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Spring 2014 - Issue 1 | Volume 11

Today

Ambulance Europe’s leading magazine for NHS,Voluntary and Private Ambulance Services Now going out directly to the email boxes of all 25,000+ UNISON ambulance members in the UK

Come to Stavanger, Norway... And Meet the ordinary people responsible for World-Beating Witnessed Cardiac Arrest Survival Rates

Photograph by Svein Lunde

2014 Prehospital Cardiac Care Special Edition

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Guest Editor Dr Gareth Grier

Let’s Learn from the Stavanger Experience! Dr Gareth Grier

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It has been over three years since we held the first London Cardiac Arrest Symposium (LCAS) at the Royal Geographic Society in Kensington. The event was created to bring the latest thinking and understanding on cardiac arrest research and management to everyday providers. Sponsored by Zoll, the symposium was a huge success bringing together professionals from the ambulance service, doctors, nurses, resuscitation officers and industry experts - both as delegates and as speakers - to focus on the vital issue of improving cardiac arrest care, both inside and outside the hospital setting. At our request, it was covered exclusively by Ambulance Today and the feedback we eventorganisers received as a result of the excellent report by editor, Declan Heneghan, reinforced our belief that encouraging discussion about cardiac care best-practice was something well worth continuing. It was out of our first LCAS event that the idea for an annual edition of Ambulance Today dedicated exclusively to prehospital cardiac arrest issues was born and I’m delighted to say that, like our own LCAS event, it has proved to be an outstanding success. So here I find myself, as Guest-Editor welcoming you all to this third Ambulance Today Prehospital Cardiac Care special edition. But first, let me offer you a snapshot of some of the highlights that were on offer at our most recent symposium. Dr Richard Lyon opened LCAS 2013 with a presentation on the TOPCAT (Temperature Post Cardiac Arrest) trial. This is a prospective observational study of patients with OHCA during the prehospital phase of resuscitation, while in the Emergency Department, and through to the ICU. Professor Simon Redwood spoke about treatment strategies for the now better-known ‘post cardiac arrest syndrome’, an increasingly recognized and complex phenomenon regarding which there are many challenges for the future, especially in the prehospital phase. Internal cardiac massage for cardiac arrest of a medical aetiology was put back at the top of the agenda by Professor Karim Brohi who made a compelling case for performing thoracotomy and internal massage to maximize cardiac output and coronary/cerebral perfusion during cardiac arrest from such causes as pulmonary embolism, and ‘hypoxic’ arrests such as drowning. Sharing information on cardiac arrest, by the construction of cardiac arrest registries can be life saving, and can transform the interventions delivered to patients. Tackling this subject, Dr Brian Mc Nally looked at the positive impact that cardiac arrest registries can have on patients. Finally, a very useful overview was given by Professor Eldar Soreide on cardiac arrest as an entire topic, with examples of where resuscitation care is at its most excellent. It is clear that there are huge contrasts in outcome from cardiac arrest across the globe, even in very similar populations and geographical areas. Dramatic improvements can be made if systems learn from areas of best practice, with a global overview. This is a topic covered in this edition in our look at the extraordinary success of the Stavanger region of Norway, of which Professor Soreide is a driving force in their constant pursuit to improve levels of prehospital cardiac care.

Spring 2014 | Ambulancetoday

Stavanger is a unique oil community that can proudly claim to offer its citizens a significantly better chance than virtually any other place on the planet of surviving OHCA. Being home to Laerdal, a global leader in cardiac care technology, has probably been a factor in Stavanger’s amazing success. However, as Dr Conrad Bjørshol and his impressive group of co-authors from ambulance, hospital and air ambulance, explain, what makes this region unique is its citizens’ strong belief that all individuals should be equally committed and equipped to do that most amazing of things – to actually intervene and begin treatment whenever they find themselves first-on-scene for a cardiac arrest. So in Stavanger when a person finds themselves as the sole bystander witness of an out-of-hospital cardiac arrest, not only do they know which number to dial to ensure the quickest possible EMS response, but they’re likely to be trained and conditioned to begin treatment calmly and confidently there and then; to make themselves the first vital link in the chain-of-survival! Also in this edition we’ve yet again enlisted some truly notable experts in the field; not least the preeminent Professor Douglas Chamberlain, seen by so many of us as the Father of prehospital cardiac training, who has generously provided us with a thought-provoking yet common-sense Foreword. SECamb Paramedic, Rhiannon Roderick, a recent graduate of the Oxford Brookes University Paramedic Science course, also writes for us on the pathophysiology and recognition of agonal breathing, providing us with reassuring evidence that, thankfully, the young blood pulsing into the veins of the ambulance service is as passionately committed to clinical research and the maintenance of high clinical standards of patient-care as any previous generation has ever been. But as our LCAS event reminds us, it’s important to remember that continuing clinical research into cardiac care is essential if we’re going to continue to improve survival outcomes for patients of OHCA. As Douglas has said for over half-a-century now, and as he continues to say as forcefully as ever: “We should always strive to do better. We owe it to our communities!” So, in closing, I sincerely hope you enjoy this special edition of Ambulance Today and that it will stimulate positive debate amongst prehospital clinicians and volunteers across the UK and the rest of Europe. For those of you who like Douglas, Rhiannon and the people of Stavanger are strongly committed to improving the level of care we provide to cardiac arrest victims, we hope to see you at our 2014 London Cardiac Arrest Symposium, being held in December, when, once again, we’ll be bringing you the latest developments in the field, from an equally talented and illustrious field of experts. Dr Gareth Grier

Guest Editor & Consultant in Emergency Medicine and Prehospital Care Royal London Hospital 3


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Issue 1, Volume 11: Spring 2014 Next Issue: Summer 2014

CONTENTS

www.ambulancetoday.co.uk This Issue is Supported by:

Visit our new-look Ambulance Today web-site and register for your free DIGITAL copy at: www.ambulancetoday.co.uk

INSIDE YOUR SPRING ISSUE: Welcome to our Spring 2014 Prehospital Cardiac Care Special P7. Are We Improving Outcomes from Out-of-Hospital Cardiac Arrest? Professor Douglas Chamberlain asks: Are we improving outcomes from out-of-hospital cardiac arrest?

P11. It Takes a System to Save a Life Stavanger – the remote Norwegian region boosting survival rates of witnessed cardiac arrest

P25. Letter From Amsterdam Dutch correspondent Thijs Gras gives a history of Prehospital Cardiac Care in a heart-beat!

P16. Medivital – Vital for Life A look at GCE’s break-through integral valve system for gas control

p26. Intelligent Electrical Engineering from Intellitec Intellitec already supply to 100% of UK fire services… Now ambulance services are discovering them!

P29. Don’t Delay Resus if Agonal Breathing Presents

P46. Eberspächer & O&H –
Improving UK ambulance fleet for 25 Years High-output air conditioning & ambulance build – a perfect partnership!

P49. Call Me, Call Me! US correspondent Jerry Overton looks at the vital role of dispatch in cardiac arrest response

P37. MEND - Focus on Advanced Stroke Life Support Solutions Training unveil the on-line US examination improving outcomes for stroke patients

P55. Focus on Interpreting ECGs Learn how to read between the ECG lines!

P64. RCA Ambulance Redesign Project Goes Pan-European We take a look at the amazing progress of the RCA’s ambitious project to redesign the 21st century ambulance vehicle

Also Inside: UNISON Update National Ambulance Lead Hope Daley’s Update

SECamb’s Rhiannon Roderick on understanding agonal breathing in cardiac arrest

ASBF News

p34. Save Time…Save Revenue… Save Lives!

Out & About

Churchill MakeReady are the UK’s first professional suppliers of vehicle preparation services to the Ambulance Sector. Learn more!

P41. Effective Team Leadership During RT A look at the role of the Paramedic team leader in Prehospital Resuscitative thoracotomy

Lorna takes up the ASBF challenge

The latest news from services around the UK

Products & Suppliers

Latest in new products, services & technology Front page photograph by Svein Lunde shows a representative group of the citizens and EMS workers from Stavanger. Everyone featured has been involved in their exceptional prehospital cardiac care success story. From left to right they are: Air ambulance physician (anaesthesiologist), paramedic, in-hospital anaesthesiologist, simulation coordinator, dispatch operator, bystander, fire fighter and an ER nurse.

We’d welcome your feedback on this edition! Contact us at: editor@ambulancetoday.co.uk EDITOR: Declan Heneghan email: editor@ambulancetoday.co.uk CORRESPONDENCE: All correspondence should be sent to: The Editor, Ambulance Today, 41, Canning Street, Liverpool L8 7NN DESIGN & Production: L1 Media email: L1media@yahoo.co.uk For advertising enquirIes call: +44 (0)151 703 0598 or FOR EDITORIAL CALL: +44 (0)151 708 8864 COPYRIGHT: All materials reproduced within are the copyright of Ambulance Today. Permission for reproduction of any images or text, in full or in part, should be sought from the Editor. PUBLISHER’S STATEMENT: Ambulance Today magazine is published by Ambulance Today Ltd, 41 Canning Street, Liverpool L8 7NN. The views and opinions expressed in this issue are not necessarily those of our Editor or Ambulance Today. No responsibility is accepted for omissions or errors. Every effort is made to ensure accuracy at all times. Advertisements placed in this publication marked “CRB Registered” with the organisation’s “CRB Registration No.” means that the Organisation/Company meets with the requirements in respect of exempted questions under the Rehabilitation of Offenders Act 1974. All applicants offered employment will be subject to a Criminal Record Check from the Criminal Records Bureau before appointment is confirmed. This will include details of cautions, reprimands or final warnings, as well as convictions and information held by the Department of Health and Education and Employment


Pearson College – Be Inspired‌ Pearson College is part of the Pearson family. We are the world's foremost education company and a successful global business with a range of world leading companies that includes the Financial Times. Pearson College has been created to develop a new approach to higher education. For our new paramedic programme we will be bringing together our unique experience of delivering the IHCD qualifications with an innovative and flexible academic programme of study. Pearson College will be offering a BSc in Paramedic Science from September 2014 which will encompass discrete awards at levels 4, 5 and 6. Our intention is that students completing the level 5 Diploma will be eligible to apply for registration as a paramedic with the Health Care Professions Council. Our paramedic programme will be delivered through a number of Provider Partners spread throughout the UK. We are seeking to appoint candidates for the following posts within the School of Applied Sciences (Paramedic Sciences department): National Paramedic Programme Lead Job Ref: NPPL Location: Home based with occasional visits to our London Campus Salary Range: 60K pro rata (negotiable, secondments will be considered) Contract: 0.6 fraction or full time Contract Type: Negotiable The purpose of this post is to take the overall leadership and management of the student learning experience and on-going development of Pearson’s undergraduate suite of programmes in Paramedic Science. The post-holder will be at the forefront of developing the nature and ethos of the Pearson paramedic programme working closely with the Vice-Principal (Education and Research). Key Accountabilities will include: overseeing the provision of the programme through a network of Provider Partners; ensuring consistency and excellence in our on-line teaching materials; supporting learning and assessment practices and processes across all Provider Partners; teaching within an area of specialism; engaging in research and/or scholarship in the fields of para-medicine and ensuring Pearson College meets its quality obligations for the paramedic programme. National Module Leads Job Ref: NML Location: Home based with occasional visits to our London Campus Salary Range: Negotaible subject to module and experience Contract: Part-time or seconded Contract Type: Freelance We are seeking to appoint a number of successful and dynamic paramedic educators and/or clinical specialists to lead in the teaching of modules across our new and innovative blended learning paramedic programme. Individuals will be seconded for part of the week from their clinical or teaching posts in the NHS or independent ambulance sector, or may fulfil this role part-time. We are specifically looking for expertise in the following areas: Levels 4 and 5 - general paramedic medical and trauma, paediatrics; obstetrics, gynaecology and care of the newborn; evidence based practice; professional issues and context of healthcare. Post registration - research methods; advanced clinical assessment; pharmacology/prescribing; primary care; critical care; education and training; leadership and management. For further information or to apply, please send a CV and Covering Letter to jobs.pearsoncollege@pearson.com. Please quote the job title and reference when applying. Applicants must be eligible to work in the UK. Closing date: Sunday 11th May 2014. Visit pearsoncollege.com


Foreword by Professor Douglas Chamberlain Sponsor of London’s Cardiac Arrest Symposium

Can we improve outcomes from out-of-hospital cardiac arrest? This issue of Ambulance Today magazine provides something of a Masterclass in the management of out-of-hospital cardiac arrest. New scientific advances will come but we have only to apply effectively what is already known to achieve a notable increase in survival; this is especially important for events that are unexpected and can be considered premature. Readers should take note of all that is written in the pages that follow, and consider what lessons and actions they and their organizations need to take to achieve improvements that may be long overdue. Cardiac arrest does provide a very great challenge because management is simple in concept yet difficult in practice and because even healthcare professionals see few cases during any one year. For all but the briefest emergencies it is safe to say that there has never been a faultless resuscitation attempt! But the closer we can get to perfection the better our results will be. The considerable differences in survival between centres has long been known but should not be considered acceptable. We have long known the term, ‘Chain of Survival’ to describe management of cardiac arrest. Consideration of the links will provide all with ideas for the improvements that we should be seeking. First comes recognition of the emergency, coupled with immediate first aid. Some training is clearly advantageous, yet only a minority in Britain have had this. By far the best time to learn is during the formative years of childhood. Norway has shown the way; since 1962, first aid instruction in schools has been mandatory. The first lessons on how to call for help can be learned by youngsters even in their first school years, with new knowledge and skill added year by year. Such early instruction is rarely forgotten, yet in the United Kingdom efforts to make this part of the curriculum have been resisted by government. A second link comes with the dispatch of appropriate help. Clearly this is a matter for ambulance services, but it should not be a matter solely for ambulances! Cardiac arrest within the community should call for a community response because the best results in resuscitation require effective treatment within about five minutes — too short an interval for most ambulances but within the range possible for community first responders in most areas if they are properly organized and suitably equipped. We have not learned how to make best use of the many within the community who would be willing to undertake training if properly encouraged and trained. Moreover, if community responders are not notified by dispatchers within 30 seconds of the professional ambulance in response to a call for collapse, then the scheme is not properly managed. Spring 2014 | Ambulancetoday

A third link relates to performance during the emergency. Whilst this applies to both professionals and lay helpers, the details are necessarily different. Paramedics should have had advanced training. But however skilful they may be, the early life support measures are threatened by understandable anxiety in the rescuers that is best countered by feedback of information on quality of compressions and ventilation — ideally during the emergency. At present, techniques for checking correct timing and depth of compressions are more readily available after the event from electronic downloads but even these are rarely scrutinised. Increasingly, however, unobtrusive methods are becoming available for immediate feedback that can be used both by professionals and by community responders. In addition, professionals should make use of other methods that reflect the efficacy of compressions such as measurement of end-tidal CO2. A patient with cardiac arrest that does not respond immediately to treatment may still have the possibility of a successful outcome but more advanced skills may be needed and should be made available by a second tier of help. Some services, but not all, do have advanced grades of paramedics, a concept supported by their College. These should have available ultrasound that can give essential information on fluid depletion, tamponade, or pulmonary embolus. Prehospital drug treatment of arrhythmias may have a role that has not been fully explored. Mechanical compression devices should be available for use in selected cases. Medical backup can be called upon in some areas, sometimes by helicopter, so even invasive treatments can be feasible, if needed, in the pre-hospital arena. A fourth link is provided in hospital care. Many patients will arrive having gained a return of spontaneous circulation (ROSC) but admission should not be restricted to these. Immediate access to catheterization laboratories, even during mechanical compression, should be available as well as effective management of post cardiac arrest syndrome, described many decades ago but only recently emphasised in the resuscitation literature. Such expertise cannot be

available in every district hospital. We need therefore urgently to expand the concept and use of heart attack centres, in the same way that we need trauma centres. We know that survival even after admission with ROSC varies markedly between hospitals. Could our continued acceptance of this be regarded as a form of negligence? We also need reliable audit of results and in a form that permits comparisons between centres and indeed between countries. This is not easy to achieve, particularly because linkage between pre-hospital data and hospital data is not always straightforward. Use of the NHS number has been suggested but is clearly impracticable; but other effective linkage techniques could be used. They are not used. Better results can be obtained if attempts at resuscitation are made in only the more promising cases. Data should therefore be available not only on the size of the populations at risk and on the number of reported cardiac arrests, but also on the proportion for which attempts are made. Other refinements are needed to make data as comparable as possible when environments can be very different. These matters are well understood but not widely practised. A final point should be made. As well as improving management, using the Chain of Survival concept, we need to be aware that many practices hallowed by long usage may be ineffective or even harmful. Very little in our guidelines are fully supported by adequate trials. Research into out-ofhospital arrest has many inherent difficulties but we should not be deterred. Let us not accept uncritically all that we have been taught. But even with our present imperfect knowledge we could and should do better. Let us not be satisfied unless our results are as good as the best. Those who achieve the best may also be in a position to do even better. We have a duty to our communities. We should not be letting them down! Douglas Chamberlain. 3 7


UNISON Update Unison Comment

AmbulanceTODAY

The worrying truth about work-related stress in the ambulance sector Hope Daley

is UNISON’s Ambulance Sector Lead. Read on to find out about the key policy areas UNISON will be addressing on your behalf in their fight to prevent the many threats to ambulance services across the UK.

Stress at work is one of the biggest health hazards in the workplace and is a major concern within the ambulance sector. It is the cause of numerous health problems and is a major contributor to work related ill health and sickness absence. In at least one ambulance trust almost three times as many staff were being signed off for stress as for a common cold or flu during 2012-13.

service makes life intolerable for many of our members. Members accept that the ambulance service is physically demanding and challenging. However they expect employers to do all they can to manage, reduce and where possible eliminate the risks to the health and welfare of their workforce. But this is clearly not the case. In response to a question on the positive interest in their health and wellbeing that managers take, only 44% of staff felt that their organisation takes positive action on

And results from the latest NHS staff survey (http://www.nhsstaffsurveys.com/ Page/1010/Home/Staff-Survey-2013/) support this as over half of the thirty-nine percent of NHS staff who had cited work related stress as the reason for their ill health during the last 12 months were those working in ambulance trusts.

These demands have led to an increase in stress and pressure in the service, which is further worsened by the rise in levels of violence faced by staff. The survey also reveals that 33% of the fifteen percent of NHS staff who had experienced physical violence at work in the previous 12 months, were from ambulance trusts.

Spring 2014 | Ambulancetoday

More can and should be done to minimise the levels of stress faced by ambulance staff. Let us work together to prevent ambulance crews becoming patients rather than deliverers of a fantastic service. As a service there are concerns that not enough is being done to help staff who are facing stress at work. More could and should be done to avoid crews being over-exposed to aspects of work that would cause stress, anxiety or anger as there is enough of that within the 999 calls that they do. The sickness policies of most Ambulance Trusts either do not include the word “stress” at all or have a single sentence which states that “cases of stress must be referred to Occupational Health Departments”. That is the policy on paper; however in practice there are some measures in place which may be limited but are a good starting point. 1. Colleague Support – system of limited training to colleagues/ contemporaries/buddies who are the first port of call when a member of staff makes a request that they wish to seek confidential help and do not mind sharing their issues with a trusted colleague.

This is no surprise given the increasingly changing demands and nature of the service.

We know that stress is a complicated matter which is not easily explained within the frequent headlines seen in the media. Issues such as the nature of the work itself, the exposure to other peoples’ trauma, the mutilations, the cot deaths, burns, deformity and fractures, plus the raw turmoil that relatives find themselves in whilst screaming at the crew to resuscitate their partner or offspring or parents cannot be simply explained in a newspaper article as just a part of the job. In addition, the frustration of lengthy waits outside hospitals to hand over patients, the constant pressure to meet targets, longer shifts, cuts in staffing levels and the outsourcing of parts of the

absence, recognise that work related stress is threatening the health of ambulance staff, and jointly develop and implement effective stress control policies in partnership with UNIS0N stewards.

2. Confidential Counselling – contact with a trained professional who can help over 4 or 5 sessions with major traumatic issues. 3. Critical Incident Debriefing – following a major incident or serious case involving multiple casualties. health and well-being and while forty-one percent of staff are satisfied with the extent to which they felt that their organisation value their work, 21% of ambulance staff disagreed. We want employers to review their management of work-related sickness

UNISON has produced guidelines on work related stress that may be helpful in any prevention process. It includes a survey to help identify levels of work-related stress. A copy of the guide can be found here http://www.unison.org.uk/catalogue/18596

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Focus on World-Leading Cardiac Survival Rates in Norway Sponsor of London’s Cardiac Arrest Symposium The air ambulance is very versatile and gives great access to remote areas within a short time span. Photo: Conrad Bjørshol

“It takes a system to save a life”

The Stavanger Experience with the Utstein Formula for Survival: Read on to find out how superb team-work between ambulance, hospital and air ambulance colleagues in the oil-producing region of Stavanger in the remote South-West corner of Norway has resulted in some of the best survival rates of witnessed cardiac arrest in ventricular fibrillation among industrialized countries across the globe Introduction Stavanger is the oil capital in the south-west corner of Norway, a country in Northern Europe. The population in Stavanger Hospital Trust (5,700 km2) is approximately 330,000 inhabitants. Stavanger University Hospital (SUH) is the only hospital receiving patients after out-of-hospital cardiac arrest. The community is partly urban, but mostly rural. The current survival rate for witnessed cardiac arrest in ventricular fibrillation is 52%,1 a rather high number among industrialized countries. The survival rate for witnessed ventricular fibrillation varies greatly between different sites, from 3 to 43%.2 What is the secret behind this figure, and can it be improved further?

Figure 1. The Utstein Formula for Survival.

The Formula for Survival The Chain of Survival3 was first described in 1991, however science soon proved to be insufficient to explain the lack of survival in cardiac arrest. For the last decade Stavanger has focused on the Utstein Formula for Survival to further improve cardiac arrest care (figure 1).4,5 The Utstein Formula for

Nursing students and medical students cooperate to examine a deteriorating patient at the SAFER simulation center. Interprofessional training has recently become an integral part of their education. Photo: Ingve Hetland. Spring 2014 | Ambulancetoday

Survival consists of three components whose product indicate the survival rate: medical science, educational efficiency and local implementation. A Society of trained CPR Bystanders In the Stavanger region, 73% of cardiac arrests of presumed cardiac aetiology receive bystander CPR. This rate is considerable compared to most other industrialized countries. The reason for this high rate of bystander CPR is assumed to be national and local focus on layperson CPR training. Basic life support (BLS) is taught in schools and private CPR courses, in the health, safety and environment focused offshore industry and to learners applying for driver’s licenses. Additionally, the presence of local medical industry (Laerdal Medical Ltd.) may influence the regions inhabitants’ awareness and knowledge of CPR. We assume that the Stavanger region’s level of bystander CPR is not correlated only to CPR knowledge and skills, but also to generalized trust in society. Yet unpublished scientific data conclude that citizens in the Stavanger region perform CPR because they believe it is their duty to provide it. Doing something is considered as a value in itself, rather than omitting action. Individuals have great confidence in imagining bystanders performing CPR should a cardiac arrest happen to themselves. They also trust being assisted by other bystanders present in the cardiac arrest situation whilst providing CPR. Unlike bystanders in other regions,6 there is no evidence that citizens in the Stavanger region fear legal consequences after providing CPR. Bystanders have great confidence in the dispatcher’s guidance and also in the immediate arrival of an ambulance in cardiac arrest situations. Despite this sense of ‘duty’, it seems that providing CPR is conditional. The reason is not because of repugnance towards the cardiac victim, which might hinder

The EMS service cooperate closely with specialists from the hospital. Intervention cardiologist Alf Inge Larsen discusses cardiac arrest with paramedics at the Stavanger Ambulance Station. Photo: Conrad Bjørshol.

people performing CPR, but more of the character of the condition. Bystanders, who are located in cardiac arrest situations which are perceived as ambiguous or unsafe, will be reluctant to provide CPR. Thus, there are reasons to believe that positive and predictable social reactions as an appreciation after providing CPR is encouraging CPR provision in society. Medical Dispatch Center For decades, Norway has traditionally had separate emergency telephone numbers for the Emergency Dispatch Center (EDC), the fire service and the police. The EDC is constantly staffed with two emergency nurses and two paramedics. The EDC at SUH coordinates 18 ambulance units, general practitioners on call, and one hospital–based, anaesthesiologist-manned rapid response unit (helicopter or car). Instructions to callers are based on a medical index designed for use in EDC’s. Since 1991, the caller of a cardiac arrest has been instructed to start CPR. This includes mouth-to-mouth ventilations if trained in the technique. Otherwise the caller is instructed to administer continuous chest compressions. 11 3


Focus on World-Leading Cardiac Survival Rates in Norway Sponsor of London’s Cardiac Arrest Symposium

Professor Eldar Søreide gives a lecture on some of the local heroes who made contributions to the cardiac arrest survival rates in Stavanger. Photo: Conrad Bjørshol.

