Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

Can undergraduate paramedic students accurately identify lung sounds?

INTRODUCTION

The accurate identification of lung sounds during chest auscultation is a skill commonly used by healthcare clinicians, including paramedics, when assessing a patient's respiratory status. It is a necessary skill as it enables confirmation of a patient's respiratory condition and guides the paramedic to a provisional diagnosis and the implementation of appropriate management. The object of this study was to identify if undergraduate paramedic students from two Australian universities were able to interpret a variety of lung sounds accurately.

METHODS

A prospective single-blinded observational study requiring 96 undergraduate paramedic students from two Australian universities to estimate the lung sounds of six audio files.

RESULTS

The findings demonstrated variable accuracy in lung sound interpretation of the six audio files. The lung sound that contained a wheeze was most accurately interpreted, whereas coarse crackles were the least accurately interpreted. Monash University undergraduate paramedic students displayed similar lung sound interpretations to Charles Sturt University undergraduate paramedic students.

CONCLUSION

In this study undergraduate paramedic students from two Australian universities were found to be inaccurate at interpreting a variety of common lung sounds. The study has highlighted that a greater emphasis needs to be given to lung sound interpretation in undergraduate paramedic education programmes.

Airtraq vs standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation

Two consecutive, randomised, cross-over trials compared intubation success rates in third-year paramedic students and experienced prehospital practitioners using the Airtraq or a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III/IV laryngoscopic view. First-time intubation rates for the Macintosh and Airtraq for students were 0/23 (0%) vs 10/23 (44%) (44% difference, 95% CI 26-63%, p < 0.001) and for experienced laryngoscopists were 14/56 (25%) vs 47/56 (84%) (59% difference, 95% CI 42-72%, p < 0.0001), respectively. First-time oesophageal intubation rates for students were 15/23 (65%) vs 3/23 (13%) (-52% difference, 95% CI -25 to -72%, p < 0.001) and for experienced practitioners 9/56 (16%) vs 0/56 (0%) (-16% difference, 95% CI -9 to -28%, p = 0.0014). Student paramedics and experienced prehospital laryngoscopists managing a manikin model of a grade III/IV view had increased first-time intubation rates and had lower rates of oesophageal intubation with the Airtraq compared with a standard laryngoscope.

Would a prehospital practitioner model improve patient care in rural Australia?

BACKGROUND

Existing rural prehospital models have been criticised for being isolated from the healthcare system, and for following inflexible clinical protocols. Greater reliance on clinical judgement and informed decision making in the prehospital setting offer the potential to improve patient care.

METHODS

Soft systems methodology was used to develop and critically appraise the prehospital practitioner model as an alternative to existing models. This approach started from the philosophical viewpoint that prehospital services should be patient centred. Soft systems methodology was used to structure the elements of prehospital systems and the relations between them into metaphors and pictures that could be analysed.

RESULTS

This analysis showed that the most powerful reason for advocating the prehospital practitioner model is that it places prehospital systems within a symbiotic relationship with the healthcare system. Unlike the existing emergency service models or the "chain of survival" model, it is an integrated system that provides a range of services at multiple points during the patient care cycle. Thus, the prehospital practitioner would have roles in the prevention of injury and illness, responding to emergencies, facilitating recovery, and planning future strategies for a healthy community.

CONCLUSIONS

Implementing this new model would see the prehospital system using its available capacity more effectively to fulfill broader public health and primary care outreach roles than is currently the case. Patients would be referred or transported to the most appropriate and cost effective facility as part of a seamless system that provides patients with well organised and high quality care.

Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference?

OBJECTIVE

To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status.

METHODS

Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways.

RESULTS

Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1).

CONCLUSION

Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.

Developing a funding model for an after-hours primary medical care service in a rural town

The study described in this paper aimed to determine a funding model for an after-hours primary medical care service in the rural town of Moe, a socioeconomically disadvantaged area of Victoria suffering the rigours of industry restructuring and privatisation. It has 12.5 equivalent full-time general practitioners servicing 21,966 persons. A break-even analysis of the financial viability compared the expected costs of providing the service with the anticipated income. A mixed funding model is recommended. This would incorporate a general practitioner incentive scheme and State Government underwriting of infrastructure and basic non-medical staffing costs during the business development phase to supplement the income from the Health Insurance Commission.

Comparison of a once-a-day sustained-release morphine formulation with standard oral morphine treatment for cancer pain

Kadian/Kapanol (K) is a capsule formulation of morphine designed for 12- or 24-hourly dosing. This double-blind study compared the efficacy and safety of K every 24 hr to K every 12 hr and MS Contin tablets (MSC) every 12 hr. One hundred fifty-two patients with cancer pain were titrated to adequate analgesia with immediate-release morphine (IRM) solution. Stabilized patients were randonized to one of the three treatments for 7 +/- 1 days. Rescue medication was IRM tablets. Efficacy and safety were assessed by time to first remedication and total dose of rescue medication, pain scores, global assessments, and incidence of morphine-related side effects. Fifty-four patients were treated with K every 24 hr. 45 with K every 12 hr. and 53 with MSC every 12 hr. Mean age was 61 years and mean total daily dose of morphine was 138 mg. Forty-six percent of the K every 24 hr patients, 51% of the K every 12 hr patients, and 55% of the MSC every 12 hr patients required rescue medication on the final day. Time to remedication was 16.0 hr for K every 24 hr, 9.1 hr for K every 12 hr and 8.7 hr for MSC every 12 hr (P = 0.0010). Patient global assessment significantly favored K every 24 hr over MSC every 12 hr (P = 0.018). There were no statistically significant differences among the treatments for any morphine-related side effects when adjusted for baseline. K had efficacy and safety profiles similar to MSC every 12 hr but had the advantage of 12- or 24-hourly administration.

The energy cost of walking with arthritis of the hip and knee

The physiologic energy expenditure of walking was measured in patients with severe arthritis. Nine patients were tested following Girdlestone hip resection arthroplasty, six patients prior to total knee arthroplasty (TKA) for unilateral osteoarthritis of the knee, and 49 rheumatoid arthritis patients prior to unilateral TKA; 27 were retested after operation. The results were compared with previously published pre- and postoperative data for total hip arthroplasty (THA) following primary osteoarthritis. There were severe energetic penalties caused by rheumatoid or osteoarthritis involving the hip or knee or following Girdlestone arthroplasty. Walking speed was severely reduced in all groups (range, 33-46 m/minute). The rate of oxygen consumption was not significantly greater than the mean rate of oxygen uptake for normal subjects; however, the oxygen cost per meter travelled was elevated because of the slow walking speed. The heart rate was significantly elevated in all patient groups. The elevated cardiac response can be accounted for on the basis of deconditioning resulting from the patients' pain, limited ambulatory activities, and the systemic effects of rheumatoid disease. In addition, the elevated cardiac response may be caused by added physical exertion by the arms in patients on crutches or walkers. The improvements in speed and energy cost were the same for the group of rheumatoid patients tested after unilateral TKA as in the group of patients tested before and after THA. The clinician can anticipate the same magnitude of improvement from surgery in a rheumatoid patient as in an osteoarthritis patient if the primary joint disease is restricted to a single joint.