital clinicians. This will enable you to use best practice to identify CSE and apply safeguarding guidelines to try and ensure the safety of the victim and their family.
Volume 15, Issue 5: Aortic stenosis – a SAD case of valve trouble
May
You are heading back for a much needed meal break when someone waves you down, you see a woman in her late sixties lying on the floor, she felt lightheaded after running for bus and has a history of aortic stenosis as well as chest pain – you start an assessment thinking through the guidelines at the same time…
CPD benefit
Aortic stenosis (AS) is the most common valvular heart condition in the UK and Europe, affecting an estimated 1.48% of people over 55 years old in the United Kingdom. Valvular heart conditions are often an area that ambulance staff have little training on, which may lead to symptoms being attributed to other causes. This article describes the anatomy and physiology of the aortic valve and goes on to discuss causes and signs and symptoms of AS, including the AS triad. There is guidance for pre-hospital clinicians on how to obtain a thorough history and assessment which is imperative to the identification of red flags associated with this condition. Such red flags should result in patients being transported to hospital, where further tests can be conducted.
Volume 15, Issue 4: Cardiac arrest in the LVAD patient – an alarming situation
April
You are working a day shift as a solo responder when you are dispatched to a category-1 call, ‘Heart machine alarming’. On arrival the patient is unresponsive and you are told he has a heart pump device. You start to assess the situation and the best course of action…
CPD benefit
The number people living with left ventricular assist devices (LVADs) in the United Kingdom has been increasing over time which means that clinicians have an increased likelihood of encountering these patients in the pre-hospital setting. This article provides guidance on how LVADs work and the best way to manage an LVAD patient in cardiac arrest. This includes troubleshooting the device with the use of algorithms and a summary of the challenges and pitfalls to be aware of when responding to these patients. There is also guidance on making sure you access care plans as well as advice from specialist centres and family members in order to ensure the best possible practice in the management process.
Volume 15, Issue 3: Antepartum haemorrhage (APH) – a bloody warning from an underlying cause
March
You respond to a call for a 23-year-old female with abdominal pain, on arrival you see that the patient, Lucy, is conscious and breathing but in severe pain and she is supporting her pregnant abdomen. You begin your assessment but wonder how best to transfer her to the ambulance?
CPD benefit
Antepartum haemorrhage presents a risk to maternal as well as fetal well-being and can give rise to conditions that cause serious complications if not promptly diagnosed and treated. This article examines the aetiology, predisposing factors and pre-hospital management approaches linked with antepartum haemorrhage. Timely recognition, accurate diagnosis and prompt intervention are crucial in managing this symptom effectively and ensuring the best possible outcomes for both patients
Volume 15, Issue 2: Shock in trauma – beware of the lethal triad
February
It’s a rainy day and you’re finishing a welcome hot drink when a Category 1 call comes through: ‘37-year-old construction worker, unconscious but breathing after an accident’. On arrival, the patient is conscious but in shock and you initiate treatment en route to ED. Your colleague hands you a bag of sodium chloride but you hesitate – should you administer fluids?
CPD benefit
Shock is an acute state of inadequate perfusion of the cells and tissues of the body, which, if not corrected, can lead to multiorgan failure and death. Haemorrhagic shock, caused by a loss of circulating volume due to blood loss, is the most common cause of shock in trauma.
This article examines how the body responds to haemorrhage and stresses the importance of patient presentation in the assessment and management of haemorrhagic shock. It discusses trauma coagulopathy and the lethal triad, and connects this with fluid resuscitation and permissive hypotension, helping you provide nuanced and up-to-date care for patients with this critical, life-threatening condition.
Volume 15, Issue 1: Shock ‒ the perils of poor perfusion
January
Shock ‒ the perils of poor perfusion
You’re heading back after a busy shift so far, an NSTEMI, a suspected PE, some D&V and a case of sepsis, quite a variety you think, but then your crewmate mentions how similar they all were. What can he mean?
CPD benefit
Shock is a life-threatening, acute failure of the circulatory system to adequately perfuse the tissues of the body. If not identified and managed appropriately, shock can lead to multiorgan failure and death. This article outlines the variety of medical or traumatic events that can lead to shock and the stages of shock through which a patient may progress. It also examines how the body responds to inadequate perfusion and the signs and symptoms to help you identify shock or the potential for it to develop. There is useful guidance on the assessment and management of shock in the pre-hospital environment to enable you to respond effectively where this life-threatening condition could be present.
Volume 14, Issue 12: Caring for patients in prolonged care situations – an opportunity to become a HITMAN shouldn’t be MISSED
December
Caring for patients in prolonged care situations – an opportunity to become a HITMAN shouldn’t be MISSED
You are just back from leave and starting your shift when a call comes in to a Category 2 for a 75-year-old man who has fallen and can’t get up. When you arrive the patient says he has been on the floor for two hours and his history indicates that you should convey him to ED. When you arrive at ED the waits are very long – should you have waited before conveying?