Automated External Defibrillators (AEDs) In the early 1990’s the EMS began a formal cooperation with the local fire brigades. Fire-fighters are regularly dispatched by the EDC as first responders in addition to ambulances; in particular when the fire brigade is closer to the scene than the ambulance. This protocol is implemented both in urban and rural areas. Approximately 10% of all cardiac arrest patients are defibrillated by fire fighters before the arrival of the first ambulance, many of whom have a shockable rhythm. This cooperation with the fire service has been strengthened over the last two decades. There are also a huge number of on-site AED’s, especially at hotels, schools, shopping centres and golf courses. Unfortunately, there is currently no national AED registry so their prevalence is uncertain. Still, a significant number of them are registered at the EDC. Recently, home nursing services have joined the regional first responder AED service. Ambulance Service All ambulances are staffed with two ambulance workers, one of which is an advanced life support-certified paramedic. The European Resuscitation Council’s (ERC) guideline changes in 2000 and 2005 were implemented shortly after their approval. Unlike the ERC guidelines, Norwegian 2005 advanced life support guidelines recommend three minutes between defibrillation attempts and that the pulse and monitor check is performed

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one minute after analyzing the heart rhythm and eventually defibrillation.7 Epinephrine is administered immediately after the pulse and monitor check. The ambulance service normally use their defibrillators in AED mode, but paramedics are licensed to defibrillate in manual mode if necessary. There is a strong focus on basic CPR quality. Therefore only basic CPR (according to ERC guidelines) and defibrillation (one shock every three minutes) is accepted when fewer than four paramedics are present. Advanced life support is only initiated after arrival of the second ambulance. There has been a strong focus on basic CPR skills both among paramedics and first responders, with regular certification on basic skills. The highlight of these basic skills has been supported by research. Airway management has been a challenge. Until recently paramedics have been certified to perform endotracheal intubation. However, due to the extensive training needs and restricted access to anaesthesized patients, we changed the advanced airway method to a supraglottic device in 2013. This change will be followed by evaluations and research and we will later decide if some paramedics will retain their certification to perform endotracheal intubations.

Air Ambulance The air ambulance at SUH was established in 1981. It consists of a helicopter and fastresponse car. The anaesthesiologist on call is employed by SUH and switches between pre-hospital and in-hospital duty. They also take part in teaching and certification of paramedics and EDC personnel. In addition to the anaesthesiologist, a rescue man assists the physician and also assists the pilot during flight. In cardiac arrests, the air ambulance offers facilitation of good quality CPR, advanced airway techniques, manual defibrillation, insertion of chest tubes and the use of ultrasound. In addition they offer rapid air transport to the regional cardiac arrest centre from rural areas, and interhospital transfer. They also participate in the training of health care providers and offer observer slots on a weekly basis.

Local general physicians are dispatched simultaneously with the ambulance service. They are a valuable resource for collecting information from bystanders, they can assist in CPR and they can also take care of relatives. Finally, they can also discontinue futile resuscitation attempts.

The Hospital For several decades, emergency medicine has been a prioritized area for Stavanger University Hospital (SUH) with a focus on integrating pre-hospital and in-hospital emergency care. SUH have been the operator of the ambulance service for more than 30 years and was the second city in Norway to establish an air ambulance service. CPR has been a specific target area for SUH for several decades within emergency care, development and research. The Emergency Room (ER) focuses on avoiding any unnecessary delays when the coronary intervention lab is ready. Necessary delays can be due to securing airways or initiating therapeutic hypothermia (TH).

ECGs are recorded immediately postROSC and transmitted to a cardiologist at the coronary care unit with whom the pre-hospital team discuss the anamnesis and specific therapy. When there is suspicion of an ischaemic reason for the arrest, the interventional coronary team is alarmed upon leaving the scene.

Most cardiac arrest patients are dispatched directly from the ER to the coronary intervention lab. The indication for acute angiography is made by the invasive cardiologist based on anamnestic information and usually a 12-lead ECG transmitted to the hospital from the ambulance immediately after ROSC.

All paramedics at the Stavanger Hospital Trust need to attend different retraining sessions. Each of these sessions last one day and are arranged 8-10 times, and all paramedics need to attend one of these dates. The subject changes every three months, and they all need to attend all four subjects each year. These retraining sessions are usually arranged at the simulation centre.

By arrival at the intensive care unit, target temperature (33°C) is normally already achieved, and TH is maintained by invasive technique or by surface cooling. TH is maintained for at least 24 hours. Instead of making decisions on whether to start TH we try to focus on making decisions on when NOT to initiate TH. The post-resuscitation treatment is regulated by a post-cardiac-

Spring 2014 | Ambulancetoday


Focus on World-Leading Cardiac Survival Rates in Norway Sponsor of London’s Cardiac Arrest Symposium

arrest procedure to avoid individual variation in treatment.8 TH was introduced as a standard treatment for unconscious cardiac arrest victims after ROSC as early as 2002.9

Figure 2. The Circle of Learning

Simulation training Stavanger Acute medicine Foundation for Education and Research (SAFER) is a local simulation centre which was founded in 2006. They use the Circle of Learning (figure 2) as a foundation for learning and achieved more than 9,000 participant days in 2013. Among other activities they conduct CPR training for the entire Chain of Survival, e.g. lay people, first responders, offshore health care providers, paramedics, dispatchers, GPs, anaesthesiologists and cardiologists. In addition to medical aspects, great attention is paid to non-technical skills, leadership, communication and inter-professional teamwork. Cardiac Arrest Research When SUH was transformed into a university hospital in 2005 more extensive cardiac arrest research was initiated. Research has been conducted on chest compressions,10,11 stress during CPR,12 CPR training,13 TH9,14-16 and survival,1,17 to name just a few. Currently, a study on using the chest compression machine as a bridge to acute percutaneous coronary intervention is being undertaken. Participation in

national and international organizations and committees have contributed to keeping procedures and standards at an internationally accepted level. A cardiac arrest Utstein registry has been run since 1996 which has provided a foundation for research and quality improvements. Several scientific congresses have been arranged in Stavanger which have increased regional and international collaboration in cardiac arrest, the most significant being the ERC Resuscitation 2006. In March 2014, the first European Resuscitation Academy was arranged in Stavanger, based on the concept from Seattle/King County. Looking ahead - Still Room for Improvement. As Mickey Eisenberg put it, “it takes a system to save a life”.18 There is no quick fix, and no person or department can improve survival significantly on their own. To achieve an acceptable survival rate the whole system has to have a continuous attention to all three factors in the Formula for Survival. For us, there are still areas where we want increased attention in the future: -We will continue to participate in scientific research on cardiac arrest. It helps us realize weaknesses in our own Chain of Survival. -We hope to implement electronic records of pre-hospital activity (including defibrillator CPR quality measurements) to increase transparency of our work, and increase individual feedback on quality. -We hope to improve educational efficiency, implement modern pedagogic techniques and possibly use telemedical equipment to facilitate learning in remote areas. - We continue implementation of high quality CPR through establishment of local paramedic training and the European Resuscitation Academy. - We intend to increase bystander CPR rates through research on CPR providers.

With these improvements in mind, there is no reason we should not have a survival rate of 60% for witnessed ventricular fibrillation within the next five years.

Figure 3. A simulated cardiac arrest in a living room at the SAFER simulation center. This simulated resuscitation was part of a research project on CPR quality during stress exposure.12 Photo: Conrad Bjørshol.

Figure 4. A simulated cardiac arrest patient arriving at Stavanger University Hospital with ongoing CPR using a LUCAS 2 chest compression device. Cardiac arrest patients are not routinely transported to hospital with ongoing CPR. Photo: Sigrun Anna Qvindesland.

Figure 5. In-situ simulation training, focusing on the three factors in the Utstein Formula for Survival: medical science, educational efficiency and local implementation. Photo: Sigrun Anna Qvindesland. Spring 2014 | Ambulancetoday

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Medivital - Vital for life 15 YEARS LIFE TIME

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• 15 year life time ensured by extended endurance and cycle testing for future market requirements

• Suitable for use in Homecare, Emergency and Hospital applications

• Slow opening shut off valve with new Patented design

• Easy read Flow Selector and Gauge

• Latest technology highest shock resistant gauge

• Shut off valve with clear open/closed status colour coded marking

• Flow selector designed for optimal gas flow and patient safety

• Ergonomic guard design allows easy handling of the cylinder package by all users

• Guard design provides maximum protection for the valve

• Compact and lightweight design less than 1150 gr • Easy clean guard material

For more information or to arrange a free trial contact Catherine Staffa at: catherine.staffa@gcegroup.com Call us on: 01942 292950 or visit www.gcegroup.com


Focus on World-Leading Cardiac Survival Rates in Norway Sponsor of London’s Cardiac Arrest Symposium

To find out more about prehospital cardiac care in Stavanger please email the corresponding author of this article, Conrad A. Bjørshol at: conrad.arnfinn.bjorshol@sus.no European Resuscitation Academy By Conrad Bjørshol In March 2014 the first European Resuscitation Academy was arranged in Stavanger. A group of employees from six different European countries were together to learn how to improve survival from out-of-hospital cardiac arrest. Instead of the traditional individual approach, the European Resuscitation Academy focuses on system improvements. Attention is paid to the individual links in the Chain of Survival and in the Formula for Survival, including bystanders, general trust in society, telephone-directed CPR, first responders, simulation training to mention but a few. The European Resuscitation Academy is developed in close cooperation with the Resuscitation Academy in Seattle/King County, and is financially supported by the Laerdal Foundation for Acute Medicine. The next European Resuscitation Academy is planned for Lugano, Switzerland in March 2015.

Conrad Bjørshol MD from the University of Oslo 1997, consultant in anaesthesiology at the Stavanger University Hospital. Facilitator at SAFER from 2008. PhD in cardiopulmonary resuscitation 2012. Member of the Norwegian Resuscitation Council, and deputy at the ERC general assembly. Editor of an internet site on defibrillation for lay first responders. Photo: Svein Lunde.

Bystander CPR By Thomas Lindner The future will see that every citizen is performing CPR when needed. Not to do so will become strange…

Thomas Lindner He started to work in the pre-hospital arena in 1986 as a paramedic in Germany. Since then his interest has been accidents and emergencies. He is currently a consultant in anaesthesiology. He has worked more than 10 years as a doctor in the Norwegian air ambulance service and the helicopter search and rescue service. Out-ofhospital cardiac arrest has been a main topic his research in recent years. Spring 2014 | Ambulancetoday

Continuous improvements By Olav Østebø When several research project over the years show good results from our own EMS service it is of utmost importance to remain modest, be able to cooperate closely with the other elements in the Chain of Survival and always strive for improvement. These are basic requirements for us to make further developments and achieve better results. I believe that capability of continuous improvements is paramount.

Olav Østebø Honoured as ‘Norwegian Paramedic of the Year’ in 2010 Olav is an authorized ambulance worker who trained as a Paramedic at Lillehammer University College. More than 20 years EMS service as paramedic, duty officer, training coordinator and currently assistant chief ambulance officer at Stavanger Hospital Trust. Participated in EMS development locally and nationally and contributed to establishing the paramedic training as a formal education. Represents The Norwegian Directorate of Health in the National Rescue Council, and had operative responsibility at the paramedic training at Lillehammer University College. Olav is still operative as a paramedic to enhance his leadership skills. Photo: Svein Lunde.

Eldar Søreide Medical co-director of the general ICU at Stavanger University Hospital and medical director for the Stavanger Acute medicine Foundation for Education and Research (www.safer. net). He also leads the Stavanger Acute care Research program (SAR), which includes several projects related to prehospital and in-hospital critical care, medical simulation and cardiac arrest epidemiology and management. Chair of the Steering group of The Norwegian Cardiac Arrest Registry.

Wenche Mathiesen Intensive care nurse with ten years’ experience from Intensive Care Unit with special competence in ventilator treatment at Stavanger University Hospital. Master degree in societal safety from University of Stavanger. Currently a PhDstudent focusing on out-of-hospital cardiac arrest, bystanders and CPR.

Stavanger Hospital Trust

• 7,300 employees • 133 PhD’s • 415,000 outpatient consultations per year • 4,900 annual births • 632 somatic beds • 327 psychiatric beds • population 330,000 References 1. Lindner TW, Søreide E, Nilsen OB, Torunn MW, Lossius HM. Good outcome in every fourth resuscitation attempt is achievable-An Utstein template report from the Stavanger region. Resuscitation 2011;82:1508-13. 2. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87. 3. Nolan J, Soar J, Eikeland H. The chain of survival. Resuscitation 2006;71:270-1. 4. Chamberlain DA, Hazinski MF. Education in resuscitation. Resuscitation 2003;59:11-43. 5. Søreide E, Morrison L, Hillman K, et al. The formula for survival in resuscitation. Resuscitation 2013;84:1487-93. 6. Savastano S, Vanni V. Cardiopulmonary resuscitation in real life: the most frequent fears of lay rescuers. Resuscitation 2011;82:568-71. 7. Lexow K, Sunde K. Why Norwegian 2005 guidelines differs slightly from the ERC guidelines. Resuscitation 2007;72:490-2. Erratum in Resuscitation 2007;73:494-5. 8. Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised treatment protocol for post resuscitation care after out-ofhospital cardiac arrest. Resuscitation 2007;73:29-39. 9. Busch M, Søreide E, Lossius HM, Lexow K, Dickstein K. Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors. Acta Anaesthesiol Scand 2006;50:1277-83. 10. Bjørshol CA, Søreide E, Torsteinbø TH, Lexow K, Nilsen OB, Sunde K. Quality of chest compressions during 10 min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model. Resuscitation 2008;77:95100. 11. Bjørshol CA, Sunde K, Myklebust H, Assmus J, Søreide E. Decay in chest compression quality due to fatigue is rare during prolonged advanced life support in a manikin model. Scand J Trauma Resusc Emerg Med 2011;19:46. 12. Bjørshol CA, Myklebust H, Nilsen KL, et al. Effect of socioemotional stress on the quality of cardiopulmonary resuscitation during advanced life support in a randomized manikin study. Crit Care Med 2011;39:300-4. 13. Bjørshol CA, Lindner TW, Søreide E, Moen L, Sunde K. Hospital employees improve basic life support skills and confidence with a personal resuscitation manikin and a 24-min video instruction. Resuscitation 2009;80:898-902. 14. Lindner TW, Langorgen J, Sunde K, et al. Factors predicting the use of therapeutic hypothermia and survival in unconscious out-of-hospital cardiac arrest patients admitted to the ICU. Crit Care 2013;17:R147. 15. Busch M, Søreide E. Should Advanced Age Be a Limiting Factor in Providing Therapeutic Hypothermia to Cardiac Arrest Survivors? A Single-Center Observational Study. Therapeutic Hypothermia and Temperature Management 2011;1:29-32. 16. Våga A, Busch M, Karlsen TE, Nilsen OB, Søreide E. A pilot study of key nursing aspects with different cooling methods and devices in the ICU. Resuscitation 2008;76:25-30. 17. Lindner T, Vossius C, Mathiesen WT, Soreide E. Life years saved, standardised mortality rates and causes of death after hospital discharge in out-ofhospital cardiac arrest survivors. Resuscitation 2014. 18. Eisenberg M. It takes a system to save a victim. Resuscitation 2013;84:1013-4.

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Focus on GCE - Gas Control Equipment

Medivital - Vital for life Spring 2014 sees the launch of the Medivital Integral Valve Cylinder Package from Gas Control Equipment Gas Control Equipment are the market leaders in the manufacture and supply of Medical combination valves. They were the first to bring the concept of a Medical integral valve to market in 1994 and this concept has now largely replaced the older style cylinder and regulator combination in hospitals, ambulances and elsewhere.

‘The MediVital keeps GCE at the forefront of technology in the integral valve market whilst delivering a significant whole life cost benefit for its users’ Mike Galvin, Managing Director GCE Ltd.

Today GCE remain the leading supplier globally of Medical integral cylinder valves and have more than 2 million valves in use worldwide.

through the hospital system, the Medivital is MRI compatible meaning that there is no need to disconnect patient breathing systems during hospital investigations. The lightweight valve also offers ultimate portability and ease of use, its size and weight making it compatible with most kit bags in use in UK ambulance services.

Medivital from Gas Control Equipment is the result of 20 years of experience in the use and design of integrated valves and cylinders. With vast experience in the Pre Hospital and Emergency markets, GCE have designed Medivital to be suitable for the demands of these most challenging environments. VITAL FOR DURABILITY The Medivital features a high shock gauge and improved guard protection to help prevent damage to the valve and cylinder in the challenging pre hospital environment. “Medivital is an interesting development; aesthetically pleasing and easy-to-use. MGS will be watching this product with great interest.” Steve Gullick Medical Gas Services Ltd

The completely enclosed quick coupler with additional protective lip means that even if the cylinder were to topple over, the quick coupler is well protected from a potential impact, preventing this common type of cylinder damage. The completely covered fill port prevents the ingression of dirt into the valve and therefore offers protection when used in dirty or dusty environments. The guard diameter has been designed to be compatible with cylinder retaining brackets in most ambulances. VITAL FOR USABILITY For a seamless transition from pre hospital

During patient transportation or complicated extrication the additional safety feature of ‘flow in between settings’ means that should the flow selector on the valve be inadvertently knocked, the cylinder will “We are very excited that GCE have developed the Medivital as we have a number of small to medium sized customers who have been waiting for this type of product to be readily available on the open market, not every customer wants to rent cylinders and now we have the solution” Steve Bray, SP Services

M e d i v i t a l I n t e g r a l Va l ve C y l i n d e r Pa c k a ge f ro m G a s C o n t ro l E q u i p m e n t 16

Spring 2014 | Ambulancetoday 3


Focus on GCE - Gas Control Equipment

always deliver a gas flow even when the selector knob has become set between one flow position and another.

Coming this Summer!

After use the ergonomic guard with very few edges for ingression of dirt is easily cleaned, aiding compliance with infection control protocols.

Ambulance Panel II

The new fluorescent gauge face also means safer use of the gas package at lower light levels, either at night or in complicated positions. The new button release quick coupler means that at the touch of a button, ancillary gas driven equipment can be removed from the cylinder with the minimum of effort from the cylinder operator leaving them free to concentrate on patient care. VITAL FOR TRACEABILITY The Medivital is available with an optional RF data chip which gives ultimate traceability of the gas package throughout the ambulance trust. This electronic data enables Trusts to have complete visibility of gas usage within the Trusts. A picture can be drawn up of gas usage, individual cylinder tracking, individual station gas usage monitoring, filling and service and maintenance which can all be correlated and analysed in a central Trust database. VITAL FOR SERVICABILITY The Medivital gas cylinder package (Medivital valve + 2 litre cylinder package from GCE) requires no service or maintenance for 10 years. This lack of service requirement significantly reduces the whole life cost of oxygen cylinder provision. (If Trusts wish to purchase the Medivital valves alone to be mounted on longer life cylinders this is possible. The life of the Medivital valve is 15 years so on a longer life cylinder the valve can remain in situ with no maintenance for 15 years.)

• The Ambulance Panel II is the next

generation of ambulance panels designed for permanent installation and use in road ambulances

Trial the Medivital now! Medivital is available mounted on a cylinder as a ‘ready to use’ gas package. For more information or to arrange a completely free trial, please contact our Regional Sales Manager (Ambulance) Catherine Staffa at:

catherine.staffa@gcegroup.com or call on: 01942 292950

• Long experience in this market has resulted in a product that gives the customer a lot of options and flexibility • There are a large range of variants available which can be combined upon request • The functions available are inlets & outlets, quick couplings,a manual switch over, gauges, flow selectors and suction • The complete installation of the Ambulance Panel, hoses and regulators is called the Ambulance Panel System (APS)

We are excited about the new GCE product Medivital and are looking forward to adding it to our product offering in 2014. We think it offers some innovative features which will be of particular benefit to the UK ambulance services and we are excited to see its’ introduction in 2014. Bruce Burns, Openhouse Products

To f i n d o u t m o r e v i s i t : w w w . g c e g r o u p . c o m Spring 2014 | Ambulancetoday

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Focus on Maximising Cardiac Output Sponsor of London’s Cardiac Arrest Symposium

By Ajay K Jain BSc MRCP MD is a Consultant Cardiologist at Barts Health, London. Competing interests: none declared and Emily Jane Cantor MBChB MRCP is a Clinical Research Registrar at Barts Health, London. Competing interests: none declared

Maximising cardiac output in cardiac arrest Every year an estimated 60,000 people suffer from cardiac arrests in the United Kingdom, half of which are treated by emergency medical services.1 However, survival still remains very low, varying between 2 and 12%.2,3 In cardiac arrest in order to achieve optimal cardiac output and improve survival rates there are a multitude of links within the chain of survival which are paramount. These are: early recognition or a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), early defibrillation and medical responders and in the case of ST-elevation myocardial infarction (STEMI); early revascularisation. Bystander CPR Multiple studies have shown that bystander CPR is associated with an improved survival rate.4 Historically CPR has not been widely delivered; this is likely due to poor training and confidence in its delivery and perhaps the ‘fear’ of performing mouth to mouth. Recent advertising campaigns from the British Heart Foundation aim at raising awareness of the importance of bystander CPR using a ‘hands only’ CPR approach. The most recent London Cardiac Arrest annual report 20122013 confirmed higher rates of bystander CPR, with bystander CPR performed in 51.8% of the 1,835 cardiac arrests witnessed by bystanders; 64.6% of those with initial ventricular tachycardia or fibrillation (VT/VF) and 52.9% with other rhythms, or none recorded (Figure 1).5

Figure 2: Showing the drop in systolic blood pressure during the pauses for ventilation (adapted from: Berg RA et al. Resuscitation. 2001;104:2465-2470).7 Mechanical devices can reliably provide chest compressions at a set rate and depth, possibly achieving better haemodynamic characteristics than manual compressions, with animal studies showing improved cerebral and coronary blood flow.8 The main two devices currently available are; the Zoll AutoPulseTM , a load distributing placed across the chest and the LUCAs deviceTM , a piston-based compression device (see Figure 3).

Figure 1: Bystander CPR observed by the London Ambulance service from 2008-2013 (London Ambulance Service: Cardiac Arrest Annual Report 2012/13). 5 Delivering correctly performed chest compressions and ventilation has been shown to significantly improve prognosis. 6 Even within hospitals there are ongoing challenges associated with the quality of CPR by well-trained staff. Abella et al. analysed the CPR performed in 67 patients who had in hospital cardiac arrests, in a single-centre, against standard guidelines finding the ventilation rate to be too high in 68.1%, the compressions too shallow in 37.4% and rate too slow in 28.1%.6 Berg et al. showed that interrupting chest compressions for rescue breathing can adversely affect haemodynamics during CPR for VF. 7 It is very clear from looking at Figure 2 below that blood pressure drops significantly when compressions are stopped. Further, it takes several compressions for the pressure to return to its pre-pause level. Summary: • Survival rates in out of hospital cardiac arrests remain low. • Predictors of survival include early recognition, bystander cardiopulmonary resuscitation (CPR), early defibrillation and pre hospital return of spontaneous circulation. • Mechanical devices allow for continuous effective CPR, especially in times when delivery of CPR may be difficult. • Early revascularisation and therapeutic hypothermia have been shown to result in improved survival, with ECGs and clinical history not being of good predictive value for coronary artery disease. Spring 2014 | Ambulancetoday

Figure 3: AutoPulse and LUCAs devices Mechanical devices are also advantageous in delivering continuous CPR when patients are being transferred and also if they proceed on to have coronary angiography and percutaneous coronary intervention, where ongoing CPR would put the CPR provider at risk of high-rates of X-ray exposure. However, whether automated resuscitation devices such as these can improve return of spontaneous circulation (ROSC), neurological recovery and ultimately increase survival rates remains controversial due to conflicting results from some of the larger studies.8 The CIRC trial, which has finished recruiting, but is waiting to be reported will be the largest randomised control trial to date looking at the use of AutoPulse versus manual CPR. Early defibrillation also remains crucial, with a decrease in 10% survival for every minute of delay. In some studies survival rates were greater than 70% when defibrillation was delivered promptly.9 This in turn has led to greater availability and public access to defibrillators. The delivery of prompt CPR and defibrillation both contribute to earlier ROSC, which itself is also a predictor for improved survival. 19 3


Focus on Maximising Cardiac Output Sponsor of London’s Cardiac Arrest Symposium

Revascularisation Coronary artery disease is responsible for 40-90% of out of hospital cardiac arrests.10 Heart attack centres (the HAC service) throughout the UK allow for immediate paramedic transfer in patients with an electrocardiograms (ECG) showing ST-elevation, some of whom may then proceed to have a cardiac arrest, or occasionally those who don’t fulfil this ECG criteria, but have had a cardiac arrest with ROSC and whom they believe will benefit from immediate coronary angiography (Figure 4).

