Volume 10 Issue 3
Prehospital unfractionated heparin prior to primary PCI
Introduction: Unfractionated heparin is an anticoagulant used by some, but not all, ambulance services in the treatment of patients who will undergo primary percutaneous coronary intervention (PPCI) due to ST-elevation myocardial infarction (STEMI). Aims: The purpose of this study is to review the effectiveness and safety of prehospital unfractionated heparin administration to STEMI patients prior to PPCI, and to consider whether this drug should be more widely used for these purposes across international ambulance services. Methods: A literature search was conducted to identify articles relevant to prehospital unfractionated heparin (UFH) administration prior to PPCI. Eighteen journal articles and ten clinical practice guideline compendiums from international ambulance services were selected for this review. Results: The reviewed literature unequivocally demonstrates that early anticoagulant administration is safe, effective and highly appropriate for STEMI patients who subsequently undergo PPCI. There are disagreements, however, about whether UFH is the more optimal anticoagulant when compared with enoxaparin. Conclusion: This study finds that anticoagulants—such as unfractionated heparin or, in some jurisdictions, enoxaparin—should be strongly considered as a standard feature of prehospital treatment regimens for STEMI patients who will subsequently undergo PPCI.
How student paramedics navigate a changing UK healthcare landscape
Background: Paramedics have witnessed a huge shift in their role as providers of prehospital emergency care, although little is known about how student paramedics manage the competing demands they face in practice. Aim: To explore how student paramedics experience the changing healthcare landscape. Method: Semi-structured, focus groups and thematic content analysis was adopted. A purposive sample of student paramedics at different stages of their diploma preparatory training were invited to participate in focus group interviews. Findings: Participants considered that other services and the public perceived the purpose of emergency paramedics as largely a traditional one, as a service to transport patients to hospital. This appears to influence how they manage complex clinical situations. Student paramedics' clinical decision-making is frequently influenced by the emotional environments in which they work, combined with difficult communication with patients and a lack of support from the various professional groups involved in patient care. Conclusion: This study has highlighted the complexity of situations that student paramedics find themselves in while making decisions, which has important implications for paramedic educators and those supporting them in practice.
Disruptive innovation: barriers, opportunities and differences internationally
Around the world, the paramedic profession evolved from a small number of pilot programmes in the early 1970s, becoming a widespread trend in healthcare across much of the world. This case study focuses primarily on the UK, and England in particular, but also reflects on the international nature of the paramedic phenomenon, seeking to learn lessons from the successful features of individual programmes and approaches, in order that good practice can be promoted and shared. It also indentifies barriers to progress as well as opportunities. The purpose of all early paramedic initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity which, in many countries, was professionally recognised and regulated. This trend can be termed ‘disruptive innovation’—something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in all ambulance services or emergency medical systems, which in some cases have lagged behind and failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, which have hampered practitioners' ability to make full use of their skills. This has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover in the UK and sometimes elsewhere. For many reasons, most evidently the reality of changing patient demand, an increasing number of ambulance services are gradually morphing into primarily urgent care organisations, de-emphasising the transport aspect of the service. Changes are therefore needed to its model of operation and to staff management and support.