CPD benefit
Out-of-hospital care has been changing in recent years, there are longer wait times outside the ED and it has now become normal for pre-hospital clinicians to deliver care for prolonged periods, which is not necessarily what they were educated to do. This article shows how the HITMAN mnemonic can be used by clinicians adapt their practice to keep up with the ever-evolving care environment. There is guidance on each element of the mnemonic demonstrating how you can support your patient and deliver a good level of care during their prolonged ambulance wait. There is also guidance on the related MISSED mnemonic highlighting some of the most crucial conditions and the regular medications that are required to control them.
Volume 14, Issue 11: Carbon monoxide poisoning – the silent killer
November
Carbon monoxide poisoning – the silent killer
It is a cold November day and it has been unusually quiet, as you are heading back to station you receive a call for a 65-year-old female with acute confusion and weakness. Initial assessment does not offer any obvious reason for this – have you considered all the possibilities?
CPD benefit
Carbon monoxide (CO) is a colourless, tasteless and odourless gas that is produced during the incomplete combustion of carbon-based compounds. CO poisoning is potentially life threatening, with around 40 deaths attributed to it in England and Wales every year. This article outlines the epidemiology and pathophysiology of CO poisoning. It provides guidance on how to assess a patient with possible CO poisoning including differential diagnosis, which can be challenging for the pre-hospital clinician. There is also advice on how best to manage the patient including treatment that can be given in the pre-hospital setting and when to convey the patient to the ED.
Volume 14, Issue 10: Migraine – what a headache!
October
Migraine – what a headache!
It’s November – grey, gloomy and damp, the second job of the shift comes in. It’s a call to a 52-year-old female with a “severe headache”. When you arrive you assess the patient and find that she has had migraines in the past, you decide to leave her at home with worsening advice for migraine. Later you start to worry – did you miss some big red flags in her history?
CPD benefit
Migraines are extremely common, experienced by around 12% of people, paramedics will often encounter patients experiencing migraines on the more severe end of the spectrum. This article describes the pathophysiology and signs and symptoms of migraine, it also provides guidance on how to provisionally diagnose migraine which can be challenging in the pre-hospital setting. There is advice on assessment, treatment options and long-term management of the condition to help you effectively manage your patient by excluding red flags and concerns of a secondary headache disorder which might warrant transportation to an ED or onward referral.
Volume 14, Issue 9: Modern slavery and human trafficking – could you be the final piece of the puzzle?
September
Modern slavery and human trafficking – could you be the final piece of the puzzle?
You are a paramedic based in police custody, working as a forensic healthcare practitioner (FHP). A detainee is brought to your attention, she was arrested for shoplifting and resisting arrest. Custody staff noticed physical signs of injury and think she may be a victim of modern slavery and human trafficking (MSHT) but she does not admit to this – should you refer her through the National Referral Mechanism (NRM) even though she does not consent?
CPD benefit
For the year ending June 2023 the UK Home Office reported 22,796 victims of modern slavery brought to their attention. This article outlines the most common types of exploitation such as labour, forced criminality and sex trafficking. It also gives guidance on how to identify a potential victim of modern slavery and human trafficking (MSHT) and the potential effects of exploitation on an individual. There is some useful discussion about treatment and how to make a referral to the police without consent to enter the National Referral Mechanism (NRM). This will enable you, as a paramedic, to support the victim and potentially help many others working to prevent the exploitation of human rights through slavery and trafficking.
Volume 14, Issue 8: Slapped cheek syndrome ‒ red cheeks
August
Slapped cheek syndrome ‒ red cheeks
It’s the start of your shift when your radio alerts you to a call for a five-year-old with a rash. On arrival you meet Hannah sitting with her mum, her cheeks are bright red, she has been off colour all week and now her rash has spread. You begin your assessment, thinking about the differentials – this could be time critical…
CPD benefit
Slapped cheek syndrome is otherwise known as parvovirus B19 or ‘fifth disease’ (as it is fifth on the list of childhood viral skin rashes, with the others being measles, rubella, chicken pox and scarlet fever). Slapped cheek syndrome is most prevalent in children aged 5–10 years and is very common, with 50% of adults and 85% of the elderly having parvovirus antibodies in their blood. This article outlines the signs and symptoms of the disease and how it is transmitted. There is also comprehensive guidance on how to assess a child with a rash, differential diagnosis (including red flags for meningitis and sepsis) and possible complications to be aware of when other medical conditions are present. This will enable you to identify the disease and give reassurance and management advice to the patient and their carers.