Figure 4: The angiography suite at the London Chest Hospital (left) and angiogpraphic projections (right) Spaulding et al. collected prospective data of 84 patients from 4 Emergency Units in Paris, between August 1994 and September 1996, who had undergone immediate coronary angiography having survived an out of hospital cardiac arrest. 11 40 patients (48%) were found to have an occluded coronary artery, with percutaneous coronary intervention (PCI) then being performed in 37 patients (44% of the total cohort). Successful PCI occurred in 28 patients, with failure being due to recurrent thrombosis or low coronary flow, despite intervention. The overall in hospital survival rate was only 38%, with predictors for survival being early ROSC and subsequent haemodynamic stability and immediate successful PCI. Interestingly in this cohort of patients clinical and ECG data were of poor predictive value, with 9 patients who presented without preceding chest pain or ST-elevation having angiographic evidence of a recent coronary occlusion. 11 A larger study by Dumas et al. looked at the long-term prognosis of patients following out of hospital cardiac arrest looking at the role of both PCI and therapeutic hypothermia (TH). 12 5 year survival was 78.7% in the PCI group as opposed to 54.4% in the non PCI (p<0.001), and was also significantly improved in the TH group 77.5%, versus 60.4% (p<0.001) with no TH.12 Mutlivariable analysis showed that both PCI and TH were independently associated with improved prognosis, as was the implantation of an implantable cardiac defibrillator (ICD). When stratifying into 4 groups according to TH and PCI, those who received neither treatment had the lowest 1 and 5-year survival estimates, whereas those who received both treatments had the highest 1-year and 5-year survival estimates (stratified log-rank p <0.001) (Figure 5).

were seen in those with an initial rhythm of VF or VT. 13 Conclusion Out of hospital cardiac arrest remains a common and frequently lethal event, with survival rates remaining low. However, following the implementation of the 2005 and 2010 resuscitation guidelines for emergency cardiovascular care for patients with both shockable and non-shockable rhythms OHCA survival rates appear to be improving. The more frequent use of therapeutic hypothermia and transfer for primary percutaneous coronary intervention have also played vital roles in this. However, further improvement is needed with primary prevention of cardiac arrest where possible, better education for lay people on how to provide effective CPR and the importance of resuscitation on survival, as well as early defibrillation for shockable rhythms. Mechanical devices can help us provide the continuous quality CPR required, especially when transferring patients and in the angiography setting. With studies showing that clinical and ECG data are not useful predictors in this setting and the high incidence of significant coronary artery disease in this cohort more consideration should also be placed on bringing patients with non-traumatic OHCA directly to heart attack centres. References: 1. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of outof-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87. 2. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Presentation, management and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology. Heart 2003;89:839-42. 3. Perkins GD, Cooke MW. Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators. Emerg Med J 2012;29:3-5. 4. Nielsen AM, Isbye DL, Lippert FK, Rasmussen LS. Can mass education and a television campaign change the attitudes towards cardiopulmonary resuscitation in a rural community? Scand J Trauma Resusc Emerg Med 2013;21(39):1-8. 5. London Ambulance Service NHS Trust. Cardiac Arrest Annual Report 2012/13. Sept 2013. 6. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O’Hearn N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293(3):305-10. 7. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW , Porter ME, Ewy GA. During cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest adverse hemodynamic effects of interrupting chest compressions for rescue breathing. Circulation. 2001;104:2465-2470. 8. Krepb H, Breila M, Heistera U, Fiecherc M, Hoeft A. Out-of-hospital cardiopulmonary resuscitation with the AutoPulseTM system: A prospective observational study with a new load-distributing chest compression device. Resuscitation 2007;73:86-95 9. Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med 2000;343:1206 10. Stub D, Bernard S, Duffy SJ, Kaye DM. Post cardiac arrest syndrome: a review of therapeutic strategies. Circulation 2011;123:1428-35.

Figure 5: Showing Kaplan-Meier survival estimates (Dumas, JACC 2012, 21-7) 12 Proclemer et al. performed a European survey in 2011 looking at the current practice for out of hospital cardiac arrests (OHCA) across 53 European countries, including the UK. 85% of the participating centres had a dedicated strategy for OHCA.13 Emergent coronary angiography was performed in >70% of cases in 31 (66%) of the centres, with more than half having significant coronary artery disease. Therapeutic hypothermia was also frequently used for 12-24 hours in >50% of patients in most centres (53%), but pre-hospital hypothermia, post ROSC, was infrequent. Again greater survival rates Spring 2014 | Ambulancetoday

11. Spaulding CM, Joly L-C, Rosenberg A, Monchi M, Webster SN, Dhainaut JFA, Carli P. Immediate Coronary Angiography in Survivors of Out-ofHospital Cardiac Arrest. N Engl J Med 1997;336:1629-33 12. Dumas F, White L, Stubbs BA, Cariou A, Rea TD. Long-term prognosis following resuscitation from Out of Hospital Cardiac Arrest: Role of Percutaneous Coronary Intervention and Therapeutic Hypothermia. JACC 2012;60(1):21-7. 13. Proclemer A, Dobreanu D, Pison L, Lip GYH, Svendsen JH, Lundqvist CB. Current practice in out-of-hospital cardiac arrest management: a european heart rhythm association EP network survey. Europace 2012;14:1195-1198.

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Recruiting Paramedics of the future No experience needed An opportunity not to be missed

Edinburgh Rocks as Cardiac Symposium Hits City The second Edinburgh Cardiac Arrest Symposium, hosted by the Resuscitation Research Group, was held on Thursday, March 27th at the University of Edinburgh. Nearly 300 delegates from across the UK attended to hear a world-class speaker line-up with a further 200 sites around the world registered to watch the speakers via live webcast. Questions were posted to the speakers live from the floor and online via Twitter. Gareth Clegg, Resuscitation Research Group Lead, opened the day with an inspiring and thought-provoking talk on the need for cultural change to improve survival from out-ofhospital cardiac arrest (OHCA). Highlighting the importance of local implementation of the Chain of Survival, Jerry Overton presented on the importance of ambulance dispatch for OHCA, stressing the need for accurate, rapid diagnosis, early telephoneguided CPR and getting the right resources to the patient at the right time. Mark Whitbread from London Ambulance Service gave an update on utilising advanced paramedics in early, postROSC care, emphasising the importance of accurate ventilation, cardiac support and triage to an appropriate specialist centre. A plenary on mechanical CPR provoked excellent debate with Lars Wik from Norway presenting the results of the AutoPulse CIRC trial and Sten Rubertsson from Sweden on LINC trial, which used the LUCAS device. The 2014 Medic One Lecture was given by Niklas Nielsen from Sweden on the impact of the recently published Targeted Temperature Management (TTM) trial and the changing approach to neuroprognostication following OHCA.

The theme of post-ROSC care continued as Simon Redwood from London reviewed the evidence for early percutaneous coronary intervention following OHCA. Simon Edgar from Edinburgh and Lanty O’Connor from the USA illustrated the importance of non-technical skills by comparing resuscitation to other high-risk industries. This was followed by a high impact video simulation of the Edinburgh Resuscitation Rapid Response Unit (3RU) team in action, introduced by Colin Crookston and Steven Short. Colin Robertson from Edinburgh closed the day with an inspirational and somewhat iconoclastic talk on the future of resuscitation which left the delegates roused to improve survival from OHCA in their local areas. The symposium was generously sponsored by Zoll, Physio Control, Cardiac Services, Laerdal and Edesix. Feedback from the day was excellent and we look forward to seeing delegates at the next symposium.

Full training provided Emergency Care Assistants The role • Assist qualified Paramedics and Emergency Medical Technicians with their duties • Work as a crew, initiating appropriate care and effective treatment to patients in both inter-hospital transfers and other pre-hospital environment The benefits • Excellent starting salary of 18k in training increasing to 24k after successful completion of probation • Training consists of 5 week residential course then 3 weeks driving training at a local base • 28 days holiday per year (including Bank Holidays) • Career pathway opportunity to becoming a Paramedic

To apply please call:

0845 4348951

or go online: www.flamehealth.com

Further information and pictures of the proceedings can be found at www.rrg-edinburgh. com .The videos from the symposium will be made available for online viewing shortly.

Spring 2014 | Ambulancetoday

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s e g a l l i v l a t s a o c ‘‘From to international o s ’s e r e h t , s t r o p r i a . ’ e ’ c n e i r e p x e o t h c u m Chris Perry, Paramedic, Luton

Paramedics. There are many reasons to develop your career with us. More contact with patients. Better career development. A unique mix of urban, rural and coastal settings. But why take our word for it when you could hear it from our paramedics themselves? They’ll be more than willing to tell you all about us. You can spend a shift with one of our crews or time in our control room really getting to know us. Start discovering who we really are at www.paramedicrecruitment.co.uk


Thijs Gras’ Letter from Amsterdam Sponsor of London’s Cardiac Arrest Symposium

The History of Pre-Hospital Cardiac Care in a Heart-Beat! Our modest but highly academic Dutch correspondent,Thijs Gras, also happens to be the Netherlands’ leading expert on the history of his homeland’s ambulance service. Below Thijs provides a brief but fascinating insight in to how this small but exceptionally forward-thinking country has played a major role in the development of improved systems of Pre-Hospital cardiac care The heart is one of the few human organs one can hear, see and feel working from the outside. It only shares this special combination with part of the bowels, that also trigger a fourth sense, the smell - but for this special pre-hospital cardiac care issue of Ambulance Today, and for reasons of decency, I would like to focus on the heart. Many languages and cultures have special expressions in which the heart plays an important role and most of these involve emotions, especially love. Funny how this is an almost universal phenomenon. In a more physiological approach, the heart is a special combination of a mechanical pump and an electrical device; especially this last feature offered a way to view the condition from the outside and influence it externally. Actually, using electricity to resuscitate people is quite old, although it was used in a Mr Bean way: someone was just shocked and doctors did not exactly know what they did. There are descriptions from the UK dating back to 1774 and 1778 (Kite). In Holland, the equivalent of the Humane Society (which was founded in 1767), was very aware of the scientific developments in resuscitation and introduced in the early 1800s electrical boxes to accompany a lifebelt, and a grapnel on strategic spots in Amsterdam and other bigger cities for reviving drowned people. The first AED’s so to speak. For a more precise and well thought out approach to electrical resuscitation the invention of the ECG was a very important step. This is attributed to Willem Einthoven, a Dutch physician. The ECG allowed description and understanding of the electrical activity of the heart. This paved the way for other researchers. Let us not be chauvinistic because a lot of people from a number of countries contributed to the solutions we have today:

a group in Geneva, suggesting the use of electricity to stop VF, the Russian physician Gurvich experimenting on animals with this shortly before and after WW II, and the American doctor Beck performing the first recorded defibrillation of a patient in 1947. A lot of technical progress was needed before defibrillators were small enough to be placed on a vehicle, and here the credit goes to Professor Pantridge who introduced the first ambulance equipped with a defibrillator in Belfast in 1965. This example was in turn followed by numerous others. The Dutch ambulance service began an experiment in three cities during the period 1969-1972 with one or two ambulances equipped with a defibrillator. It failed completely but paradoxically was a big success. It showed very clearly that a defibrillator was so essential and it was so difficult to predict when it was needed, that the best option was to have one on all ambulances. And so, during the seventies and the eighties a growing number of Dutch ambulances had them on board and were staffed with nurses who knew how to operate them. Because of the use of nurses, cardiology has always been a strong point of the Dutch system. There was a close alliance with the hospital and quite a few ambulance nurses had their roots in the CCU. The initiative to transmit ECGs to the hospital, to involve them in the decision to take someone to a cardiac intervention hospital, found fertile ground in the Dutch ‘polder’ground. In a lot of regions this is now standard practice: an ambulance is sent to a person complaining of chest pain, an ECG is taken and if it shows signs of acute myocardial infarction or the history from the patient is suspicious this is going on, it is sent to the intervention hospital where a cardiologist casts an eye on the ECG and confers with the ambulance nurse because we should always treat patients, not ECG’s . Then a decision is made. If the intervention hospital is appropriate, everything is prepared there so the patient receives quick and smooth treatment. Just to give an idea: in the Amsterdam region with three intervention hospitals covering about 2.0 million inhabitants, a total of 1871 ECG’s were sent in 2013, showing in 613 cases signs of AMI.

And now? Now we have Internet, now we have iPhones, now we have connection almost everywhere. And now the special features of the heart come in very handy. Although not new (there have been experiments in the nineties with connection via phone lines showing the heart rhythm to a doctor who could then advise on a patient), we can have a far better and far more reliable look at the heart at a distance. Who knows: we may soon be able to intervene from a distance. But still the ambulance is indispensable, providing mobile care, transport to a hospital and – last but most certainly not least – a caring and skilled team providing support on a human level and standing next to the patient. It would be very interesting to see what the possibilities are for improving cardiac care in the streets, using new techniques. A lot of people suffer from it and a lot of people could gain by it. I also see this as an important component of the ambitious Royal College of Art Ambulance Redesign project which is now moving forward steadily with the participation of ambulance providers across Europe and of which, I’m delighted to say, my own service, Ambulance Amsterdam, is a proud consortium member. Like the expressions and sayings about the heart, the problems with the heart are universal. Not afraid of new developments in cardiac care and proud of our tradition in this field, we in Holland fully support this project. It would be a marvellous way to celebrate the 250th anniversary in 2017 of the foundation of the Dutch Society for the rescue of drowned people. Thijs Gras

Tell Thijs what you think by emailing him at: th-gras@hetnet.nl

This edition of Ambulance Today goes out to all 25 Dutch Ambulance Regions courtesy of Procentrum

Procentrum - Learn to feel the drive www.procentrum.eu Spring 2014 | Ambulancetoday

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Focus on ambulance vehicle electrical systems

Intelligent Engineering from the Intellitec Team With over 2M of their Battery Guard 2000 low battery protection systems supplied globally, Wirral-based Intellitec are already the electrical systems provider of choice among 100% of all UK Fire & Rescue services. Just four short years after their MBO of the UK operation from Intellitec’s founders, Paul Smith (Technical Director) and Duncan Hughes (Sales & Marketing Director) are quickly repeating this success in the UK ambulance market with their IPLC Junior Task & Power Management system and their iCAN 999 telematics system. Below Sales & Marketing Manager, Brian Aston, introduces the team and the technology already taking the global ambulance market by storm!

Who are Intellitec? History & Structure Intellitec LLC in Florida have been designing and producing specialist vehicle electronics since 1976, with Intellitec in the UK being formed as part of the VIP Group in 1994. In September 2011 Paul Smith (Technical Director) and Duncan Hughes (Sales & Marketing Director) completed a successful MBO of Intellitec UK with Paul taking over the day to day running of the UK operation and Duncan moving to the American factory to head up group worldwide sales and marketing. Markets & Services Intellitec in the UK have been designing, manufacturing and supplying electrical systems for the emergency service market for over 16 years. They have built an excellent reputation within this very important market for providing robust high quality products and excellent technical support coupled with in depth customer product and software training at their site on the Wirral. The Intellitec IPLC and PMC system is in use on many Blue Light response vehicles including Ambulance, Police and Fire & Rescue. The Battery Guard 3000 battery power management system for example is currently installed throughout the UK on 100% of all Fire & Rescue vehicles in service. 26

Product Being the first company ever to offer a low battery protection system (Battery Guard 2000) Intellitec has supplied well over 2 million systems worldwide. In 1996 a landmark product was launched taking Intellitec into a whole new era, this was the company’s Programmable Multiplex Control System (PMC). This again being a first within the specialist vehicle sector took Intellitec on to the next level allowing vehicle builders and converters, to take advantage of the company’s expertise of not only producing high quality components, but offering a turnkey solution to electrical system design and installation. Development Since the MBO in 2011 the new product development and investment has continued at an incredible pace with the introduction of many new products including the new generation Battery Guard 3000, IPLC and iCAN-999 Telematics. IPLC standing for

Brian Aston: European Sales Manager

Intellitec Programmable Logic Control is a fully programmable Task & Power Management system aimed specifically at the front line ambulance market, which offers full vehicle CAN bus system integration and control. IPLC was closely followed by its little sister IPLC-Jnr designed and built with the ever growing smaller RRV type market in mind. IPLC-Jnr offers the vehicle converter and end user most of the benefits of IPLC, but at a reduced cost to help fleet engineers and managers meet with ever growing constraints on their budgets. Telematics The latest offering from Intellitec is the iCAN-999 Telematics system, again a first in its field as it not only interfaces direct with the OEM vehicles CAN system, but also the bodybuilder / converter body

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Focus on ambulance vehicle electrical systems

electrics. Offering high quality information such as vehicle journey routes (999 active routes differentiated by blue on the map), vehicle speed, engine RPM, fuel usage and harsh braking to name but a few. Quality Intellitec’s commitment to quality and service is clearly visible from the test and approvals all their products are put through and the quality approved system in place within both the UK and USA facilities. All new products are approved to latest European certifications to meet with new vehicle type approvals. Customers are welcome on site at any time and the company holds a strong belief that the next customer question asked or problem needing to be solved could be the next product launched.

Duncan Hughes: Sales & Marketing Director

Paul Smith: Technical Director

Team Intellitec The Intellitec team consists of a good mix of mature personnel with vast industry experience mixed with the healthy exuberance and ambition of youth. It is a great credit to both Paul and Duncan that they have been able to bring together such a committed blend of strong minded individuals and mould them into such a successful team. I am sure in today’s ever changing and testing industry this is an Intellitec team that will continue to go from strength to strength. To find out more about our full products range call us on: 0151 482 8970 Intellitec MV Ltd Unit 9, Woodway Court, Thursby Road, Bromborough, Wirral CH62 3PR To find out more visit Intellitec’s website at: www.intellitecmv.com

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Focus on Agonal Breathing in Cardiac Arrest Sponsor of London’s Cardiac Arrest Symposium

Don’t Delay Resus if Agonal Breathing Presents! Each year an estimated 30,000 out of hospital cardiac arrests are treated by the ambulance service (Malholtra and Rakhit 2013). Of these, it is estimated that up to 40% suffer a phenomenon known as agonal breathing, an abnormal respiration pattern that can occur after the heart has stopped beating. Below SECamb Paramedic Rhiannon Roderick explains why it is vital that clinicians and laypersons have an understanding of the potential for agonal breathing in cardiac arrest. Purpose of the Paper

What is agonal breathing?

Agonal respirations occur in a relatively high number of cardiac arrests; whilst the presence of this condition indicates recent onset of collapse, the diverse clinical presentation may delay rescuers who are unable to differentiate between agonal respirations and signs of life ultimately postponing the recognition of cardiac arrest and subsequent resuscitation. Patients are potentially suffering a poor outcome from cardiac arrest because agonal breathing is not being immediately recognised.

Agonal breathing has been described as a slow rate of gasping, laboured breaths as well as irregular groaning or snorting, however there are a wide range of clinical presentations reported and the more allencompassing term ‘abnormal breathing’ has been adopted.

This paper will examine the pathophysiology and recognition of agonal breathing and will conclude that awareness needs to be increased amongst clinicians as well as the general public to ensure there is no delay in beginning cardiopulmonary resuscitation on patients who have suffered a cardiac arrest with ongoing abnormal respirations. It has been posited by Bobrow et al (2008) that agonal breathing is associated with increased chances of survival; this is potentially due to the fact that the phenomenon is usually witnessed in the early stages of cardiac arrest and as initial rhythms are usually shockable (Vukmir 2009) there is an increased likelihood of a return of spontaneous circulation post resuscitation. It is unfortunate therefore that this positive omen of survival may be mistaken as a sign of life by a layperson or clinician, which subsequently delays resuscitation leading to a poor outcome. It is undoubtedly easier to identify a cardiac arrest when breathing is absent, however in the presence of abnormal or agonal breaths, it is vital that resuscitation is not delayed. This piece aims to examine the pathophysiology and recognition of agonal breathing in order to increase understanding of the condition and have a positive impact on consistently identifying cardiac arrests and minimising the delay in administering chest compressions. Spring 2014 | Ambulancetoday

Agonal breathing is caused by cerebral ischaemia, and is thought to be a final reflex of the brain stem in an attempt to increase oxygen perfusion and preserve life (Dennis et al. 2012).Despite being first documented as early as the 20th century, the clinical importance of the ventilations agonal breaths provide is only just being recognised. It has been demonstrated through cardiac research on animals that some gaseous exchange does take place during these abnormal respirations which leads to an increase in arterial oxygenation, furthermore an increase in artery pressure was also noted during expiration which may allow some coronary perfusion (Rea 2005). Despite this the body is fundamentally unable to perfuse the major organs without cardiac blood flow therefore without intervention agonal respirations will gradually decrease into terminal apnoea. A recent media campaign aimed at increasing bystander intervention in out of hospital cardiac arrests has focused on hands only CPR for the untrained layperson who is unable or unwilling to perform rescue breaths; in these cases the additional oxygenation gained from agonal breaths combined with chest compressions will be incredibly beneficial, particularly if it can be maintained until the arrival of a clinician or automated external defibrillator (AED). Recognising agonal breathing The presentation of agonal breathing is diverse, patients breathing may be seen as: gasping, laboured, noisy, snorting, shallow, or slow. It is relatively common, particularly in

witnesses arrests and is shown to last from around 2-7 minutes after the heart stops beating in swine models (Perkins et al 2006). If a patient is seen having agonal respirations, it can therefore be assumed that they have had a recent onset of cardiac arrest which may be a positive indicator for survival if early and effective chest compressions are commenced. Agonal respirations may present a particular problem to emergency medical despatchers as they rely on information passed by the caller; standardised questions allow the recognition of cardiac arrest but misinterpretation of irregular breathing as a sign of life will delay the despatcher in providing CPR instructions which consequently has a negative impact on patient outcome (Vaillancourt et al 2011). A 2009 study by Bohm et al showed a significant increase in correct recognition of cardiac arrest by those despatchers who had benefitted from additional training in agonal respirations. The 2010 resuscitation council guidelines emphasises that cardiac arrest should be recognised in those patients who are unresponsive and not breathing normally, a vital word change designed to minimise the instances where CPR is delayed due to mistaking agonal breathing for a sign of life. This is further emphasised by the JRCALC (2013) guidelines where it is stipulated that the rescuer should look, listen and feel for normal breathing for up to ten seconds

Rhiannon Roderick Rhiannon is a graduate paramedic who has recently begun working for South East Coast Ambulance Service. She has a keen interest in resuscitation medicine and after attending a lecture on Protocol C by Professor Douglas Chamberlain; Rhiannon was compelled to research agonal respirations further. 29 3


Medical Gas Solutions Medical Gas Solutions Limited (MGS) is a leading provider of medical gases and equipment to ambulance services both large and small throughout the UK. Key features are: Provision of both Medical Oxygen and Nitronox (analgesic pain relief gas) in a range of cylinder sizes. Cylinder Range – Ambulance crews can take advantage of our ultralightweight carbon fibre wrapped cylinders with integral valves which are easy to use and handle with minimal risk. Filled to 300 bar, each cylinder carries more gas than conventional cylinders, meaning you’re less likely to have to change cylinders mid emergency and overall retain less stocks. Our cylinders range from 1 litre portable through to 10 litre. Delivery Options – MGS can offer a range of delivery options depending on customers’ requirements. This can range from our prompt response to your exchange request right through to a tailored gas management service where we can deliver on agreed days direct into your cylinder store. Cylinder Tracking – Utilised since 2006, this allows MGS to accurately monitor customer stock holdings and gas usage. Full reports are available to customers. This also allows full traceability of the medical product. Innovative Products – MGS also provide a range of major incident equipment to complement our cylinder range. This enables ambulance providers to attend large scale events knowing they have the capacity to deal with major incident that may arise. Support and Training – MGS provides full support to deal with any queries and emergency requirements. For more information, please contact us: Telephone: 01352 736050 Email: sales@medicalgassolutions.co.uk Medical Gas Solutions Ltd Unit 19, Manor Industrial Estate Bagillt, Flint, Flintshire, CH6 5UY


Focus on Agonal Breathing in Cardiac Arrest Sponsor of London’s Cardiac Arrest Symposium

in the unresponsive patient as well as observing for signs of life such as moving, talking and coughing; in the absence of these chest compressions should be started. Critically JRCALC states that if there is any doubt about whether the patients breathing is classes as ‘normal’ chest compressions should be commenced. It is worth noting that agonal respirations are most commonly seen in ventricular fibrillation (Einsenburg 2006) though this may be due to the correlation between agonal breathing lasting 2-7 minutes from the time of collapse and ventricular fibrillation being a common initial rhythm. Increasingly, agonal breaths have been noted in asystolic patients. Conclusion Ultimately, it is vital that clinicians and laypersons alike have an understanding of the potential for agonal breathing in cardiac arrest. By educating those likely to be delivering early compressions, it would be possible not only to increase the chances of a positive outcome but also dispel fears amongst the general public who may be more likely to delay compressions in case of ‘doing it wrong’ when a patient is agonal breathing. Health care professionals should be competent in confirming cardiac arrest regardless of any abnormal respiratory patterns. Due to agonal breathing only being present in the early stages of cardiac arrest, as well as having a high chance of being in a shockable rhythm, there is logically an increased chance of return of spontaneous circulation with early intervention. It is vital therefore, that during this optimum period of survival, compressions are not paradoxically delayed by lack of recognition. There is currently limited research available on recognition of cardiac arrest with agonal breathing due to difficulties in collecting data in the pre-hospital environment; however increased public awareness of this condition may have a beneficial effect on positive outcomes for patients suffering a cardiac arrest.

Key Points • Agonal respirations occur in up to 40% of arrests • Health care professionals must be confident and competent in the swift recognition of agonal breathing • There is a positive correlation between agonal breathing and survival to discharge • Whilst the phenomenon can occur in any rhythm it is most likely to be seen when the heart is in ventricular fibrillation • Agonal respiration can be mistaken as a sign of life by rescuers and delay resuscitation • If there is any doubt about whether the unresponsive patient is breathing normally or not, compressions should be started • An increase in public awareness of agonal breathing may have a correlating positive effect on swift intervention

Other Abnormal Breathing Patterns Kussmaul respirations: occurs in diabetic ketoacidosis, recognised by rapid, deep or panting breaths Cheyne-Stokes: Cyclic respirations getting faster and deeper before an onset of temporary apnoea Ataxic respirations: Complete irregularity of breaths and intermittent apnoea – ataxic breathing may deteriorate into agonal respirations

Special thanks to Professor Douglas Chamberlain who, as well as inspiring the piece during a lecture on Protocol C, was incredibly generous with his time in

References: Bobrow BJ, Zuercher M, Ewy GA, Clark L, Chikani V, Donahue D, Sanders AB, Hilwig RW, Berg RA, Kern KB. (2008). Gasping during cardiac arrest in humans is frequent and associated with improved survival. Available: http://www.ncbi.nlm.nih.gov/pubmed?orig_ db=PubMed&cmd=Search&term=circula tion%5BJour%5D+AND+2008%5Bpdat% 5D+AND+BoBrow%5Bfirst+author%5D. Last accessed 05/12/13. Bohm K, Stalhandske B, Rosenqvist M, Ulfvarson J, Hollenberg J, Svensson L. Tuition of emergency medical dispatchers in the recognition of agonal respiration increases the use of telephone assisted CPR. Resuscitation. 2009 (80):1025-1028. Dennis M, Talbot Bowen W, and Cho L (2012).Mechanisms of Clinical Signs. Australia: Churchill Livingstone. 74. Eisenberg M. (2006). Incidence and significance of gasping or agonal respirations in cardiac arrest patients. Available: http://www.freewebs.com/ clinicalupdates/Agonal1.pdf. Last accessed 05/12/13. Joint Royal Ambulance Liaison Committee(JRCALC) (2013) UK Ambulance Service Clinical Practice Guidelines 2006. Warwick: Warwick University. Malhotra, A. and Rakhit, R. (2013). Improving the UK’s performance on survival after cardiac arrest.British Medical Journal.347 (f), 4800. Perkins G, Walker G, Christensen K, Hulme J, and Monsieurs K. (2006). Teaching recognition of agonal breathing improves accuracy of diagnosing cardiac arrest. Resuscitation. 70, 432-437. Rea T. (2005). Agonal respirations during cardiac arrest.Current Opinion in Critical Care.11 (3), 188-91. Vaillancourt C, Charette M, Bohm K, Dunford J, Castrén M. (2011). In out-ofhospital cardiac arrest patients, does the description of any specific symptoms to the emergency medical dispatcher improve the accuracy of the diagnosis of cardiac arrest: A systematic review. Resuscitation. 82 (12), 1483-1489. Vukmir R. (2009). Initial Cardiac Rhythm Correlated to Emergency Department Survival. Clinical Medicine: Cardiology. 3 (1), 9-14.

providing feedback and advice.

Spring 2014 | Ambulancetoday

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We’re delighted to announce we’ve extended our 10-year partnership with SECAmb for a further 3 years until 2017

Introducing ‘Make Ready’

We will continue to deliver Ambulance Services industry-leading ‘Make Ready’ April 2014 and Vehicle Preparation Services


New National Ambulance College is an investment in the future

The National Independent Ambulance College (NIAC) recently launched its first range of ambulances courses supported by Pearson, the world’s leading education company that helps millions of people make progress in their lives through learning and Falck Denmark A/S, the world’s leading provider of ambulance services. The first group of students attending NIAC in April will be on the career pathway to becoming paramedics of the future, and will start three years of work/study with a five week residential Emergency Care Assistant (ECA) course followed shortly by a three week Institute of Health and Care Development (IHCD) blue light driving course. Candidates for this career defining course will be expected to undergo rigorous testing to ensure that they have what it takes to be part of this exciting opportunity. Supporting the successful candidates financially will further ensure that students remain focused on their studies. Selecting people who are passionate about a career in the ambulance and prehospital emergency care service is a key consideration when developing training courses that will allow students to work effectively in this arena. David Ellis, Principal of NIAC, wants the college to be the leading force in encouraging young people from all walks of life to consider the ambulance service as a career: “We want more young people to view the ambulance service as a dynamic career opportunity that has job satisfaction very few jobs can provide. One of our key

objectives is to provide all our students with an opportunity and access to quality education which will enable them to add value to their jobs and support them throughout their careers. “The new five week residential ECA course is the first of many such opportunities that will allow us to provide individuals committed to developing their careers through quality educational courses with on the job training“. NIAC will work with a number of educational partners to provide students with learning and development opportunities that surpasses any other in the industry. One such partnership will be with Pearson who have an international reputation for top class education services. The five-week ECA course will be hosted by Aston University in Birmingham. The National Independent Ambulance College (NIAC), one of the UK’s leading dedicated independent ambulance training facility, provides accredited educational courses to staff of independent sector ambulance providers, NHS staff, self funding students and organisations needing first aiders. NIAC is accredited by awarding bodies, such as Pearson and works in partnership with universities and colleges such as Aston University and Oldham College together with other educational institutions to ensure students are furnished with qualifications that are recognised throughout the healthcare sector in the UK. For more information about NIAC and its courses, please contact David Ellis on: 0207 871 0382 Or email him at: communications@niac. uk.com To book courses email: bookings@niac.uk.com

Spring 2014 | Ambulancetoday

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Focus on Churchill ‘MakeReady™ Ambulance Preparation Services

Save Time…Save Revenue …Save Lives!

Built on the expertise of Lightbridge Support Services, Churchill MakeReady are the UK’s first professional suppliers of vehicle preparation services to the Ambulance Sector and providing a comprehensive range of ‘Make Ready’ services, including clinical deep cleaning, infection control, stock management, flexi fleet services, medicines management, medical device management and asset management. Below Martyn Johnson, Support Services Director, Churchill MakeReady™ explains how Ambulance Preparation Services can help you run a cleaner, more efficient ambulance operation. ‘Make Ready’ or Vehicle Preparation is now a common term in the modern ambulance service; however little is really understood about what it incorporates and why indeed it forms an important and integral part of a modern ambulance service. Today, the demand upon the NHS is continuing to increase; patients increasingly call ambulance services using either the 999 emergency system or the newly introduced 111 service as they feel there is little other option available. This situation has been exacerbated over the years by the decreasing role of the local GP with regards to out of hours cover. This invariably has increased demand upon our ambulance services. With hard pushed resources, tighter budgets and ever increasing call demands, it is vital that the ambulance crews’ time is maximised so that they are delivering optimal patient services from the time they book on duty to the time that they finish their shift. To assist in ensuring our ambulance services are able to focus on their core activity of delivering patient services, Churchill MakeReady™ provide bespoke Vehicle Preparation, ‘Make Ready’ and Infection Control Deep Cleaning Operations. These services incorporate every part of a typical pre-operational ambulance preparation so that a crew arriving on shift are able to book on with control and become immediately available as a resource that can be dispatched to a patient.

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This helps maximise crew unit hour utilisation and reduce wasted down-time regarding checking, cleaning, restocking and packing of ambulances. Furthermore, because this process is undertaken by professional personnel who have been trained for this task, patient safety is increased further as crews are not rushing to book on and respond to calls.

achieved by reducing stock levels, stock wastage, reducing VOR rates and increasing crew utilisation. The other big financial benefit is that loss of expensive equipment is significantly reduced by having in place an asset control process that both meets the needs of the Care Quality Commission (CQC) and Medical & Healthcare Products Regulatory Authority.

Financial Benefits A major question that often arises within Trusts when discussing ‘Make Ready’ is the affordability of the service in today’s difficult economic climate. There are several answers to this, but in truth the service is self-funding when it’s set up correctly and run by professionals. Savings will be

Having in place a robust professional ‘Make Ready’ or Vehicle Preparation programme unites operations, logistics and fleet. It further ensures that vehicles are infection free at the time of delivery to operational crew and that the vehicle is fully equipped and ready to respond to all patients’ needs. Decade of Experience Churchill MakeReady™, which was born out of Lightbridge Support Services, has over 10 years’ experience at designing and implementing ‘Make Ready’, Vehicle Preparation and Deep Cleaning programmes. Today, we are the leading Spring 2014 | Ambulancetoday


Focus on Churchill ‘MakeReady™ Ambulance Preparation Services  

provider of these vital services and our comprehensive service encompasses: • Full ‘Make Ready’ Services – Once Daily and 24 hour MR • Vehicle Preparation Programmes – Once Daily Preparation of vehicles • Infection Control Deep Cleaning Programmes – 6, 9 and 12 weekly • Asset Tracking and Asset Management Systems • Medicines Management and Medicines Packing • Stock Control and Stock Management • Testing of Medical Devices including calibration of some medical devices • Premise Cleaning to Department of Health Standards and CQC compliant services

the highly responsible job of preparing a modern ambulance service vehicle. The training modules that have been developed internally, have been approved by four NHS Ambulance Trusts and accepted by the Paramedics Professional body. Therefore when a vehicle is handed over with all the response bags sealed and the lockers packed / sealed, it is the responsibility of the MakeReady™ Team and not the Paramedic. Failure rates by MR Teams are lower than 0.05% and no critical packing or testing failures have occurred in the past 10 years, proving that the training and systems used are fit for purpose. Partnership and Collaboration A key component that assists in the delivery of a high performance model is the integration with the Fleet Team. Our MakeReady™ Team(s) work closely with all Ambulance Trust Fleet Departments to ensure that vehicles are made available as requested for service. Minor repairs such as

replacement of mirror glasses, wiper blades and indicator bulbs are all now part of the MakeReady™ Team(s) role.

Introducing ‘Make Ready’ Ambulance Services By completing these minor tasks, we reduce

Trust through Leading Training Critical to the success of ‘Make Ready’ Services is the level of training that is given to the Operatives that are entrusted with this vital and important work. It is essential that Paramedics have full confidence that when taking a vehicle at the start of their shift they will have all the critical medical equipment and consumables required to deliver high quality life-saving medical services and that the safety of their patients is not in any way compromised. Churchill MakeReady™ has a highly qualified and experienced Training Team that has a 10-year proven record of delivering effective training over a four week period that successfully equips all relevant individuals who have no medical knowledge for

Spring 2014 | Ambulancetoday

the burden and any potential hold ups with regards to the vital service schedules, which in turn, releases Fleet Technicians to meet their targets without constantly being drawn away from regular routine work to deal with these minor jobs. It is this partnership and collaboration that has brought about measurably improved Fleet performance and helps put vehicles back into operation quickly that has made ‘Make Ready’ a key component of meeting today’s targets.

April 2014

Churchill MakeReady™ is a part of the Churchill Services Group and is a specialist division within the Group providing these vital services to assist our hard pushed partners in the NHS Ambulance sector meet their ever increasing targets and demands whilst focusing on improving patient safety and services.

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The future depends on what you do today. Mahatma Gandhi

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Today, tomorrow, the future. To find out more visit: airwavesolutions.co.uk/thefuture


Focus on SOLUTIONS TRAINING

Advanced Stroke Life Support for Clinicians Online Course New skills for clinicians including the â&#x20AC;&#x153;MENDâ&#x20AC;? examination improving outcomes for stroke patients Released in 2014, the Advanced Stroke Life Support Course (ASLS) represents an entirely new concept in the delivery of stroke education in the UK. The course was first introduced in the USA in 1997 and is currently delivered to over 400 organisations, across 22 states. At the heart of the course is the Miami Emergency Neurological Deficit (MEND) exam, which equips clinicians with new to the UK assessment skills required to recognise the more subtle presentations of stroke, T.I.A. or Stroke Mimic. Armed with this knowledge themselves clinicians will be able to make more detailed patient assessments and fast track patients to specialist care. Containing the latest stroke information, supported by a wide range of videos and assessment exercises, the course takes learners through real life scenarios to embed the MEND exam within their practice.

New skills:The MEND exam

Written by clinicians for clinicians, the course fully supports the delivery of the National Stroke Strategy, NICE guidelines and the Ambulance Quality Indicators. On completion of the course and assessments certification is endorsed by the UK Stroke Forum, Education and Training and the University of Miami.

Established in 1994 by Paul Meek formerly an Operations Director and Paramedic Tutor in the Ambulance Service, Solutions Training & Advisory Ltd have an impressive track record of working with the ambulance, fire and rescue, rail, health & social care, logistics, local authority special needs, voluntary sector and local government across the UK and Ireland reducing risks and ensuring compliance. A BTEC approved centre the company has been offering accredited instructor programmes in moving and handling and conflict resolution to the ambulance sector since 2002 and in 2004 made the move into on line and blended learning. In addition to the advanced stroke life support course now being launched the company has developed on line learning for the ambulance sector in Conflict Resolution (versions for ambulance crews and community responders) including training instructors in disengagement skills (for one tenth of the cost of face to face training) plus manual handling, C.B.R.N.E on line all specifically for the ambulance sector. It has also developed a learning management system that can be used as a standalone for hosting on line courses or as part of a system. The reporting features are designed to deliver the robust evidence of learning required by sectors such as health and fire and rescue. Demos of the manual handling and CRT courses can be run for free at: www.solutionstraining.co.uk

Spring 2014 | Ambulancetoday

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Focus on SOLUTIONS TRAINING

How will this benefit clinicians and patients? An online course covering the skills taught within this Advanced Life Support programme is not available from any other provider in the UK as it is exclusively licensed by the University of Miami to Solutions Training and Advisory Ltd. ‘20% of strokes may be missed by the FAST test, in particularly those relating to the Cerebellum and Brain Stem’. NICE 2008. The MEND exam significantly reduces the risk of missing these conditions. Early recognition and rapid transport to a stroke centre by pre-hospital providers are essential in the care of stroke patients.

The MEND exam incorporates all three components of the Cincinnati Pre-hospital Stroke Scale (CPSS) (speech, droop, drift) and eight additional components from NIHSS: Level of consciousness; gaze, orientation, commands, visual fields, leg motor strength, limbataxia and sensation. The MEND exam can provide an expanded baseline exam in the pre-hospital setting without delaying scene times. Additionally the MEND exam can be used as an initial evaluation tool by nurses and for subsequent exams in the Emergency Department or Intensive Care Unit. Copies of assessment records can be downloaded.

The online modules can be studied anytime and anywhere where access to the internet is available subject to required IT specification. Staff can complete the course at a time, place or pace to suit themselves.The course can be completed in ‘’bite sized chunks’’ as the system will automatically take learners back to where they last logged out (bookmarked).

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Focus on SOLUTIONS TRAINING

What exactly is the Advanced Stroke Life Support Online Course?

Course Contents The online course takes approximately 4.5 hours to complete Replacing two days of equivalent classroom based learning, the course provides robust, comprehensive, educationally endorsed knowledge on emergency stroke care management. Learners are supported through the following modules: • Introduction stating basic facts about incidents of strokes, causes and the need for fast actions; • Stroke Facts and Rationale; • MEND (Miami Emergency Neurological Deficit) Exam: A Focussed Neurological Assessment which are new skills for UK clinicians; • Major Stroke Syndromes and Stroke Mimics; • Stroke Management: Pre-Hospital and General Principles; • Practice Video Scenarios; • Transient Ischaemic Attacks (TIAs); • Health Promotion and Screening; • Final Assessment.

The modules feature clinicians in videos, graphics, stills, animations and other learning interactions to engage all learning styles. Assessments at the end of each module evidence that users have acquired the necessary knowledge to be able to apply it.

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Focus on SOLUTIONS TRAINING

Why should you consider the online approach? A clinically led solution designed with educational rigour Solutions Training and Advisory Ltd has a long established reputation for delivering nationally recognised training and education courses to health care professionals; both instructor led and on-line. The course has been developed in partnership with NHS South, South Western Ambulance NHS Foundation Trust, The University of Miami and stroke specialist clinicians. • Huge cost savings when compared to face to face training. • Learn at a time, place, pace to suit each individual. • Highly engaging developed by world class e-learning specialists • Reduced CO2 emissions – no need to travel to learning

Course Feedback … ‘I’m a Registered General Nurse with the experience of residential care and district nursing. In a previous life I worked in IT and was involved in the development of e-learning. I have completed the Advanced Stroke Life Support Course, produced by Solutions Training and Advisory Limited and I’ve found it to be of high value as not only did it teach me new skills including the MEND examination, but reinforced my knowledge in other areas including a better understanding of Transient Ischmeic Attacks. It was easy to use and to navigate, highly interactive and engaging. I would strongly recommend this course to develop the skills of all Clinicians’. Sarah Gwilliam—Registered Nurse In the case of patients experiencing a stroke, the National Ambulance Clinical Quality Indicators demonstrate that prehospital clinicians are good at managing patients who present with FAST positive signs. The challenge now is for clinicians to develop their skills to spot and correctly manage the far more challenging group of patients who are not FAST positive; those who present with issues that are rapidly identified by the MEND exam. The health promotion module within the course provides a comprehensive overview to help clinicians embrace their new role.’ Adrian South, Deputy Clinical Director of South Western Ambulance Service

Our partner Harbinger System Limited is one of the world’s largest and most long standing e-learning specialists. It has over 20 years of experience in developing high quality, interactive online learning solutions for leading clients in the public and private sector across the world. The Online Advanced Stroke Life Support course is highly cost effective at only £39.75 (including VAT), per learner.

Go now to www.solutionstraining.co.uk to run a free demonstration of the Advanced Stroke Life Support Course, or to purchase. For more information about the Advanced Stroke Life Support, or training courses please contact us 01932 40

880147

One of the key areas where this new e-course will be so valuable is in the teaching of the MEND clinical examination technique. This approach to consistent, replicable assessment of stroke and TIA symptoms is key to be able to take emergent stroke assessment to the next level. MEND which supports and is consistent with validated stroke scales such as FAST, CPSS, ROSSIER and NIHSS, crucially allows clinicians to be able to identify stroke symptoms which may otherwise have been missed, allowing more patients to gain timely access to stroke treatment. David Davis, Clinical Informatics Advisor – AHP National Lead Spring 2014 | Ambulancetoday


Focus on prehospital resuscitative thoracotomy for trauma Paramedic Team Leadership during prehospital resuscitative thoracotomy for trauma by Dr Gareth Grier, Shaun Rock, Graham Chalk, Neil Jeffers & Dr Gareth Davies

Effective Team Leadership During RT Prehospital RT (Resuscitative thoracotomy) is carried out during cardiac arrest following penetrating trauma, often in a scene with high levels of emotion. For most rescuers it will be the first time they have been present when RT is performed, creating considerable pressure on all involved to work in a coordinated and constructive way if the patient is to benefit. But ensuring that this highly complex procedure is carried out despite these inevitable distractions and stressors is the core role of the Paramedic team leader. Prehospital resuscitative thoracotomy has been well documented to greatly influence survival in selected patient groups1,2,3,4,5. The first documented case was described in 1994, being carried out by a physician riding with EMS crews in the USA6. Resuscitative thoracotomy (RT) has been defined in a variety of ways in the literature over the years, with some authors restricting the description to patients who are in cardiac arrest, and others considering ‘resuscitative’ to reflect the procedure being carried out in the ‘peri-arrest’, ‘emergent’ or ‘moribund’ patient. This leads to some confusion when interpreting outcome data, with variable success reported7. In addition, the definition of ‘cardiac arrest’ in injured patients is not universally agreed, especially when ‘electrocardiograph activity’, ‘pupil reactivity’, or the ‘agonal’ state are used in various ways to define the point at which RT is performed. In the London’s Air Ambulance system, standard operating procedures for performing the procedure have defined the patient group to which the procedure can be applied (box one)8. Previously, we have described how to perform the procedure, with case reports and case series of survivors9,2,1. It has been shown that for selected patients, RT can give rise to neurologically intact survivors where this would previously have not been expected. Traditional indications for prehospital resuscitative thoracotomy8 Penetrating trauma to the torso Cardiac arrest occurring in previous 10 minutes Tension pneumothorax excluded as a cause Although the technical aspects of performing the procedure and outcomes have previously been described, the management of the prehospital scene during RT has not received a great deal of attention. However, for RT to be successful in the prehospital phase, it is essential that Spring 2014 | Ambulancetoday

there is a clear strategy for scene and team management. We describe the role of the flight paramedic as the team leader during prehospital resuscitative thoracotomy in an urban physician-paramedic system, and explore common challenges faced at the scene. Human factors in prehospital team leadership There has been an interest in the impact of human factors on team performance during medical emergencies for some time, especially in error management10. For some authors, the term ‘human factors’ relates to the emotional impact of emergency situations, but the term has more formally been adopted in the analysis of error mitigation. The terms ‘crew resource management’ (CRM), and ‘team resource management’ (TRM) are increasingly used during resuscitation team leadership training 11.12 . An understanding of the impact of human factors on the prehospital RT scene is essential for team leaders. Pre-hospital RT is carried out during cardiac arrest following penetrating trauma and it is not difficult to imagine that the scene usually has high levels of emotion, not only in terms of the patient, their family, friends, or other bystanders, but also for the rescuers. For most rescuers, whether they are from the emergency services, or incidental medical or paramedical helpers, it will be the first time they have been present where RT is performed. For those who had been delivering care prior to the cardiac arrest, the experience of a patient ‘dying’ in their presence is highly emotive. There is considerable pressure on all team members to work in a coordinated and constructive way if the patient is to benefit. Ensuring that the procedure is carried out despite these inevitable distractions and stressors is the core part of a team leader role. Who should lead the team at prehospital RT? The importance of a structured team response to trauma resuscitation has been emphasized for many years13. For

many flight doctors, although they will have rehearsed the RT procedure many times in a training environment, it is often the case that they will not have extensive experience in delivering the procedure, especially in the prehospital phase. Even experienced doctors and surgeons, when faced with a prehospital thoracotomy, have little ‘bandwidth’ remaining in which to address the issues of the scene. Their focus will almost entirely be on the technicalities of gaining access to the chest cavity, and identifying and releasing a cardiac tamponade if present. It is essential that the scene does not stall during this phase. The flight paramedic has an essential role in team leadership during prehospital RT. The doctor will usually make introductions to the team, establish that the indications for RT are met, and take the decision to perform the RT. On making the decision, the doctor verbally identifies the flight paramedic as team leader. This stage mirrors the guidance from the world health organization on safety in emergency situations and is an important first initial step in managing the team14. HEMS pilots give useful analogies for behaviours during emergencies. During an in-flight emergency, the concept that one pilot concentrates on flying the plane and another ‘works the problem’ has been one which has been translated into clinical practice for our prehospital teams during challenges such as the difficult airway. ‘Eyes out’, where one team member visualizes the whole scene, and ‘eyes in’ where a colleague focuses on a single detail, is another concept that is useful to apply to the RT work. The doctor has ‘eyes down’, performing a ‘motor program’ of making incisions and suturing wounds, often with minimal situational awareness, whilst the flight paramedic has ‘eyes out’, managing the scene, with a view to maximizing this situational awareness. The art of an effective team leader will be to retreat, expanding bandwidth and becoming less ‘hands-on’ the more complex a scene becomes. This concept has been applied to the medical management of major incidents for some time, but is essential if a RT scene is to be managed well. 41 3


Focus on prehospital resuscitative thoracotomy for trauma

Specific roles of the team leader Establishing 360 degrees of access to the patient The principle of 360 degrees of access to a prehospital patient was introduced by LAA in order to deliver prehospital anaesthesia safely and successfully15. This concept is also applied to the RT scene. It is extremely difficult to undertake RT where a patient is in the confined space of a basement, or bathroom for example. A rapid ‘snatch’ of the patient a short distance to a wider area can dramatically improve the ability to perform the technical procedure. Even when it seems impossible to do this, an experienced paramedic team leader will be well versed in finding access.

In patients who have an isolated cardiac tamponade then distended external jugular veins (EJV) may well be present. Ambulance paramedics are usually well versed in inserting EJV cannulae and it is important that these veins are accessed early, prior to the tamponade being released. The team leader will ensure that this takes place. Where hypovolaemia is present, intravenous access may be extremely difficult. There are then several options, usually tackled by the flight doctor after release of tamponade has been achieved. The role of the team leader here is to weigh the advantages and disadvantages of the various routes of access, against the needs of the patient, the familiarity of the doctor with each route, and the purpose of that access.

It is not unusual for multiple ambulance service and other responders to be present on scene with their equipment. The team leader rationalizes the presence of equipment at the scene, remembering that where a scene is crowded with equipment bags, furniture and other paraphenalia then the rapid initiation of lifesaving interventions, and removal of the patient from scene to hospital can be significantly impeded. Paramedic team leaders will therefore create a ‘red zone, amber zone, and green zone. In the ‘red zone’, only essential life saving equipment is permitted, together with ‘hands on’ personnel. In the ‘amber zone’, personnel will be preparing ‘back up’ equipment or drugs, and in the ‘green zone’’ redundant equipment, non medical emergency personnel, and individuals preparing the route to hospital will be ready.

• Subclavian venous access Subclavian venous access is commonly used in the resuscitation room for central access to the circulation. The route may also be used during RT, however with the chest open, this may not be straightforward. • Femoral venous access The femoral vein is usually accessible, but is frequently very difficult to access during hypovolaemic cardiac arrest. It is commonly stated that the femoral vein should be avoided in trauma in case of haemorrhage in the proximal venous circulation however this does not necessarily preclude the placement of femoral access in a RT patient where there is no other option.

Figure 2. The ‘kit dump’ concept – the fire rescue service, the anaesthetic kit dump and the RT kit dump.

Figure one – structure of the prehospital RT scene

Team leader activity in the ‘red zone’ The RT procedure is carried out with minimal and simple equipment9. Additional equipment, is carried by the team and the team leader performs a ‘kit dump’ next to the patient. The kit dump is once again a procedure learned from extensive experience with prehospital anaesthesia, but also used by the fire and rescue service at the scene of road accidents. Whilst the thoracotomy proceeds, the flight paramedic will ensure that there is simultaneous activity, utilizing the talents of team members already on scene. 42

Airway management Undertaking endotracheal intubation whilst resuscitative thoracotomy is taking place is not easy. The intubator can easily be distracted by the other events on scene, and the position of the patient (often on the floor) does not always result in an easy view of the vocal cords. To minimize the potential for an oesophageal intubation, the flight paramedic will ask a team member to insert a supraglottic device at this stage. This is especially helpful when there is no one skilled at intubation on scene, and allows the RT team to focus on their own tasks. It may be necessary to intubate once the RT is complete and successful but this can then be done in a controlled way. Circulatory access The team leader ensures that intravenous access is secured. Intravenous access is deemed important at this stage for two reasons: • Once the cardiac tamponade is released the patient may start to wake up, requiring anaesthetic agents • The patient may need a blood transfusion on scene.

• Intrathoracic access Various members of our team have placed cannulae into the cardiac chambers where more peripheral access is difficult, and report varying success. However, in the beating heart, securing and maintaining a cannula in position can be difficult. For the administration of blood, the right atrium is preferred, again, where other options are not feasible; The use of a foley catheter for intracardiac access is well described but not without problems. • Intraosseous access Intraosseous access is used as a temporizing measure whilst larger bore access can be secured. Members of the ambulance service team can assist with this. There are often difficulties with the administration of relatively large volumes of blood via this route. The timing of prehospital blood transfusion during RT It is clear that successful prehospital RT is associated with the rapid release of pericardial tamponade9 The initial focus of the team must be in identifying and treating this pathology. Except for the medical team, there is usually no one on scene familiar with assembling blood warming equipment and with the setting up of a blood transfusion. This task therefore has to be carried out by the flight doctor or paramedic. Where hypovolaemic shock exists as the sole cause of cardiac arrest, Spring 2014 | Ambulancetoday


Focus on prehospital resuscitative thoracotomy for trauma

or in combination with cardiac tamponade, results are usually less favourable than with the release of isolated tamponade. In addition, decisions around blood transfusion are not taken lightly. Blood is a precious resource, but it may well be that a transfusion is commenced following the release of tamponade where further attempts at resuscitation are indicated. • Crystalloid, colloid, and other fluids. There is little to be gained from the administration of saline or other non-oxygen carrying fluids at this stage. Team leader role in sustaining a heartbeat In the ‘ideal’ situation and following the release of a cardiac tamponade, the heart will beat spontaneously and this cardiac output will be maintained. Where this sequence of events takes place, it is important to move to hospital as soon as is safely possible. The ability of the heart to restart following an injury that is severe enough to have resulted in cardiac arrest is dependent on a number of factors. Where it is difficult to achieve a sustained ROSC, team leaders should rapidly help establish the reason why ROSC is not possible. In real time, this will be to ensure that a supply of welloxygenated blood reaches the coronary arteries. Quality internal cardiac massage, combined with ventilation is vital. Team leaders will pay attention to the quality of internal massage. Common mistakes include: the operator lifting the heart from its natural position resulting in a disruption of venous inflow; allowing a rate of internal massage which prevents the heart from filling – common whilst a transfusion is in progress; and the use of a one handed technique where there is a risk of atrial perforation. Cardiac tamponade may develop quickly or slowly, depending largely on the location of the cardiac wound. A slowly developing cardiac tamponade, for example caused by a low pressure right atrial stab - oozing over a period of time, may well result in an extended period of cardiogenic shock prior to a cardiac arrest. In this case, there will be a degree of metabolic catastrophe by the time cardiac arrest occurs, and it may be difficult to achieve or sustain a ROSC. Compare this with a rapidly expanding tamponade that accumulates within minutes, only to be released by the team immediately following cardiac arrest, where the heart might make an enthusiastic recovery. Where haemorrhage has caused cardiac arrest, it is very common for ROSC to be difficult to sustain, if this is achievable at all. By the time cardiac arrest has occurred in hypovolaemia, the heart is often ‘plegic’, distended, and ineffective as a pump. Even for very experienced teams, maintenance of spontaneous cardiac output in this state can be challenging. Where there is ventricular fibrillation, the heart may either be in a recovery Spring 2014 | Ambulancetoday

phase; for example following the release of a tamponade, or in failure. Decisions to cardiovert the fibrillating heart during RT should be taken in light of the proposed aetiology. In many cases, delivery of oxygenated blood and quality internal massage may convert fine, resistant VF into a more shockable rhythm. Most doctors will still take their hands out of the chest during defibrillation but ‘hands off ’ time for internal massage is as important as that for external chest compressions. A cold heart will not start. Some patients, especially but not only the elderly, may have underlying cardiovascular disease that may contribute to instability. Other factors, such as septal perforation, valvular disfunction, disruption of the coronary arteries, and electrophysiological tract disruption can impede sustainable ROSC. External pacing using the defibrillator may be helpful where there is nonconducted atrial activity. Where there is an extended period of difficulty in sustaining a ROSC, a decision must be taken around the termination of efforts. Often, the team will discuss the case with an on-call experienced clinician at this point. Activity in the ‘amber zone’ Team leaders help coordinate the ‘amber zone’ where spare oxygen, blankets, spare airway equipment are held. Monitoring equipment is kept in the amber zone until return of spontaneous circulation and visual stability is achieved. RT should certainly not be delayed or interrupted by the attachment of meaningless monitoring. Activity in the ‘green zone’ The ‘green zone’ usually contains police officers, the ambulance trolley, and in some cases patient relatives. The police will have a vital role during the thoracotomy scene, firstly in ensuring and maintaining scene safety, and then in the preservation of forensic evidence as the scene progresses. The police will be very keen to control access and egress of personnel at the scene and to record details of interventions. The team leader will usually work with a senior member of the ambulance service in order to satisfy the important needs of the police service during prehospital RT. It is again important for team leaders to recognize that for most police officers however senior, witnessing prehospital RT can be an extremely harrowing experience. Relatives and friends It is not unusual for relatives, friends, or people who claim to be relatives or friends to be present during prehospital RT. Whilst the prehospital team have a multitude of tasks to perform, attention to the needs of loved-ones on scene is crucial. As harrowing as the scene might be for emergency personnel, the experience for family and friends can be profound. Whereas much has been written about the benefits of relatives observing resuscitation efforts, it is unusual

for family members to remain on scene during RT. This usually means that the team leader allocates an appropriate member of the police or ambulance service to help relatives at this time. As the circumstances of the events leading up to the RT are usually unclear, the police are usually reluctant to allow family members to make contact with the patient at this point. However, the paramedic team leader must exercise all of their non-technical abilities in ensuring that high quality care is delivered to relatives during this process. The team leader will usually ensure that if there is an opportunity to do so, the doctor speaks with the family prior to leaving scene. Removal of the patient to hospital Usually, where interventions do not bring about a return of spontaneous circulation, and the heart is not contracting, a team decision is made to pronounce life extinct on scene. Where ROSC occurs, the team leader will have already planned the route to the awaiting ambulance, ensured that the ambulance is not ‘trapped’ by other emergency vehicles, and that the person driving has the keys and is ready to move. Not infrequently, the roadway becomes blocked by other emergency vehicles, ambulance batteries run flat resulting in technical problems with mechanical ‘tail lifts’, all of which should be confirmed as functioning by the team leader, before the patient is moved. Depending on the configuration of the ambulance, team leaders should ensure that there is ready access to the heart during the transfer, should internal cardiac massage or defibrillation be required. This can be especially difficult during helicopter transfer, and the team will make a risk – benefit analysis of the mode of transport to hospital. Specifically for transfer by helicopter, it is vital that the team discuss strategy prior to loading and lifting. Pilots should be included in this conversation. An unstable, post RT patient can be extremely challenging for the team in flight and it is vital that flight safety is not impaired. Decisions such as removing safety harnesses in order to undertake interventions should not to be taken lightly. Many helicopters in the UK are not cleared for in-flight defibrillation and it is not wise to discover this after loading the patient. Team leader role in post ROSC strategy for prehospital RT Hypothermia Hypothermia is a direct effect of both haemorrhage and cardiac arrest itself, and is not helped by the chest cavity being open. There should be serious attempts to prevent excessive heat loss although it is recognized that the principles of therapeutic hypothermia quite probably apply to this group of patients in terms of cerebral protection. Where there has been a treated isolated cardiac tamponade, our team will use a strategy of mild therapeutic hypothermia. 43 3


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Focus on prehospital resuscitative thoracotomy for trauma

Use of drugs during and post resuscitation It is important for prehospital team leaders to grasp the relative usefulness of drug therapies during prehospital RT. Where published algorithms exist for the management of cardiac arrest, these usually concern cardiac arrest from a medical context, and reliance on drug regimens in the hope that ROSC will suddenly occur as a result of any particular drug during RT is not sensible. Whereas a detailed analysis of the benefits of each ‘ALS’ drug during the various prehospital RT scenarios is not the remit of this paper, it must be emphasized that with a small team attempting to perform multiple tasks during RT, loss of a team member to prepare a drug which has no scientific or rational purpose in a given scenario wastes resources. Each drug decision must therefore be rehearsed during local training. The overwhelming principle must be that nothing must distract the team from effectively delivering oxygenated blood to the brain and to the heart. Hyperoxia post prehospital RT Although there is considerable interest from experts in resuscitation on the effects of hyperoxaemia, particularly on the brain in post cardiac arrest patients, there are no studies that examine this subject in post RT care. Prehospital strategies in this context must focus on delivering oxygenated blood to the heart in order to sustain ROSC. In the case of an extended prehospital phase, consideration could be given to controlled reoxygenation, avoiding hypoxia. Debriefing the prehospital team In partnership with the doctor, the team leader must ensure a ‘hot debrief ’ of team members at the scene. In the case of a rapid evacuation to hospital, this debrief must take place as soon as possible - either at the hospital, or elsewhere with the help of the senior ambulance officer on scene. The ‘hot debrief ’ is an opportunity to provide an explanation of the events on scene and to answer any questions of other responders. Paramedic team leaders can be effective at facilitating the debrief. The debrief should always conclude with a summary of how the actions of the team References 1. Coats, T. J., Keogh, S., Clark, H., & Neal, M. (2001). Prehospital resuscitative thoracotomy for cardiac arrest after penetrating trauma: rationale and case series. Journal of Trauma-Injury, Infection, and Critical Care, 50(4), 670-673. 2. Davies, Gareth E., and David J. Lockey. “Thirteen survivors of prehospital thoracotomy for penetrating trauma: a prehospital physicianperformed resuscitation procedure that can yield good results.” The Journal of Trauma and Acute Care Surgery 70.5 (2011): E75-E78. 3. Deakin, C. D. (2007). From agonal to output: an ECG history of a successful pre-hospital thoracotomy. Resuscitation, 75(3), 525-529. 4. Corral, E., Silva, J., Suárez, R. M., Nuñez, J., & Cuesta, C. (2007). A successful emergency thoracotomy performed in the field. Resuscitation, 75(3), 530-533.

Spring 2014 | Ambulancetoday

Mr Shaun Rock

‘Death and disability meeting’ following prehospital RT

set out to help the patient, even when there was not a successful result. It is good practice to arrange a more structured and formal debrief some days later, inviting all emergency personnel, led by a senior clinician. Training for the role of RT team leader For many prehospital advanced interventions, team management can be straightforward when standard operating procedures apply. Human factors training is key to being an effective team leader, and the combination of technical and nontechnical skills can result in effective scene and patient management. Conclusion The role of the team leader during prehospital resuscitative thoracotomy is an important one, which can be readily undertaken by the flight paramedic in a physician-paramedic system.

Mr Graham Chalk Graham has been the lead paramedic at London ‘s Air Ambulance for ten years. He is responsible for the recruitment, mentoring and training of HEMS paramedics in London, and is closely involved with clinical governance processes in London . He lectures internationally on dispatch of air ambulances to major trauma, and is the deputy course director of the Pre-hospital Care Course at the Institute of Pre-hospital Care at London ‘s Air Ambulance. 5. Silfvast, T. (1997). Prehospital Thoracotomy for Cardiac Arrest Due to Perforating Chest Wounds: Case Reports of Two Patients. Prehospital and Disaster Medicine, 12(S1), S21-S21. 6. Wall Jr, Matthew J., Paul E. Pepe, and Kenneth L. Mattox. “Successful roadside resuscitative thoracotomy: case report and literature review.” Journal of Trauma-Injury, Infection, and Critical Care 36.1 (1994): 131-134. 7. Moore, E. E., Knudson, M. M., Burlew, C. C., Inaba, K., Dicker, R. A., Biffl, W. L., ... & WTA Study Group. (2011). Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. Journal of Trauma and Acute Care Surgery, 70(2), 334-339. 8. London’s Air Ambulance Standard Operating Procedure for penetrating trauma and prehospital resuscitative thoracotomy. 2011 9. Wise, D., Davies, G., Coats, T., Lockey, D., Hyde, J., & Good, A. (2005). Emergency thoracotomy:” how to do it”. Emergency medicine journal: EMJ, 22(1), 22.

Shaun is a flight paramedic with London ‘s Air Ambulance, is a HART paramedic, and is extensively involved in the training and mentoring of junior and senior paramedics. He has significant experience of working in doctorparamedic teams.

Dr Gareth Davies Gareth is the medical director of London ‘s Air Ambulance and has led and developed many of the significant innovations in prehospital care in the UK and abroad. He is one of the world’s most influencial figures in prehospital care. He is a consultant in emergency medicine and prehospital care at the Royal London Hospital.

Dr Gareth Grier Gareth is the clinical director of the institute of prehospital care at London ‘s Air Ambulance, the course director of the Pre-hospital Care Course in London and a consultant in emergency medicine and prehospital care at the Royal London Hospital.

Capt Neil Jeffers Neil is the chief pilot of London ‘s Air Ambulance. He is an instructor and mentor to air ambulance pilots and has a significant interest in human factors, team resource management and team working both in aviation and during medical emergencies. He lectures on trauma team leaders courses on this subject. Neil is an instructor on the Pre-hospital Care Course of the Institute of Pre-hospital Care. 10. Ornato, J. P., & Peberdy, M. A. (2013). Applying lessons from commercial aviation safety and operations to resuscitation. Resuscitation. 11. Ornato, J. P., Peberdy, M. A., Reid, R. D., Feeser, V. R., & Dhindsa, H. S. (2012). Impact of resuscitation system errors on survival from inhospital cardiac arrest. Resuscitation, 83(1), 63-69. 12. Cole, E., & Crichton, N. (2006). The culture of a trauma team in relation to human factors. Journal of clinical nursing, 15(10), 1257-1266. 13. Driscoll, P. A., & Vincent, C. A. (1992). Variation in trauma resuscitation and its effect on patient outcome. Injury, 23(2), 111-115. 14. http://www.who.int/patientsafety/safesurgery/ tools_resources/SSSL_Manual_finalJun08.pdf 15. Mackenzie R, Lockey DJ. J R Army Med Corps 2001; 147: 322-334. Pre-hospital Anaesthesia 16. Hommers, C. E., & Nolan, J. P. (2012). Controlled Oxygenation after Cardiac Arrest. In Annual Update in Intensive Care and Emergency Medicine 2012 (pp. 519-534). Springer Berlin Heidelberg. 45 3


Focus on Eberspächer & O & H – 25 Years of Successful Partnership

Eberspächer & O&H – Improving UK ambulance fleet for 25 Years Eberspächer UK, have been supply leading UK ambulance builder, O&H, with a UK-designed and manufactured range of very compact, high-output air conditioning and climate control products for both their home and export markets for 25 years. With a varied product range famous for its reliability, Eberspächer supply robust solutions ideal for the ambulance market, while O & H’s remarkable growth now sees it positioned as one of the UK’s go-to ambulance builders. Below their MD’s explain how their close partnership is shaping the future of UK ambulance fleet. Eberspächer has recently rolled out an all new Accreditation training programme for its nationwide dealer network and approved installers at OEM level. Launched as part of Eberspächer’s comprehensive TLC (Total Life Care) package, the Accreditation programme was designed to standardise their high quality of customer support and ensure that all customers receive the same high levels of customer service, wherever they are located. Vince Lee, Eberspächer Managing Director explains: “Investing in our after-sales support is incredibly important to us. It ensures our market leading products are installed and maintained to the best possible standards by knowledgeable and competent engineers and it means that ambulance operators can be confident that if they need help, they will always receive absolutely first class service.”

being forwarded on to other ambulance converters. In 1996, O&H acquired new premises, adding a further 20,000 sq.ft of factory space which enabled expansion of its product range into ambulance Patient Transport Service vehicles. From the start this included the fitting of Eberspächer heating and air conditioning units. O&H now boasts one of the biggest ambulance/WAV hire fleet in the country, topping over 100 vehicles covering its full range of products. Not only is it probably the largest specialist hire fleet in the UK, but all its vehicles are less than 5 years old, with the majority of vehicles less than 3 years old, making it also the youngest fleet available. In 2012, O&H became the first UK converter to achieve ECWVTA on a front line A&E ambulance, based upon the Fiat Ducato 4250kg GVW. This reinforced O&H’s commitment to both design and quality working alongside major suppliers like Eberspächer.

O&H now employs over 250 people at its Goole site and produces over 1200 conversions a year. It is a major supplier to all the ambulance trusts in the UK as well as to a large number of UK councils, care homes, schools and motability operations. More recently, O&H has become a major provider of PTS vehicles to the Independent ambulance sector which runs an increasingly large proportion of the UK’s PTS contracts.

O&H was established in 1988, under its original name of Oughtred & Harrison (Facilities) Ltd, then a small subsidiary of the Oughtred & Harrison Group and based at its original site at the Old Goole Ship yard. The business has been transformed to one of the leading vehicle converters in the country. O&H (Facilities) Ltd, started business with just 13 employees and was used to perform small modifications to imported vehicles, progressing to perform “pre-ambulance” modifications to vehicles including the fitting of Eberspächer heaters, before 46

Spring 2014 | Ambulancetoday


Focus on Eberspächer & O & H – 25 Years of Successful Partnership

O&H have assembled a team of experienced, industry-trained specialists who work closely with their clients to devise a bespoke specification. The build process is lean and flexible, working closely with vehicle manufacturer and suppliers to ensure all modifications carried out complement the quality, durability and safety of the original vehicle. This enables O&H to offer a flexible approach to supplying vehicles to suit individual requirements and also gives them the flexibility to apply the same high quality and attention to detail to single vehicle orders as well as the capacity to deliver large volume contracts. O&H Vehicle Conversions pride themselves on providing customer service to the same high standards as those reflected in their high quality products. O&H is run by an

experienced and friendly team that work closely with their customers to ensure the design, build and supply process meets with their requirements and continues to do so throughout the lifespan of their investment.

UK ambulance fleet supply, Eberspächer MD, Vince Lee finishes by saying: “O&H are one of our oldest clients so we look forward to working with them for another quarter of a century!”

“Eberspächer have been a long standing supplier to O&H, supplying heating and ventilation systems for all our products. They give us great service, both on Kevin Wheatman site during the installation MD of O&H and in the field, and always support the needs of our growing list of ambulance customers,”comments Kevin Wheatman, Managing Director. Agreeing that theirs is a partnership making a significant contribution to improvements in

Steve Shaw of O&H (left) with Steve Farnsworth, Head of Fleet Services, East Midlands Ambulance Service NHS Trust Spring 2014 | Ambulancetoday

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Jerry Overton’s Letter from America Sponsor of London’s Cardiac Arrest Symposium

merge

“Call Me, Call Me…!” When Deborah Harry and Blondie first sang the lyrics “You can call me any day or night . . . Call me” sometime ago, it really was not about ringing the local Emergency Medical Dispatcher (EMD) and requesting immediate care (If you do not remember exactly to what the lyrics referred, just ask the editor of this fine journal as I am sure he will know!!!). However, today, more and more (and more), patients, family members, bystanders, citizens, and public safety officials are calling EMS for both their acute and non-acute medical needs and it is those answering that call that have the first opportunity to control the eventual outcome for that patient. Nowhere is this more evident in the race for time then when a patient suffers cardiac arrest. In 1991, the peer review journal Circulation first published the concept of the “Chain of Survival” as an American Heart Association Medical/Scientific Statement, along with Resuscitation. The Chain, as we all know, emphasized that the four links were interconnected (hence a chain!!!) and were time dependent, using the word “Early.” When the Chain was updated in 2010, again “Early” began each link with the exception of “Post Resuscitation Care,” replacing “Early Advanced Care (which I still prefer as it better describes your role in resuscitating the patient).” Essentially, if we are not “early” it is clear that the patient will not survive and to be “early” demands quick and professional action at that initial point of contact, the Emergency Medical Dispatch center. Gone are the days when the Dispatch Center was nothing more than a room the size of a closet where an untrained operator (assigned perhaps because of an on duty

injury) answered a telephone and then pushed a button to talk into a microphone to send an ambulance on its way. In the past several years, an evidence base has been built around the need for effective and efficient EMD and its impact of each link of the Chain. In fact, no longer, in the year 2014, should we even refer to it a ‘Dispatch Center’, as it has now evolved into a clinical hub with trained professionals that can equate to those professionals responsible for delivering the care at the scene. This evolution becomes apparent as we examine the “patient journey” through the EMS system, or from the time a patient recognizes that he or she needs care to the time that a definitive outcome is achieved. Several years ago I had the privilege of being the American investigator in the European Emergency Data Project and what we found in plotting the “patient journey” was that almost fifty percent of the steps were either initiated or impacted by the actions in the

Dispatch Center (clinical hub). And in no patient is this more true that one in cardiac arrest. An examination of the role of the EMD in a successful resuscitation quickly reveals the reasons. Let us start with three premises. Premise One is that survival from out of hospital cardiac arrest (OHCA) requires a systemic approach. Premise Two is simply that dispatch is integral for the success of Premise One. And, finally, Premise Three requires us to really understand the role of dispatch and that is integral to Premise Two. More simply stated, if does not go right at the point of dispatch, the chances of a successful resuscitation are reduced to about zero!!! Continuing our examination, we can now take a quick look at each link in the Chain of Survival and how it is affected by the dispatch process. In the first link, “Early recognition and call for help,” it is obvious. There are two very interdependent factors that drive a successful outcome, the EMD and the protocol. Quite simply, the EMD is a trained professional and to achieve that status, the training must be structured, have a continuing education component, and be part of an ongoing quality assurance program. Results from a study published in the Emergency Medical Journal in 2004 by the London Ambulance Service provided all the evidence we need. Complying with a structured protocol, Principal Investigator Andy Heward and his team found an increase of 200 percent (yes, you read that correctly) of patients accurately identified in cardiac arrest. Other studies lend further support. The other interdependent factor is the protocol itself. Interestingly, when we arrive at the scene of the cardiac arrest

Spring 2014 | Ambulancetoday

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Jerry Overton’s Letter from America Sponsor of London’s Cardiac Arrest Symposium

(or shooting or stroke), most systems have a very specific protocol to follow. We certainly did while I was Chief Executive of the Richmond Ambulance Authority as my Medical Director demanded it. For different reasons, some obvious and some not so obvious, this stringent adherence to a structured dispatch protocol has not been given the same priority. As the previous cited study proved, this can no longer be the case. A structured protocol that can both identify the acuity of the caller, and prioritize that acuity, is evidenced based and its application can directly lead to the success, or failure, of the next link of chain.

EMD and early defibrillation does have potential implications and those implications are becoming more obvious in countries like Denmark. Having the locations of the AEDs electronically available to the EMD, and having the EMD “dispatch” a bystander to that location has obvious benefits. Other countries are following and it will be fascinating to review future research results. The final link in the chain, “Post Resuscitative Care,” or as I prefer, “Early Advanced Care,” may not be obvious at all from the clinical hub perspective. But because it is a

clinical hub, it is clearly important. As any EMD know, resources are limited. Demand continues to rise, response time pressure continues, and taken together, finding the right resource to send to the right patient reads much easier than it actually is. If we are going to increase survival from OHCA, the ultimate outcome requires the ability to allocate and reallocate resources and that, in turn, requires a structured dispatch protocol that can reliably distinguish between the acute and the non-acute patient. Using this valuable tool, “early advanced care” can, indeed, arrive “early” and our highly skilled field personnel can begin “Post-Resuscitative Care.” Peter Gabriel made it sound relatively simple when he sang: “Shock the monkey to life.” But we are not dealing with monkeys and it is far from simple. In the end, it is the beginning that truly makes the difference!

“Early CPR” means bystander CPR and bystander CPR most commonly means EMD CPR instructions. The more we learn, the more we know the instructions work. From Australia to Richmond, they can make a difference, not only in Return of Spontaneous Circulation (ROSC), but discharge from hospital. Equally important we are learning why the bystander is reluctant to get involved. In the past, researchers had believed it was fear of disease, but more recent results actually show that it is because of a physical limitation or because a family member is too emotionally distressed to act. The most important work in our understanding of telephone CPR is now being done by the Emergency Medicine Research Group at the University of Edinburgh. By identifying the different time intervals involved in what their researchers have identified as the 12 stages of telephone CPR, we can begin to fine tune the instructions to place hands on chest faster and increase survivability. Bystander CPR provides the opportunity to activate the third link. At first glance “Early defibrillation” might not seem that relevant for the EMD, however that is not the case. The link between the Spring 2014 | Ambulancetoday

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Focus on IAA Conference 2014

IAA conference told “Ambulances central to radical changes in Urgent Care” The audience of 80 delegates at the second IAA second annual conference in London on 2 April were given 3 clear messages by the influential platform of speakers from the NHS and regulatory bodies: • There will be a pivotal role for the independent ambulance sector in the newlook urgent care services; • Opportunities will exist for partnerships because the NHS ambulance providers will need help; • The new CQC inspection regime being introduced next year will be more robust and customised specifically for ambulance services. Professor Jonathan Benger, National Clinical Director for Urgent Care, NHS England, who is a member of the Keogh Review, said that the new system will see an increased provision of care over the phone, at scene and in the community, with transport to A&E the exception rather than the rule. This will require an increase in community provision, free flow of information, joined up work with social care, enhanced clinical support and workforce development. A range of new opportunities will exist for independent ambulance services in the new system, ranging from the support of new models of care to urgent transportation to transfer and retrieval for the most seriously ill and injured patients. He added: “There is an appetite for change within Government and all those engaged in the review. Ambulance services are central to the changes which will be radical

and there will be a pivotal role for the independent ambulance sector”. Mark Docherty, Lead Commissioner, London Ambulance Service, said that CCG’s were in the driving seat of the changes but there were massive challenges ahead. He acknowledged that NHS ambulance providers on their own would be unlikely to be able to solve all the urge changes. “They will need help and the independent providers should take the opportunity to step forward….partnerships are likely and relationships are key.” Mark Pawsey, Conservative MP for Rugby, one of the few politician to have visited an independent ambulance service, said it was clear the sector had a bright future and was poised to contribute to a modern ambulance service but he gave delegates 3 pieces of advice: 1. Demonstrate the add-on value you bring to the nation’s healthcare service; 2. Deliver a good service at a fair price to overcome any suspicion that you are not as good nor as professional as the public sector; 3. Urge your members to invite their local MPs to visit their companies to get first-hand what for most will be an understanding of a private ambulance service and the role it plays in the local community. Sir Mike Richards, the CQC Inspector of Hospitals, outlined for the first time how the new inspection regime will be customised for ambulance providers, based on 5 questions - Is the service safe, effective,

caring, responsive to patients’ needs and well-led. A team of inspectors, including an ambulance industry expert, will check equipment and training methods, review patient reports, gather feedback from patients, and question companies’ leadership, vision, strategy and culture. He told delegates: “We want to work with the independent sector to produce a robust, fair and effective approach to inspections and ratings for ambulance services.” Dr Anthony Marsh, Chair, The Association of Ambulance Chief Executives and Chief Executive of West Midlands Ambulance Service NHS Foundation Trust addressed the issue of improving patient experience. He said that the review provided the opportunity to prepare staff for change in three specific areas – the introduction of a national standard for clinical training based on quality, innovation and improvement, embracing the new CQC inspection regime and more focus on technology, covering data tracking, mobile data terminals, patient care records, modern equipment and vehicles. Other speakers at the conference included Dr Rekha Elaswarapu, Senior Policy Adviser and Research Manager, The Patients Association, Professor Ric Marshall, Director of Pricing for NHS England, currently attached to Monitor, Andrew Foster, Chief Executive Officer, Wrightington, Wigan and Leigh NHS Foundation Trust, and Dr Andrew Carson, GP & Medical Director, West Midlands Ambulance Services, NHS Foundation Trust.

Look who is exhibiting! Visit the web site to see the list of exhibitors Customers want to meet you, see them at Ambulex - Book your stand now Ambulex2014, now in its sixth year, will be returning to the Ricoh Arena in Coventry on 9th and 10th July. Ambulex will be the only national event for 2014 covering community, public sector fleet, accessible and mobility transport. The Ricoh proved to be a popular choice of event venue with both exhibitors and visitors in 2013. This year sees some important developments, with Ambulex working closely with the CTA to present Ambulex as an opportunity for CTA members to meet vehicle and equipment suppliers, see the latest product and service developments, to discuss their individual Spring 2014 | Ambulancetoday

requirements and catch up with industry professionals. Ambulex also caters for the ambulance and PTS sector. Many community transport operators recognise the potential of this sector and Ambulex provides them with a forum to view the latest equipment and to meet up with colleagues to discuss industry issues. The CTA will have an information stand in the exhibition and will also be holding a Community Transport Masterclass on Wednesday 9th July at the same venue as Ambulex. Featuring the latest updates in legal, technical and operational management issues, this training event will be discounted

for CTA members and Corporate Supporters. In 2014 Ambulex will again host the Independent Ambulance Association (IAA) annual lecture. This year the guest speaker will be Alastair McLellan, editor of the HSJ, who will speak on “Healthcare: A Political, Social and Economic Vision of tomorrow”. The Ambulex exhibition will also host a series of free-to-attend workshop seminars which will be of interest to public sector fleet operators and suppliers.

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Focus on Interpreting ECGs Sponsor of London’s Cardiac Arrest Symposium

ECGs - Reading Between the Lines! Interpreting ECGs can be one of the most difficult learning challenges for prehospital clinicians in all areas. Below freelance cardiac physiologist, Maxine Guillen, Paramedic and Continuous Professional Development expert, Andrew Ormerod, and Ambulance Clinician and globally-followed ECG skills blogger, Jason Winter, join forces to explain how to gain the skills and confidence needed to develop one of the most vital skills needed in the ambulance world - How to read between the ECG lines!

Life in the slow lane … Looking at the plethora of ECG books on my bookshelf I’m struck by words such as “easy”, “simplified” and “rapid” in the titles. I guess the reasons for this are mostly marketing ones. After all, who wants to buy a book that states interpreting ECGs can be incredibly difficult and will take you rather a long time. Needless to say twenty three years ago I was told to read one of these books and I couldn’t even get past the first page. Even though my formal training was four years long, only a fraction of classroom time was dedicated to this subject. My education in this respect then, consisted of gradually picking up snippets of information either from text books or from well-meaning work colleagues. Over many years, and mainly through experiential learning, I managed to construct a fairly decent understanding of ECGs. However, for me, it was only through teaching others that I was eventually able to plug the remaining gaps in my knowledge. Ten years down the line I then began to wonder why I ever found any of it confusing in the first place and why it had been such a long drawn out process. One of the reasons I believe this subject is difficult to learn (and to teach) is because so many of us in the medical profession are required to attain this skill. Take my ECG classes for example. In any given group there is a considerable mixture of professions and abilities. These range from healthcare support workers to doctors, and everything in between. On the one hand you don’t want to oversimplify the subject matter, for then the learner gains no understanding other than simple pattern recognition. On the other hand, you don’t want to launch into something like action potentials when the learner is still struggling with recognising positive and negative waveforms. Too little challenge and the student doesn’t progress; too much and the student retreats. Another reason is that as learners we desperately want to get the “right” answer. Understandably new students believe it’s the teacher’s job to impart unambiguous information, and learning is simply a matter of information exchange. Granted, some Spring 2014 | Ambulancetoday

ECG concepts are fairly black and white, but there are a lot of grey areas whereby an ECG only forms part of a diagnosis. Take ST elevation, for example. There are a number of different causes for this finding, but unless you put it into some sort of clinical context you may never know the correct answer. Therefore, in this respect I believe the process of interpretation and the context is as important, if not more so, than simply trying to label an ECG straight off the bat.

more structured, and students are assigned mentors or are required to keep log books. However, even after all these years there is still a look of fear on my students’ faces at the beginning of every seminar. I see them visibly relax when they realise they’re not the only desperate souls out there struggling with this subject. Perhaps we just have to accept that whatever our profession, it is a long road to ECG competency, if we ever really get there. Once we realise this we can stop being so hard on ourselves. A medical student recently showed me his e-learning cardiology resources – on the first slide the tutor recommends an ECG book – sound familiar?

Maxine Guillen: Cardiac Physiologist & Teacher

Finding the right level for you can be a nightmare, and it doesn’t help that cardiology is laden with a lot of confusing terminology. Thus I find a fair amount of my teaching time consists of explaining all the jargon. With the rise of the Internet we also have instantaneous access to a lot more information than we used to. But, I wonder if this makes it even more confusing for the learner. I certainly still have trouble sifting through good and bad material because whatever mode of education you use, it is all susceptible to inaccuracies, assumptions, and misunderstandings. Not to mention that as students we seem to accept anything that is passed down ‘from above’. Reading a book, signing up for an e-learning course, or attending a seminar is a great start, but it doesn’t automatically make you proficient. They definitely have their place, but my advice is to use them as a basis for developing your own knowledge through your own working practices, and perhaps more importantly take your time and question everything! But surely things have changed since I was a student? And, perhaps I’ve unintentionally painted a rather gloomy picture. Certainly, in my profession, degree courses have become

Maxine is a cardiac physiologist and teacher with over 20 years of experience. She is author and tutor of Cardio Rhythms’ ECG Interpretation Seminar, the Advanced ECG Master Class, and the ECG Instructors Course. She has to date authored and developed 3 e-learning modules for Cardio Rhythms Online, and is presently co-writing several e-learning modules with Jason Winter, currently under development. She has worked in numerous hospitals throughout the UK specialising in both invasive and non-invasive cardiology techniques. She founded Cardio Rhythms in 2000 and has written and taught many ECG interpretation courses to cardiology students and other health care professionals alike. She is a member of the RCCP, is accredited by the British Society of Echocardiography, and was the lead ECG tutor and examiner for Guy’s and St Thomas’ MPI stress testing course. Aside from her qualifications in physiological measurement she also holds a PGCE in teaching & learning in higher education. Maxine lives quietly in Bournemouth by the seaside with Oscar and their son Jack. As well as her work in cardiology she is an accomplished pianist and holds a first class undergraduate and postgraduate degree in music. She enjoys horse riding, loves watching tennis, and is trying to improve her Spanish! Contact info: maxine@ cardiorhythmsonline.co.uk 55 3


Focus on Interpreting ECGs Sponsor of London’s Cardiac Arrest Symposium

Demystifying the Myths CPD by Andrew Ormerod Continuing Professional Development (CPD) is not just about reading and recording; it is a very real and necessary part of our role in the NHS and independent ambulance services. It is not a management tool to hit key performance indicators (KPI) or a governing body quirk to cause unnecessary suffering or stress. In fact it exists to assist professionals in becoming skilled and well-informed employees. CPD is an emerging field in pre-hospital care; succinctly described by the Health Professions Council (HPC, 2006) as: ‘A range of learning activities through which health professionals maintain and develop throughout their career to ensure that they retain their capacity to practice safely, effectively and legally within their evolving scope of practice.’ (p.6) Perhaps an easier way to conceptualise CPD is to think about a brick house, each building block representing a learning experience, which, when combined with other learning experiences, completes the whole structure. The secret to CPD is the ability to recognise and demonstrate how each of these blocks of knowledge creates a safe and effective professional, whilst being able to take a step back to evaluate and reflect upon your work. One of the more important stages of CPD is…RECOGNITION, let’s take an example: You recognise that you have concerns about understanding electrocardiograms (ECG) and that you struggle with the basic waveform and recognition of a normal sinus rhythm. The fact that you have recognised you need a better understanding of ECGs is the biggest hurdle. Having unlimited access to online learning and development regarding interpreting ECG waveforms is advantageous in today’s busy work / learning climate. Historically as clinicians, we would routinely rely on colleagues to share sample ECGs they have taken and give an explanation of the recording. However, data protection and patient confidentiality now frowns upon this ritualised practice. Sibson (2008, p.74) states that CPD should be an activity ‘at the discretion of the

individual and should be specific to their role and environment.’ CPD is described as ‘…the profession’s response to the increasing sense of accountability demanded by today’s society’ (p. 74). Lawton and Wimpenny (2003) suggest that CPD is the need to ‘put one’s house in order’, indeed if you imagine CPD as the analogy described previously of a brick house, then you are the master of your own learning experience and builder of your own CPD. Step two of successful CPD is … RECORDING, let’s take an example: The Health and Care Professions Council (HCPC) states that registered professionals must present a written profile containing evidence of their CPD on request. CPD is assessed against specific criteria, Sibson (2008) suggests that each health professional should have a Professional Development Portfolio (PDP). Forde et al., (2009) describe said Portfolio as a ‘collection of material put together in a meaningful way to demonstrate the practice and learning of a practitioner’. Step three of successful CPD is… REACTION, let’s take an example: Sibson (2008, p.75) recognises that the driving force behind any CPD is how ‘…the CPD Activity has contributed to your clinical/ professional practice and has benefited the service user, the patient or carer’. Indeed Armitage (2011) recognises that ‘…there is a fundamental need for understanding in order to develop clinical skills and make informed clinical decisions based on underpinning knowledge and clinical reasoning’. Step four of successful CPD is… REFLECTION, let’s take an example: The HPC (2010) cite that the lack of observable reflection in portfolios resulted in a significant figure of submitted portfolios being returned to the auditee. The difficulty lies with the ability to document reflection, some of which the individual may feel is private to themselves. The HCPC does not recommend any one model or template for reflective practice; however templates and models are available and can be used (see. Gibbs (2008) and the CPDme.com reflective diary). CPDme was formed in 2009 with the aim of preparing and assisting people from various health and social care professions to keep an online CPD log, and to enhance their personal portfolios in order to meet the standards set by their governing body, as well as preparing them for interviews, reviews, and for all future engagements within their developing professions, and for staff new to higher education. Our members enjoy access to our free CPD portfolio building iPhone application and four levels of website membership to streamline professional development recording using www.CPDme.com.

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Further Information and References www.CPDme.com Armitage, E. (2011). Evaluation of the use of portfolios in paramedic practice: part 2. Journal of Paramedic Practice, 3, 328-332. Forde, C., McMahon, M., & Reeves, J. (2009). Putting Together Professional Portfolios. SAGE publications, London. Gibbs, G. (1988). Learning by Doing: A Guide to Teaching and Learning methods. London: Further Education Unit. Health Professions Council (2006). Your guide to our standards for continuing professional development. HPC, London. Health Professions Council (2006). Continuing Professional Development and Your Registration. HPC, London. Health Professions Council (2010). Written request under Freedom of Information Act 2000 in relation to CPD audit of state registered paramedics in 2009. Reported in Armitage (2011). Lawton, S. & Wimpenny (2003). Continuing professional development: a review. Nursing Standard, 17, 41-44. Sibson, L. (2008). An Introduction to CPD for paramedic practice. Journal of Paramedic Practice, 1, No 2.

Andrew Ormerod Andrew Ormerod is the founder of CPDme an online Continuing Professional Development (CPD) portfolio building website, he is also the developer of a free CPD portfolio smart phone application. CPDme was created from Andrew’s professional practice project whilst studying towards a master’s degree at Bolton University. Prior to studying towards an MSc, Andrew was one of the first Paramedics to graduate with a BSc (Hons) in Paramedic Practice from the University of Central Lancashire. Andrew is passionate about professional practice, and aims to simplify, demystify and encourage CPD for over 20 health and social care professions across the UK. He currently is involved with a project in Australia and New Zealand and will shortly launch an international business venture with SP Services (UK) Ltd. Andrew is a Paramedic registered with the Health and Care Professions Council (HCPC) and works full-time for a large NHS ambulance trust. Spring 2014 | Ambulancetoday


Focus on Interpreting ECGs Sponsor of London’s Cardiac Arrest Symposium

ECG Monitor -The Coolest Kit We Carry! When I first started my training on 12 lead ECGs sometime ago now, I was amazed by the wriggly lines seen on the printout and monitor, finding out later, these are known as waveforms, that can give you so much information about the many conditions/ syndromes and pathologies that can affect the heart, I was then hooked on learning more. I remember thinking to myself back then this is the “coolest piece of kit we carry on our ambulance”. When it comes to ECG interpretation, I have said for many years now that training should be better for EMT’s and paramedics. Hopefully many pre-hospital personnel would agree with me. They are mostly given a crash course mainly on “ACS or acute STEMI recognition” so it’s left to ourselves to educate ourselves in ECG interpretation, to gain a level of competency to interpret 12-lead ECG’s. My advice would be to find a good book or ECG App or eLearning course that suits your own style of learning. This is achievable only through experimental learning. Also by taking part in online ECG discussion groups. You will only become thoroughly competent by viewing thousands of ECG examples that are now online and by taking part in group discussions, . Repetition, I found, was my best way of learning to interpret ECG’s. Classroom Theory ECG education theory modules should have a good foundation of cardiovascular anatomy and physiology. Again, a lecture only on ECG education in my opinion is not ideally suitable for the novice. Access to online eLearning modules would also be an advantage. Classroom sessions should include ECG case presentations, because learning in groups will help students understand and retain information better. The students will gain a great deal of information and appreciation for subject matter if they’re afforded the opportunity to learn in groups, sharing case studies with each other. I feel that modules should be developed that give the student a detailed insight into the electrical anatomy of the heart, cardiac blood flow, cardiac cycle and cardiac muscle cell contraction (e.g., sodium/ potassium pumps, action potential). If this was concentrated more over a longer period of time at universities, Spring 2014 | Ambulancetoday

students should have time to understand in detail how the ECG really works, and apply this in practice. Students should also learn how to read blocks on ECG paper, understand the fundamentals of Einthoven’s Triangle and understand about vectors. It’s also important that students should be able to calculate time and voltage using ECG paper. The most important part of ECG education is interpretation, because this tends to be the most difficult, in my opinion. Student needs to learn about waveform definitions and recognition. Good practice would be to have the students circle waveforms of different morphologies and calculate rate. It’s paramount to the student’s ability to grasp the information that is needed to interpret ECG’s. Clinical Practice Practical skill stations will help students be competent in ECG practice monitoring, electrode/skin prep and to understand why correct lead placement is so important. Performing and interpreting 12 lead ECGs is non-invasive, but is being able to intubate, give drugs, and perform IV cannulation, and so on, at the same intensive skill level as ECG interpretation? The ECG machine is such a valuable diagnostic tool we carry on our emergency ambulances, so why does the training on ECG’s across the globe not reflect this? Most observations we perform such as pulse, temp, heart rate etc are variables that are categorised as high or low, but a 12 lead ECG tell us much more about the patient’s pathologies and conditions. I always find it important that for most observations we perform, for example blood pressure, we like to get at least three readings if we can: 1st (baseline), 2nd (comparison), and the 3rd looking for (trends). This should be the same for performing serial ECGs in suspected ACS and should be taught to all students. My suggestion also would be to have nominated ECG Mentors in the ambulance service, or on every station if possible, so when a new graduate or anybody else is finding it difficult to grasp ECG interpretation, they can have some support out on the road. Ideally this mentor should have a folder of real patients’ ECGs for training purposes. Another problem I have

come across is attitudes to learning and understanding ECGs. I have heard numerous times quotes from paramedics such as “if I can’t treat it, I don’t need to know about it” or “I am not a cardiologist, so why do I need to know that”. A common thing I see is when pre-hospital staff record only a 3-lead ECG, they only look and print out lead II, but it only takes a few seconds to flick through the six leads to check for any other abnormalities that might be missed in the 3-lead ECG, like the axis deviation, lead misplacement or ST elevation/ depression, or reciprocal changes in other areas of the heart. In the world we are living in now, as professionals we are responsible for our own personal development and continued professional development (CPD). We should be proud of our profession and how far we have come over the past two decades. ECG interpretation is a difficult skill to master; only practise will make you truly competent.

Jason Winter: Jason Winter has over 20 years of experience in emergency care, working in the UK and abroad, including the USA and South Africa. Jason was inspired to join the Ambulance service by his father, who retired a few years ago after completing 42 years service. He has also worked in two major hospitals and has spent the rest of his career working in pre-hospital emergency care. He is now currently working as a clinician for an NHS Ambulance Service in the Midlands in the UK. Jason has always had a passion for ECG education and training and enjoys the challenge of trying to make this sometimes difficult subject easier and more fun to understand. This has resulted in a vibrant community of ECG aficionados on Facebook. He is also the editor and creator of the ECG & Cardiology blog (formerly 12-lead ECG Experts blog) and ECG Lessons online blog. His other sites, listed below, also include probably the largest cardiology social networking page online, called “ECG & Cardiology Facebook Fan page”, and ECG Study cards page that you will find on his Facebook. Jason also helped to develop an ECG iPhone app, and has his own ECG Training app coming out soon that will be available on all mobile platforms. all his projects combined reach a staggering 2-3 million people weekly! His interests and pastimes include Cardiology, ECG interpretation, aviation, flight simulation, flying light aircraft, (he completed his private pilots licence, back in 2005). Other interests include: travelling. He is also a big fan of online medical education blogs & websites. Jason has two children. Born in Barnsley, South Yorkshire, he now lives in Derbyshire. http://ecg-experts.blogspot.co.uk/ http://ekg-library.blogspot.co.uk/ https://www.facebook.com/EKG.ECG https://www.facebook.com/EcgStudyCards https://www.facebook.com/groups/ECG. Cardiology 57 3


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Focus on Open Heart

Open your arms to Open Heart Open Heart is a new online cardiovascular journal, advocating open access, open peer-review and open data, and it’s keen to hear from any ambulance researchers who would like their work published quickly to a global audience A new online journal covering a broad range of cardiovascular research was launched in January by BMJ and the British Cardiovascular Society, and it is keen to welcome manuscript submissions from all sections of the global pre-hospital community with an interest in publishing their research on cardiac care. Called Open Heart, it is edited by Dr Pascal Meier, a Consultant Cardiologist at the Heart Hospital London, and recently appointed as a Consultant Cardiologist at the University Hospital of Geneva. A frequent contributor and advisor to Ambulance Today on pre-hospital cardiac care, Pascal is passionate about the idea that good quality cardiac research should be shared as widely and as quickly as possible between all concerned groups of healthcare professionals. “There are many benefits to sharing research on cardiac treatment between hospital and out-of-hospital clinicians”, explained Pascal, “because they focus on different parts of the chain-of-care it’s useful for them to share their findings and experiences with each other. As we all know, it’s often only through doing this that vital information is identified that might otherwise be overlooked.” Open Heart’s expert editorial team will primarily assess original contributions for robust research methodology, with the objective of publishing high quality research that presents confirmatory or negative results. It will, however, also welcome smaller, specialist studies providing preliminary or descriptive data that might be considered ‘hypothesis generating’ rather than definitive. Spring 2014 | Ambulancetoday

Authors will not be required to pay the Article Publishing Charge (APC) until the point of acceptance. Manuscript reviewers and those that agree to deposit their research data in open repositories will receive a discount on the standard APC. As Open Heart is published exclusively online, without any page restrictions, it allows its editors to base their assessment of submitted content purely on the quality of the study, rather than on its length. “We expect that Open Heart will offer some other advantages too”, explained Pascal. “For example, it should have even greater impact than subscription-based journals because the open access publishing model will ensure that everybody can access articles free of cost, anywhere.” Pascal continued: “Having Open Heart hosted by bmj.com is also a fantastic benefit because it ensures visibility; exceptional articles will attract press release through BMJ’s Press Office, and Open Heart will utilise BMJ’s channels such as blogs and social media. The editorial board has good contacts with specialist medical journalists as well.” “Unlike other journals we’ll be able to publish research findings really quickly, bringing valuable learning outcomes to working clinicians so that they can more quickly decide whether to introduce them into their practice. Authors can initially just submit an abstract for a quick review by the editorial team; if interested, we will then request submission of the full paper.” Pascal finished: “We’re very excited about this venture and the opportunity it brings for us to work even more closely with ambulance clinicians and to publish their

research in a manner that ensures it is widely seen by their colleagues in hospitals. To that end, because of its unrivalled coverage across the whole of Europe, we’re looking forward to working closely with Ambulance Today and we hope that ambulance clinicians will approach us with any research papers that they’d like us to consider for publication.” For further information about how to submit, please visit the Open Heart website at openheart.bmj.com. You can also contact Dr Pascal Meier directly by emailing him at: pmeier@bmj.com

Biography: Dr Pascal Meier Dr Pascal Meier is an interventional Cardiologist who has been trained at the University Hospital of Bern, Switzerland, and at the University Hospital of Michigan, USA, before coming to the UK to work at The Heart Hospital, University College London Hospitals. His research interests include cardiac emergencies and out-ofhospital cardiac arrest, he has published widely in this field. He is an associate editor for the journal ‘Heart’(www. heart.bmj.com), an international journal for cardiovascular research which also publishes current research articles about cardiac emergency management. www.drpascalmeier.com 59 3


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Focus on Tablet Technology

On the frontline Those working on the frontlines in the ambulance service will find themselves dealing with others whose lives are in danger – such is the nature of the job. Being able to respond to that danger is vital, and as the old saying goes; to be forewarned is to be forearmed. Information, and crucially, the ability to share information, can be a vital tool in helping first responders save lives. In emergency situations, ambulance crews need to be able to rely on the equipment that gives important information to them about a casualty, which will help them provide more effective treatment which could be the difference between life and death. A reliance on technology is something that paramedics share with their counterparts in other emergency services, as well as military and defence sectors. And so when it comes to technology choice, medical first responders can feel reassured that they can rely on rugged technology solutions that perform in a military environment. Global designer and manufacturer of rugged computing technology, Getac, already has units deployed in the British military, and now, the new Getac Z710 Titan, a fully rugged 7-inch Android tablet, is undergoing trials with global security company Northrop Grumman, with a view to securing full MoD project accreditation. That’s because

the tablet offers everything an operative on the frontline needs, both in terms of security and usability. The Z710 weighs just 800g, with an operational battery life of 10 hours. Built with a glove-friendly touchscreen, the fully integrated device includes a 1D/2D barcode reader and advanced GPS technology accurate to 1.5 metres. The tablet has also been certified to MIL-STD-810G and is IP65. The Z710 is configured with military-grade secure software from security specialist Becrypt, which ensures that all device application and user data is protected with FIPS 140-2 compliant encryption. Administrators also have complete control, so they can create separate encrypted user accounts or personas, enforce strong authentication, and manage different application and device policies - all of which reduce support and maintenance overheads. In partnership with Becrypt, the Getac Z710 Titan puts military standard hardware in the palm of ambulance crews’ hands. Is it time you had the best on the frontline? If you would like to discuss any aspect of your rugged computing requirements, call 01952 207 221, e-mail: Sales-Getac-UK@getac.com or visit: www.getac.co.uk


Focus on

Lorna takes up the ASBF Challenge …While Steve takes up his Paint-Brushes! Chairman of the Ambulance Services Benevolent Fund (ASBF), Paul Leopold, recently announced the appointment of Mrs. Lorna Birse-Stewart as the Charity’s first Director. But it was with a tinge of regret that he then accepted the news that long-standing Trustee and Communications Lead, Steve Evans, has decided to step down after a decade’s tireless and highly-successful service Commenting first on Lorna’s appointment, Paul Leopold said: “An active response from a vast range of talented candidates from our countrywide advertising campaign made selection for interview challenging, but we were delighted that following this extensive process we have appointed Lorna as the first Director of the ASBF.” Paul welcomed Lorna to the ASBF Team saying: “On behalf the Trustees I’m delighted to welcome you to the team as our first ASBF Director. Your expertise and professional experience will unquestionably bring a progressive lead for further development of our ‘Moving Forward’ initiatives.” Speaking about her appointment as Director of the ASBF Lorna said: “I’m delighted to have been appointed to this new role and I’m looking forward to working with the Trustees and the team of hard working volunteers to take the ASBF forwards. The ASBF has done a great deal in the last 27 years to support ambulance service workers and their families and with increased demands and an ever-growing need for support for ambulance personnel during their time of need, the time is now right to further enhance and develop the range of care and support programmes the ASBF can provide. It’s important that the “Care for the Carers” programmes for the ambulance service community

are developed in line with other emergency services so I’m very pleased to be involved in taking this and other initiatives forward for the ASBF.” Paying tribute to Steve Evans, Paul recalled that it was at his own request that the former WMAS Head of Press and Communications agreed to take on the additional responsibility of coordinating all Press and Public Relations matters for the charity, at a time when it was undergoing significant change. “As a career-long volunteer and supporter of the ASBF, poor Steve naively joined our Board of Trustees, keen to ensure that his own recent retirement would involve something relatively undemanding that would keep his mind occasionally active”, explained Paul. “But after the brilliant job he’d done managing Press and Communications for one of the UK’s busiest ambulance services, we had other ideas! So after a short campaign of pleading and encouragement from all his fellow Trustees, Steve soon found himself as the one Trustee offering himself up for a rather more full-time voluntary role.” Paul added: “The service and expertise Steve has given to the ASBF in the last ten years simply can’t be under-estimated. Strong PR has been at the heart of every major initiative we’ve developed, from campaigns to bringing on-board more volunteers across ambulance services, to drives to attract more sponsorship from ambulance supply companies, right the way through to engaging more effectively with the general public to win their

support as well. So much of what we have achieved has been with a strong reliance on Steve’s outstanding PR skills.” Paul finished by saying: “Steve has been fantastic throughout and his mix of communications expertise, coupled with his natural affinity with our goals due to his background as a longserving ex-Paramedic, made him the ideal ambassador for our rapidly-growing ASBF. We’ll miss him tremendously and we really can’t thank him enough”

“I must stress that there’s no link between Lorna’s appointment and my retirement. The time was just right for me to step down but I feel relieved that with Lorna’s guidance the ASBF will continue to go from strength-tostrength.”

Speaking of his decision to step down, Steve said: “Being part of the ASBF is one of the proudest accomplishments of my entire ambulance career. It’s a fantastic and caring organisation, run and supported by some fantastic and very compassionate people. But, while I’m sure I’ll stay involved, if only as a volunteer and occasional cheerleader, the time came where I really did want to spend more time with my family and on my other main passion, painting.”

THE ASBF IS MOVING FORWARD WITH DEVELOPING ITS CARE FOR THE CARERS PROGRAMMES. IF YOU ARE INTERESTED TO UNDERTAKE A CHALLENGE IN 2014, TO HELP US WITH FUNDRAISING OR VOLUNTEER AS AN ASBF ADVOCATE, WE WOULD LIKE TO HEAR FROM YOU. IDEALY WE WOULD LIKE TO HAVE PLEDGES FROM MORE AMBULANCE SERVICES TO SUPPORT OUR EXCITING AND IMPORTANT DEVELOPMENTS. IF YOU ARE INTERESTED THEN PLEASE CONTACT US TO DAY!

In fact painting has been a hobby of keen oil-painter and watercolourist Steve from before he first joined the Ambulance Service in Worcester in 1974 and, despite his modesty on the subject, he’s already enjoyed a number of successful exhibitions of his work. Steve finished by adding: “Bringing Lorna on board as our first-ever full-time and professionally experienced Trust Director is an amazing and exciting development for the ASBF.

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by visiting the ASBF website: www.asbf.co.uk Or email the National Secretary: enquiries@asbf.co.uk “THE AMBULANCE SERVICES BENEVOLENT FUND IS CARING FOR THE CARERS AND TOGETHER WE WILL MAKE A REAL DIFFERENCE”! PATRON: SIMON WESTON, OBE REGISTERED CHARITY: # 800434

Enter 70070 into the “to” box - Write in the code ‘ASBF44’ and then add the amount you want to donate which can be £1, £2, £3, £4, £5 or £10 - Your text might look like this ‘ASBF44 £5’ Press ‘Send’ - Congratulations, you’ve just donated to the ASBF...it’s that simple! Spring 2014 | Ambulancetoday

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Out & About News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

101 Dumb Emergency Calls: Paramedic’s New Book Dials into the World’s Most Stupid & Shockingly Unbelievable Emergency Calls Every year the media is awash with stories and recordings of recent stupid or hoax calls received by the emergency services. Having become victim to dozens of these during his long career, Paramedic Stuart Gray highlights the extent of the problem in an entertaining new book. ‘101 Dumb Emergency Calls’ does exactly as it says on the cover, collecting transcripts of calls from around the world and fusing them with comic strips created by fellow Paramedic, Paul Dodd.

Synopsis: 101 Dumb Emergency Calls is a collation of the most stupid and irrelevant calls to the emergency services that have been highlighted in the media in recent times. Mostly from the USA and UK, they bring into sharp focus the extent of the abuse of our critical life-saving services. With cartoons to depict calls and hyperlinks to take the reader to the original audio (some of them released in the public domain by the police and ambulance services in order to show the world how badly a minority of individuals will misuse valuable resources), this

book promises to amuse and shock every right-minded person who understands what these services are here for. The author and illustrator are professional front line paramedics, so they know a thing or two about the subject; and from calls to the police for directions to 999 rants about the lack of buses, they have experienced their fair share of such stupidity. You won’t believe some of the calls that have been made in the name of personal crisis. You simply won’t believe what some people think is an emergency!

About the Author: Stuart Gray is a Paramedic working in
Central London.
 His blog ‘a Paramedic’s diary’ is read all over the world and was recently featured in the Times Newspaper Top 50 Blogs that really matter. This inspired him to write books. First from the blog itself:‘ a Paramedic’s Diary; Life and Death on The Streets’, then about the profession and how to survive it: ‘The Street Medic’s Survival Guide’ and his first ever novel, ‘The Station’, which is a fictional look at his profession. Stuart loves to write and hopes to continue writing more stories from ‘The Station’ in the future.

SECAmb trialling electric hybrid vehicle South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is thought to be the first ambulance trust in the country to be trialling a new electric hybrid vehicle in its A&E fleet.

The Volvo V60 D6 Plug-in Hybrid is currently being trialled by a small group of staff operating out of the Hastings area. SECAmb will be exploring the potential savings in both running costs and its carbon footprint with the new single responder vehicle over the coming months. The vehicle is charged via electric charge points which have now been installed in all of the Trust’s Make Ready Centres. SECAmb environmental manager, Julia Brown, who approached Volvo about running the trial, said: “The

vast majority of our emissions are associated with the mileage resulting from our operational activity of delivering an emergency response service. This trial with Volvo is a valuable contribution to our overall plans to improve the resilience of our business by being able to operate our vehicles on a mix of fuels, rather than relying on one individual fuel, and reducing our carbon footprint in the process.” The vehicle is able to switch between three modes: Pure - uses pure electricity to create a zero emissions electric car

with a range of up to 31 miles. Hybrid - engages both the diesel engine and the electric motor - returning up to 155 mpg with emissions as low as 48 g/km CO2. Power - a 215hp turbo diesel engine combining with a 70hp electric motor to reach 60 mph in under 6 seconds. Paramedic John Anderson, who is in part of the team testing the new vehicle, said: “I think there will be plenty to discuss when the trial comes to an end and it is proving very interesting to be a part of it.”

Respected doctor receives MBE One of West Midlands Ambulance Service’s Medical Incident Officers has received his MBE from Her Majesty the Queen, for services to emergency medicine.

Waterloo Chamber, watched by his proud wife and children.

Dr. Malcolm Russell was formally invested as a Member of the Order of the British Empire at Windsor Castle on Friday 7th March after being named in the New Year’s Honours List.

Dr. Russell often responds for West Midlands Ambulance Service as a BASICS Emergency Doctor as part of the Mercia Accident Rescue Service (MARS). In addition he has been deployed to natural disasters such as the Japanese Tsunami and Christchurch earthquakes as part of emergency aid and support for those countries.

The father-of-two was presented with his award at the castle’s

He said: “I felt honoured to have been presented with my MBE from

Her Majesty the Queen at Windsor Castle. “I was delighted that my family were able to attend as guests. It was an incredible day and I met some amazing people who were also being invested. “I thought very much about all the good medical work carried out in the West Midlands and how, as many different organisations including the NHS and voluntary services, we manage to work very well together for the sake of our patients, who must always remain our focus.”

Would you like to join the RCA’s EU-Wide ambulance redesign Project? If your ambulance service has a clinical or technology-based innovation project you think might benefit Europe, we’d like to hear from you
 Please contact Declan Heneghan Email: editor@ambulancetoday.co.uk Or call: 0044 (0)7914 606 693 Spring 2014 | Ambulancetoday

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Focus on RCA Ambulance Redesign Project

RCA Ambulance Redesign Project Goes Pan-European After last Spring’s successful consultation day at Imperial College, London, the Royal College of Art’s (RCA) ground-breaking project which aims to design and build a prototype A&E ambulance vehicle to help reduce hospital admissions and allow ambulance crews to increase the volume of treatment they can provide on-scene, has gone Europe-wide. Ed Matthews, Project Lead of the Helen Hamlyn Centre for Design’s ‘Redesigning the A&E Ambulance’ project has been working with a team of advisors to broaden the scope of their originally UK-focused project to ensure Ed Matthews that the future clinical, procurement and financial benefits of the project will benefit ambulance providers across the whole of Europe, rather than confining the project, and by implication its potential benefits, to just the UK and our own ambulance providers.” The new European Ambulance Redesign consortium, operating under the name of SAPPHIRAE (Smart Ambulance: Personal Patient Healthcare In-place of Returning to A&E), already involves ambulance services, hospitals and allied academic health researchers from 12 European countries as consortium partners, with especially strong support coming from those countries commonly held to have the best or most rapidly-improving ambulance services in the EU. “We have three Dutch ambulance services actively signed up, as well as the main supplier of ambulance services across the whole of Denmark, the highly-respected global provider of both fire and ambulance services, Falck.” “We also have an exciting partnership agreements in place with the Capital Healthcare Region of Denmark, which serves both Copenhagen and its outlying areas, and with INEM (Instituto Nacional de Emergéncia Médica), the organization which coordinates all ambulance care across Portugal. Since we invited a number of European ambulance services to consult with us in London last Spring we’ve been quite overwhelmed by how quickly word of 64

our project has spread, and we’re absolutely delighted at how many ambulance providers from different countries, sometimes with very different models of ambulance care, have approached us, saying that they share our belief that the ambulance vehicle desperately needs re-designing”, explained Mr Matthews. Other countries now signed up to participate include Switzerland, Italy, Spain, Sweden and Finland, but talks are already underway with prospective ambulance consortium partners in countries such as Poland, Norway, France and Greece. To which end a representative from the consortium will be attending an EUorganized conference focusing on how to maximize technology and innovation-based healthcare procurement opportunities taking place in Thessaloniki later this month, using the opportunity to meet ambulance leaders from across Greece to explore how the project might benefit its country’s ambulance system, currently comprised of a mix of regional deliverers and private hospitals. Mr Matthews explained the impressive growth of the RCA project, saying: “We’re conscious that some UK Ambulance staff might feel that the project has gone a little quiet since our very successful consultation day last Spring, which attracted ambulance service representatives, clinicians, ambulance builders and technology partners from 9 European countries. However, the fact is that nothing could be further from the truth; in fact we’ve actually been extremely busy – there are many complexities attached to achieving our next objective, which is to build working prototype vehicles, put them to the test of working in frontline service, and develop the design for commercialization. But to do this simultaneously with ambulance partners from right across the EU zone is a complex and ambitious goal so, while we may not

appear to have been quite so visible here in the UK, the truth is that with our goal of working with a broad range of EU partners in mind, we’ve spent the last year travelling across Europe and further afield, meeting a very broad range of ambulance providers, to find out what their own design priorities are, and exchanging often strongly-held ideas on what clinical and design elements are needed to create an ambulance vehicle that will meet the needs of as many European ambulance services and their patients as possible.” Jonathan Benger, Professor of Emergency Care at the University of the West of England, Bristol, and also the National Clinical Director for Urgent Care for NHS England has been the project’s clinical lead since its inception and, as an Jonathan Berger academic with strong links globally with other clinical innovators, he’s positive about this move, saying: “It is really encouraging to see the enthusiasm with which other European countries have embraced our work to date on improving ambulance design, and their willingness to contribute their own expertise in taking this forward as a pan-European project.” A view backed by the project’s original clinical champion, Lord Ara Darzi, who recently lent his support to the project’s EU expansion when they submitted the first of three major EU funding bids last month which, if successful, will see the project build and test their prototype ambulance across a wide range of ambulance systems spread across the whole of Europe. ‘’Ambulances of the future will not just simply be a mode of transport for patients and paramedics. Hospital networks are transforming across urban and rural settings Spring 2014 | Ambulancetoday


Focus on RCA Ambulance Redesign Project

and are providing a growing series of timesensitive and specialist emergency services, including stroke, trauma and cardiac care.” Commented Lord Darzi. Adding: “ It’s therefore vital that the future model of ambulance design Lord Ara Darzi centres on developing a robust platform for the diagnosis and early management of disease, as well as creating a safeguard for the appropriate referral of patients to hospital and championing the clinical prerogative that the right patient gets to the right place at the right time. Through cutting edge healthcare design, new advances in technology, diagnostics and networking, tomorrow’s ambulance will be so much more than just a means of transport.” Lord Darzi finished: I am strongly supportive of this important proposal.” Jaap Hatenboer, Manager for Policy and Innovation with UMCG, a leading ambulance service in the Netherlands, expressed the enthusiasm of many of the project’s new consortium members after visiting the London consultation, Jaap Hatenboer saying: “We were delighted to finally meet with the RCA design team after having followed their research on video for such a long time. So when the possibility to join forces with the project presented itself, we were very happy to come on-board. Of course, we have our own views on ambulance delivery in the Netherlands and we would also like the project to include the proposals of earlier research on the equipment that paramedics take with them outside the ambulance. In addition we also see the potential to use new IT solutions that could effectively make the ambulance a “Base station” that supports communication, such as videoconferencing and telehealth, between the Paramedic on scene treating the patient and the extended healthcare system back at the hospital, remote but able to offer advice and suport.”

Brian Winn

systems to meet changing needs. “ The huge response from hospitals and ambulance services across Europe to the invitation from our procurement lead, NHS Commercial Solutions, to join our proposed consortium to bid for EU funding goes to show how widely recognised the need for reformed Ambulance Services is and how broad the level of agreement that the potential to achieve that innovative reform is possible. Due to structural reasons, the only way such reform is ever going to be achieved is through collaboration, and the EC H2020 platform provides exactly that opportunity at precisely the right time. I believe this is a unique opportunity, and one that we must all firmly seize.” Leading on communications and advising on the widening of the consortium is Ambulance Today magazine, brought onboard to advise the RCA on all aspects of ambulance delivery and technology in both the UK and across Europe. Editor, Declan Heneghan, commented. “Partnership is always the best route to meaningful

improvement, especially in socially important areas such as ambulance delivery. Having visited and worked with so many excellent ambulance services and with ambulance technology experts across Europe, I commend the Helen Hamlyn team on their bold vision and their confidence in making this move forward. If there’s one thing better than being involved in building a UK ambulance that’s finally fit for purpose, it’s the idea of doing so with partners from across the whole EU zone, and then seeing all the EU’s citizens benefit equally from our positive and trusting collaboration.” So, wherever you are in Europe, if you would like to find out more about the RCA-led Ambulance Redesign project, or if you would like your ambulance service or technology provider to be involved in the EU-wide consortium, please email either Ed Matthews at: ed.matthews@rca.ac.uk Or contact Ambulance Today at: editor@ambulancetoday.co.uk

Leading the strategy to make the RCA project a genuinely European consortium is former CEO of the NHS National Innovation Centre (NIC), Brian Winn, a recognized expert in applying new healthcare technologies to help reshape healthcare delivery

Spring 2014 | Ambulancetoday

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Out & About News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

Anthony Marsh named as top NHS chief “I am humbled, but incredibly proud to be named as one of top Chief Executives in the NHS.” Those are the words of West Midlands Ambulance Service Chief Executive Anthony Marsh on finding out he has been named as one of the Top 50 NHS Chief Executives by the Health Service Journal. Described by the leading health publication as ‘innovative and influential’, Mr Marsh is among a list of the top leaders in the NHS. The list was judged by a panel of leading experts, including NHS England Medical Director, Sir Bruce Keogh; Jan Sobieraj, Managing Director of the NHS Leadership Academy; Jeremy Taylor, Chief Executive of National Voices; Peter

Carter, Chief Executive of the Royal College of Nursing; and Niall Dickson, Chief Executive of the General Medical Council. The HSJ said of Mr Marsh: “Our judges appreciated his presence on the frontline and the way he has established good relationships with colleagues in the police and in mental health services.” In an extensive ambulance career beginning in non-emergency patient transport services over 25 years ago, Mr Marsh has held a number of senior posts and is currently the Chair of the Association of Ambulance Chief Executives and National Ambulance Advisor to the Department of Health. Most recently, he received a Queen’s Ambulance Service Medal in Her Majesty’s New Year’s Honours.

Following the announcement today (Friday), Mr Marsh said: “I am very touched and flattered to have been chosen by such an expert panel and to be ranked alongside some fantastic colleagues across the country. “Whilst it is a humbling experience and I am obviously very proud, this award is a reflection on the hard work of all of the staff who work with me in the West Midlands, whatever their role within the organisation. “The passionate way in which they go about their work is a credit to the service. From my conversations with them, I know how dedicated they are to providing the very highest level of care possible for each and every patient.”

The HSJ reports on health management and policy. For more information on the Top 50 Chief Executives list, visit: http://www.hsj.co.uk/resourcecentre/supplements/hsj-topchief-executives-2014/5069202. article

Stress epidemic stretches ambulance service to stretching point UNISON, the UK’s largest health union is warning the ambulance service is on the verge of breaking down and that the consequences on patient safety could be dramatic. Tight targets, long hours and the physical demands of the job place an enormous burden on overworked ambulance workers according to a UNISON survey released on Friday 11 April. The survey of 1332 NHS ambulance workers reveals a worryingly high level of stress, with one in five saying they have a ‘terrible’ work-life balance. A third of respondents (34%) say they have taken time off due to work related stress in the past year. Some say they suffer in silence as they are too scared of the repercussions while others are looking to leave the profession. A large proportion of respondents added that management had taken no step to remove or reduce stress, despite having a legal duty to do so. UNISON Head of Health Christina McAnea said: “The Government needs to take work related stress in the ambulance service seriously or it will break down. “Our members accept that their jobs can be physically demanding and challenging. However, some now tell us they are suffering from heart palpitations, flashbacks, nightmares, migraines, depression and an overall feeling of despair. As a result, many are actively looking to leave the profession.

“Millions of patients rely on ambulance staff at some of the most traumatic times in their lives, for their high quality level of care, expertise and good will. But last year, a third of ambulance workers experienced violence in the line of duty. And sadly, they are seen as easy targets especially late at night when the pubs and clubs turn-out. “Stress is a silent time bomb ticking away and it is unacceptable that such high levels are part of normal life for ambulance crews. It is clear the pressure caused by funding cuts is having an impact on patient safety. Higher call out rates and lengthy waits outside A&E add to the problem.

“The Government needs to take urgent action before the service breaks down.”

and the noise in the control room is unbearable.”

Comments from paramedics:

According to the survey, 74% said they suffered from mood swings and irritability and two-thirds said they were sleeping too little. More than half suffered from anxiety.

A paramedic said: “Our shifts over run and meal and rest breaks are sporadic. The job is emotionally straining especially when working alone with long backup delays for seriously ill patients.” Describing their stress another one said: “I suffer from panic attacks, high blood pressure and feel like crying at times.” “I left two shifts early because I was stressed to the point of exploding. I finished many many shifts despite being hugely stressed.”

“Work-related stress is the elephant in the room. Employers can’t keep on ignoring it. We expect them to do all they can to manage and where possible eliminate the risks to the health and welfare of their workforce.

Another paramedic said: “We have no time between jobs even for serious life threatening ones. We are just expected to move on without any downtime. But it’s becoming increasingly difficult to provide the care I want due to pressure from management.”

“Ambulance staff who join the service will be expected to work until they’re 68. And this won’t be sustainable long term if things don’t change.

Ambulance workers in the control room are also feeling the pressure. One explained: “We’re struggling due to lack of staff, lack of working ambulances, the hours are too long

Spring 2014 | Ambulancetoday

Unison Com

More survey findings:

The survey shows that respondents were ten times more likely to turn to friends and family (60%) to cope with work-related stress rather than talk to a manager (6%). Others said they talk with colleagues (55%), a third (33%) said they eat comfort food, and 12% have sought medical help. When asked about the future, 39% said they might need to take time off sick if the situation doesn’t improve and another 42% said they were already considering it. The latest NHS staff survey showed half of ambulance staff have suffered work-related stress in the last 12 months, making them most likely to experience stress at work compared with other NHS staff. And 46% have experienced bullying, harassment or abuse from patients.

Work related stress and industrial injuries in the ambulance is one of the hot issues that will be debated at the UNISON annual healthcare conference in Brighton between 13 – 15 April 2014.

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Out & About News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

‘Super Paramedics’ to look after Londoners The London Ambulance Service has appointed its first advanced paramedic practitioners who will be treating the most seriously ill and injured patients in the capital from May. The 12 advanced paramedics will receive additional training and will respond to the most serious one to two per cent of life-threatening incidents. These include patients in cardiac arrest and those who are continually fitting and are difficult to convey to hospital. They will also be able to administer more powerful drugs currently only given by a doctor.

Their training will include a four day trauma course with doctors from the Service and London’s Air Ambulance and an advanced paramedic science course at Hertfordshire University. Clinical Team Leader Chelsey Pike is one of the successful applicants. She said: “I thought it was a new and exciting opportunity and I’m all for developing my career.

Director of Paramedic Education and Development Mark Whitbread said: “We are very keen to develop the paramedic profession. Paramedics are a trusted brand but there is a lot more we can do by developing our paramedics as really skilled clinicians. “Appointing advanced paramedics shows our determination to do

better, both for our patients and our staff.” The role was introduced as part of the clinical career structure. Twelve advanced paramedics have been appointed and subject to funding, a further 24 will be recruited.

crews and paramedics, when responding to an emergency call, to the existence of an individual care plan for specific patients or highlight medical conditions. ERISS will remind GPs when an alert is due to expire, prompting them to review patient history and set a new alert, if required. Steve Barnard, NWAS Head of Clinical Governance explained: “ERISS is a secure, easy to use and intuitive system for clinicians and healthcare professionals, throughout the NHS network. It acts as a single point of access when sharing patient information. The system supports improved Information Governance whilst reinforcing review cycles and strengthening data quality

through automated reminders. As an emergency service, North West Ambulance Service has developed ERISS as a reliable, secure and technologically advanced system which enables our clinicians to access valuable patient information en route to a patient. This enables and supports informed clinical decision making when assessing and treating the patient, in order to deliver safe care closer to home and avoid unnecessary admission to hospital, for those patients with long term or identified care needs”.

“The Service is pioneering in terms of training and drugs trials and I think this will keep us at the forefront. It’s also a great promotional opportunity that allows clinicians to remain largely clinical, rather than go into a managerial role.”

• For further information about the London Ambulance Service or this news release please contact the communications department on 020 7783 2286. • Follow us on Twitter at www.twitter.com/ldn_ambulance or visit us on facebook at www.facebook.com/ londonambulanceservice

NWAS launches ERISS North West Ambulance Service (NWAS) NHS Trust has launched an Electronic Referral Information Sharing System (ERISS) which is available to all health and social care providers across the North West. ERISS has been developed by NWAS to enhance communications between the Trust and other NHS organisations throughout the North West, to improve patient care and outcomes. ERISS delivers two key functions; referral processing and alert request management. For example, when an ambulance crew or Paramedic respond to a 999 call and, after

assessment or treatment, the patient does not need to go hospital, they can check which referral pathways are available within that area. A referral can be created which alerts the patients care provider. Patients suffering from Chronic Obstructive Pulmonary Disease (COPD), Diabetes, fall frequently or have safeguarding needs, are all potential for referral to their appropriate healthcare professional or community teams in their area. Referrals are securely managed within ERISS, which provides reporting capabilities and ensures all referrals are followed-up. In addition, ERISS provides GPs with the ability to ‘Alert’ ambulance

For Further information about ERISS, please visit: www.eriss.nhs.uk

‘Back to School with a Defib’ Campaign The North West Ambulance Service NHS Trust (NWAS) has been lending its support to a community campaign based in the Accrington and Hyndburn area. The ‘Back to School with a Defib’ campaign which is being led by retail giant ASDA, the UK’s heart failure charity, The Pumping Marvellous Foundation along with the Media Village - a print and design business based in the Hyndburn area, has so far raised approximately £7,200 in funds to supply Automated External Defibrillators (AED) to as many local schools as possible. To date the initiative has led to

the successful implementation of AEDs in seven schools; St Wulstan’s Primary School, Peel Park School, St Bartholomew’s Primary in Great Harwood, Wood Nuck Primary, St Christopher’s C of E, Early Start Preschool, Oswaldtwistle and Hollins High School. Fundraising is continuing within the Accrington and Hyndburn ASDA stores and there are already nearly enough funds to purchase an additional AED for placement in another local school. NWAS has provided AED and Basic Life Support training to teachers and some school students to ensure they are equipped to deal with a potential emergency situation. As

well as this, NWAS has also provided British Heart Foundation ‘Heart Start’ training to representatives within Pumping Marvellous, meaning staff are qualified to train the public where an AED has been placed. NWAS has registered all of the AEDs placed through the scheme onto the 999 call system, to ensure they are fully utilisied whenever an appropriate emergency call is received. Cheryl Pickstock, NWAS Chain of Survival County Coordinator commented: “The Partnership to place additional AEDs across the Hyndburn area has been very successful and it has been lovely to

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see the general public engaging with their local communities to place these life-saving devices in their local schools. Defibrillators can significantly increase someone’s chances of survival when used in the first few minutes of cardiac arrest, and therefore the more that are placed increases the number of lives saved.” For further information on heart awareness and defibrillator schemes in your area please visit: www. cardiacsmart.nwas.nhs.uk/ For further information on Pumping Marvellous, please visit: www.pumpingmarvellous.org

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Ambition 2014, 29 â&#x20AC;&#x201C; 30 April 2014 2014, will host its 4th edition at Olympia, London and is the only show with the full support of all NHS ambulance services and therefore the guaranteed attendance of a broad range of frontline staff and senior managers from across the emergency services sector. The event will focus on delivering excellence in pre-hospital care, resilience and interoperability by bringing the emergency response sector together. Register your attendance today to discover new innovative best practice, products and solutions to drive excellence in pre-hospital care.

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New T800 8.1” fully rugged tablet designed for the mobile worker Global designer and manufacturer of rugged computing technology, Getac, is launching a new tablet designed specifically to boost productivity for mobile workers, the 8.1” Windows 8 Getac T800. The thin and light Windows OS device has been designed based on demands from mobile workers from Utilities, Field Services and Public Safety sectors. Getac has responded to those demands by developing a device that offers all the power, performance and usability of a highquality consumer device, without compromising on the tablet’s full ruggedisation. With its 8.1” screen, the optimal screen size for Windows 8, a thickness of 24mm and weighing just 0.88kg, the innovative T800 is small enough to fit in a pocket or your hand, but still offers all the power and performance a remote worker needs. Getac’s unique SnapBack expansion system allows users to add expansions to the T800 such as an extra battery, increasing the

operation use to greater than 16 hours. Mobile workers will also benefit from the fully rugged design which has MIL-STD-810G and IP65 ratings, meaning the device can handle shock, drops and vibration to military grades while also being sealed against dust and water. The 8.1” screen is built with LumibondTM, Getac’s proprietary screen technology that offers excellent touch control and sunlight readability, without compromising battery performance. Peter Molyneux, Getac UK President says: “The T800 gives the best performance of any fully rugged Windows 8 tablet in the market today. Our customers have given us tremendous feedback on the T800’s

thin and light design, while offering high levels of integration and field performance. We always target to give our customers the latest in fully rugged computer technology with no compromise on performance, and again we feel confident we have achieved this in the T800.” Powered by the latest quad-core Intel N3530 2.17 GHz processor, the T800 also provides unparalleled connectivity and can be configured with 4G LTE cellular data with an auto tunable 8-band antenna capable of quickly switching between bands. It also includes the latest 802.11ac WiFi for data transfer speeds up to 3 times faster than 802.11n products. The T800’s optional GPS offers double search capacity, faster location positioning and improved accuracy. Key features • Intel Bay Trail quad-core N35320 2.17 GHz processor • Windows 7 & 8, OS • Tablet size: 227 x 151 x 24mm; 8.1” screen • Weight: 0.88kg • Multi-touch display

Peter Molyneux, Getac UK President • 64 GB / 128 GB SSD • SiRFstarIV™ GPS • Gobi 5000 • Fully Rugged, MIL-STD 810G, IP65 • Ultrafast Wifi Connection: 802.11 ac • Strong Connectivity, in-house patented 3D antenna design • SnapBack expandability: Optional barcode reader/SD card/RFID Battery • Battery life: 8 hours • Tri RF pass-through (WWAN & WLAN & GPS)

Ferno innovative new gadget in the hands of medical charity Cleckheaton-based Ferno, a world leading manufacturer of medical and patient handling equipment, will see its new Ferno² Fingertip Pulse Oximeter deployed in the field in Haiti. The company has donated a number of oximeters to the Hospital Bernard Mews/ Project Medishare, which runs a volunteer programme where foreign doctors and other medical personnel travel to Haiti and work with Haitian medics to give free emergency aid to the local community. Ferno’s Business Development Manager Darren Sharman presented the Ferno² Oximeters to Oxford-based Dr Joanna Cherry after being approached by Madeleine Radburn, Medical Devices Advisor at the South Central Ambulance Service.

Madeleine supports the Hospital Bernard Mews/Project Medishare through her local Lions Club charity and helps keep Joanna supplied with a range of medical equipment to help with the care of the spinal patients she treats in Haiti. The new devices which fit on to a patient’s finger measure blood-oxygen saturation levels and heart (pulse) rate quickly and accurately. The tool is ideal for the hospital and pre-hospital workplace, from the emergency services, search and rescue to Accident & Emergency. Jon Ellis, managing director at Ferno, said: “The Ferno² is a must-have accessory for the front-line healthcare practitioner. It is reliable, very easy to use and lightweight. It can be worn on a lanyard around the neck so it’s at your fingertips when you need a quick and accurate reading of

blood-oxygen saturation levels and pulse rate. I’m sure that Dr Cherry and her team will find the devices useful on a regular basis.” Dr Cherry said: “I will be taking them to Haiti and they will be used at the Hospital Bernard Mews/Project Medishare which is a trauma hospital in Port au Prince where we work with local doctors and patients to try and ease the burden of high level trauma in Haiti. “We treat high level trauma, medical and surgical conditions in patients from all backgrounds and are proud to serve the Haitian people in their time of need. We continue to rely on donations of equipment to keep our facility running and our standards of care high and your pulse oximeters will be put to good use.”

The Ferno² Fingertip Pulse Oximeter has a large OLED display which has 10 brightness settings to suit the working environment and can be viewed at any angle with a choice of read-outs and orientations. A built-in “auto power off ” feature saves battery life which, under normal operating conditions, lasts a minimum of 30 hours and the hard plastic casing protects the device from the rigours of daily use.

Left to right - Ferno’s Business Development Manager Darren Sharman, Madeleine Radburn, Medical Devices Advisor at the South Central Ambulance Service , and Dr Joanna Cherry

Get your Daily-Updated Ambulance News at: The news stories you just read in our Out & About section are only a taster of the news service Ambulance Today provides every day on our free-access news website Click on

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Luigi Vernazza named new commercial director at Ferno Ferno, a world leading supplier and manufacturer of medical equipment to the emergency services and funeral sector, has strengthened its team with the appointment of Luigi Vernazza as Commercial Director Mr Vernazza joins Ferno with a wealth of experience in many of its main markets, having worked in medical device sales for more than 15 years. During that time he has worked at companies including Guidant UK Ltd, Siemens Medical Solutions and, most recently, Merit Medical Ltd in

a range of positions covering sales and marketing. Mr Vernazza started his career as a medical practitioner, training and working as a radiologist before making the move into sales. Ferno managing director Jon Ellis said: “Luigi joins Ferno during an exciting period in its development as we continue to introduce a wide range of patient transport innovations and continue to grow our market share in the UK. “As well as determining and implementing strategy, Luigi’s role will be hands on. He will enhance

the existing team by bringing in strong leadership and management skills, working closely with all the commercial team to ensure that they are able to work to their full potential. Ferno, based in Cleckheaton, West Yorkshire, exports to more than 156 countries worldwide and is recognised as a global leader in the manufacture and distribution of patient-handling equipment to the emergency services, funeral and mortuary, hospital and medical sectors as well as general industry

and organisations. The company is also building a portfolio of products for the military.

Ferno launches training service for best use of equipment Ferno, a world leading patient handling and medical equipment manufacturer, has launched a new training service for new and existing customers to ensure the safe use of patient transfer equipment. The training service covers emergency medical services, building evacuation and the funeral and mortuary sector. Jon Ellis, Ferno managing director, said: “Where anyone is involved in the transfer of patients or injured people, Ferno has developed a training programme to ensure that operators are using the equipment to the highest standard with the emphasis on protecting the safety of the operator and the patient.” The Ferno equipment “Familiarisation” course is designed

for authorised personnel to be trained in the expert use of Ferno’s specialist equipment. During the halfday course delegates will develop a greater understanding of the features and benefits of Ferno’s specialist equipment as well as the knowledge required in the correct deployment in a range of scenarios. Ferno has also launched an extended course aimed at “Training the Trainer” – which helps delegates to put in place the skills and knowledge to train designated personnel in-house. At the end of the one or two-day course trainers will leave with skills to devise a training plan and the knowledge to successfully deploy it throughout their company. These training courses are available across the wide range of Ferno products and can be delivered to up to ten delegates. All courses

are delivered by Ferno equipment specialists who are ‘Preparing to Teach in the Lifelong Learning Sector (PTLLS)’ qualified trainers. Mr Ellis said: “The technology of patient transfer equipment has advanced incredibly over the past ten years together with increased concerns about health and safety during patient transport and the duty of care obligations organisations face in both the public and private sector. “Our new training service recognises these twin problems and the courses have been designed to ensure that our customers are equipped with the skills and knowledge in the safe use of equipment in all our key sectors including Ambulance and Hospital, Rescue and Evacuation, Funeral and Mortuary and Commercial Health and Safety.

Jon Ellis, MD For further information about Ferno’s training packages call +44 (0)1274 851999 or visit www.ferno.co.uk

Vehicle Conversion Specialist, O&H shows 5 high quality vehicle conversions at this year’s Commercial Vehicle Show O&H is appearing at this year’s Commercial Vehicle Show in Birmingham. From the 29th April until the 1st May 2014, the vehicle conversions supplier is showing its extensive portfolio of products with our partners in Hall 5, stand 5D120, 5E100 and Hall 3 3C80. The link with O&H’s key partners enables the company to display a large range of vehicles for varying markets in the commercial vehicle world - thus illustrating the diversity of O&H’s capabilities as a leading vehicle convertor. Vehicles on display: Well bus - The new concept in the welfare vehicle market. With onboard microwave, toilet, running hot water, canteen facilities and capacity for 8 crew this vehicle is the first

choice for fleets. Further information is available at www.wellbus.co.uk

users, plus a Taxi version of the vehicle.

“Flexi-Ramp” system Wheelchair Access Vehicles - The Citroen Berlingo’s “FlexiRamp” system is one of the most versatile small wheelchair accessible vehicles currently available in the UK. When the ramp is stowed, the system allows a full size luggage compartment with no obstructions. The ramp is easily unfolded to create ample space for a wheelchair. There are various seating options available to accommodate up to 4 persons plus 1 wheelchair occupant. Available with a manual or automatic gearbox to suit all drivers. O&H will be demonstrating a standard Citroen Berlingo “Flexi-Ramp” suitable for many types of markets including care homes, NHS trusts and individual

Wheelchair Access MercedesBenz Sprinter- With the release of the new Mercedes- Benz Sprinter, O&H have subsequently designed, developed and produced a demonstration vehicle. The vehicle, which includes wheelchair accessibility, is for use at exhibitions and customers’ premises. The vehicle demonstrates the capabilities of the company and the products O&H can offer to any potential customer. Custom seats, layouts, heating, passenger accessibility, and much more can all be bespoke to O&H customers. NHS Front Line Ambulance Developed with several NHS Trusts, the storage facilities in O&H’s A&E ambulances have been designed

Spring 2014 | Ambulancetoday

to ensure an efficient use of space and to create a well-organised and professional workspace. An ambulance is a life line and at the heart of any ambulance is the electrical system. O&H Vehicle Conversions equip A&E vehicles with the latest technology, making operation as easy and effective as possible. For further information please visit O&H Vehicle Conversions at the Commercial Vehicle Show at the NEC Birmingham. Stands 5D120, 5E100 and 3C80. 73


Products & Suppliers News Visit the only daily ambulance news site on the net at: www.ambulancetoday.co.uk

New ambulance promises to be the industry’s most advanced yet Iveco and Cartwright have teamed up to launch a new accident & emergency (A&E) ambulance, which is being made available for trials with NHS Ambulance Trusts and private ambulance operators across the UK and Ireland. The body has been designed and developed within Cartwright’s 38- acre manufacturing site in Altrincham, Cheshire, using materials proven in aerospace and motorsport environments, combined with cutting edge metallurgy and the company’s 62 years of experience in vehicle body design. Cartwright says the body is unique in the marketplace for being easily transferable onto a second chassis, of any make, during a projected 15 year minimum service life.

The launch vehicle is based on an Iveco Daily 50C17 chassis, which is popular with blue light operators throughout Europe. Key features include its truck-style chassis frame which guarantees structural rigidity, fatigue resistance and long-term durability, combined with an impressive turning circle and a chassis offering maximum bodybuilding flexibility. Wes Linton, Blue Light Development Engineer at Cartwright Group, says: “We’ve invested significant resources into advancing the construction techniques and materials used in ambulance body design.” Martin Flach, Product Director at Iveco, explains: “From an early stage we knew Cartwright was working on something very special and we were keen to support them. Selecting the Daily chassis for the launch highlights its suitability for ambulance operations; it’s also a model many blue light fleets already operate.” The bodywork comprises a unique combination of high strength fibrereinforced plastic (FRP) laminates, high density structural foam core, special plastics manufactured by

Wes adds: “Ambulance electrical systems are worked extremely hard with constant parasitic communications loads combined with regular high current requirements for the tail-lift. For this new body, we have developed what we are confident is the most advanced electrical system of its type in the blue-light sector.”

VEKA and high strength aluminium extrusions.The FRP laminate offers Prior to launch, Cartwright says it undertook the largest prototype testing regime ever undertaken for an ambulance body in the UK. Rather than over-engineer one test body to survive all crash tests, it invested in multiple crash test bodies, each designed to provide the strength required to survive each directional crash test once. This allowed for substantial weight and material savings and ensures a finished product with zero internal panel reinforcing. Key to the body’s modular nature is Cartwright’s decision to mount the lightweight body structure onto a reinforced substructure to provide a strong, rigid mounting point for battery lockers, step wells, steps and tail-lift. Unlike existing ambulance bodies in the UK, this allows fleets the option to remount the body onto a different chassis and wheelbase in the future – ensuring the base vehicle can be replaced after approximately seven or eight years in service, in line with current industry standards.

Cartwright As one of the UK’s leading commercial vehicle body and trailer manufacturers, Cartwright has been operating for more than 60 years. Its 38 acre site based in South Manchester houses all four major divisions of the company; Manufacturing, Finance, Rentals & Fleet Services. Founded in 1952 ‘Manufacturing and More’ has been the ethos that has driven the company to the forefront of UK manufacturing and bespoke bodybuilding. For more press information from Cartwright contact: enquiries@cartwright-group. co.uk Or Tel: 0161 928 0966

New skills to assist in diagnosis of stroke patients Each year in the UK over 110,000 people suffer a new or recurrent stroke resulting in 60,000 deaths annually. Stroke costs the NHS 2.8 billion pounds a year 1 billion pounds more than the cost of coronary heart disease, (source NHS 2009) To improve outcomes for stroke patients in the UK a unique on line training course (accredited by the UK Stroke Forum, Education and Training), has been launched to assist clinicians make better diagnosis for

patients who are suspected of having a stroke. Recognising this condition quickly and getting a person to a specialist hospital for treatment is the priority and has proven to save lives and reduce the devastating effects of a stroke where these new techniques now available to UK clinicians have been applied in the U.S.A. GP’s nurses and ambulance crews working in the community will particularly benefit from undertaking this course. Developed with a team of UK stroke specialists the unique benefit is that clinicians will learn how to apply the Miami Emergency Neurologic Deficit Test or MEND examination. The MEND s assessment takes just three minutes to complete and does not require any specialist equipment just the knowledge of the clinician which they will learn from the course. It involves

responses around mental status, cranial nerves and limbs. The MEND assessment can then be continued from the pre hospital stage into hospital. Originally devised in the USA where it has proven to save lives and reduce the effects of strokes the four hour on line course also increases knowledge and skills in other areas of stroke recognition. The MEND exam will reduce the likelihood of the 20% of patients missed when the FAST test alone is done. As it is on line clinicians can take the course wherever and whenever they have access to the internet. As they complete the course learners will undertake assessments to ensure they have understood and can apply the new skills. At the end of the course the learners watch a number of film clips where they have to

make their patient assessment and if successful automatically receive a certificate endorsed by UK Stroke Forum and the University of Miami.. Feedback from the paramedics and nurses completed the course so far has confirmed the value of reinforcing existing knowledge and learning new skills. To find out more: call Paul Meek Managing Director SolutionsTraining & Advisory Ltd Tel: 07748 770112 or email: paulmeek@solutionstraining.co.uk Or, Julia Cake Business Development Manager SolutionsTraining & Advisory Ltd Tel: 07738 711906 or email: juliacake@solutionstraining.co.uk

Promote your Company or Service in our next edition! Email us now to learn how you can promote your ambulance product or service and reach over 90,000 ambulance personnel

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A must have for the leading-edge, front-line healthcare practitioner FERNO’s Fingertip Pulse Oximeter is a reliable, lightweight device that quickly and accurate displays blood-oxygen saturation levels and heart (pulse) rate. It’s an accurate device and extremely simple to use! A durable unit that is perfect for the hospital and pre-hospital workplace. It is suitable for EMS, Search & Rescue and A&E. This device meets the most demanding needs. The compact unit can be stored in its own pouch, or can be hung on the supplied lanyard, making it easy to carry. The large OLED display has ten different brightness settings, making it a great Pulse Oximeter for use in a broad range of environments. The built in “auto power-off” feature saves battery life and helps to ensure that the unit is ready for the next important patient assessment or spot check. FERNO Inspired Safety Innovation. For a more information call +44 (0) 1274 851 999 email sales@ferno.co.uk www ferno.co.uk Ferno (UK) Limited, Stubs Beck Lane, Cleckheaton, West Yorkshire, BD19 4TZ England.

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