Knowledge, attitudes and practices of smallholder farmers on foot and mouth disease control in two Cambodian provinces.

Food-and-mouth disease (FMD) is endemic in Cambodia. The control programme for FMD has relied on vaccination, with poor vaccination uptake by smallholder farmers becoming an increasing concern. A study to improve the understanding of farmer knowledge, attitudes and practices of FMD control and vaccination was conducted in two Cambodian provinces (Kampong Cham and Pursat). The aim was to identify opportunities to improve the livestock disease control programmes provided by both the government and private sectors. The survey comprised 300 smallholder farmers using a one-on-one interview technique and was completed between January to February 2014. Results identified that over two-thirds of the respondent farmers had not vaccinated their cattle over 2 years (2011-2013). Of those who did, most cattle were vaccinated either once a year or once every 3 years. A booster had never been administered. It was concluded that the FMD vaccine had only been administered through an unreliable and limited government vaccination programme, and private FMD vaccination services were not accessed in the study areas. FMD outbreaks occurred every year during the study period, with a morbidity rate of over 30%. Isolation of first infected cattle from the household herd was not practiced, with treatment identified as the first preference intervention. Farmers often assisted other farmers to restrain and treat infected cattle both before (57%) and after (43%) their own cattle were infected. This indicated that most farmers did not practice basic biosecurity measures and chose to report FMD outbreaks to the village animal health workers (VAHW), friends, neighbours and relatives in preference to government officials. It was concluded that poor knowledge of disease transmission and biosecurity, with low FMD vaccination coverage and a focus on treatment, contribute to regular FMD outbreaks in these communities. Improvement of FMD control requires the cooperation of villagers, VAHWs and village leaders in disease reporting, with either improved funding of government vaccination services or establishing a private FMD vaccination service. Training programmes for farmers on disease transmission, and the importance of biosecurity and vaccination, including information on the cost-benefits of treatment versus full fee bi-annual FMD vaccination, are required.

Contributions of village animal health workers to foot-and-mouth disease control in Cambodia.

Local animal health services in rural communities in Cambodia are mainly provided by village animal health workers (VAHWs), although the participation and contribution of VAHWs to livestock disease prevention are uncertain. The participation of the VAHWs as identified by their 'dropout rate' was examined in a desktop review in December 2020 of the national data on VAHWs recorded between 2011 and 2020. The contribution and involvement of VAHWs in disease prevention programmes were examined in a survey conducted between February and March 2014, then analyzed in the context of other surveys of VAHW knowledge, attitudes and practices. The survey involved guided group discussion with VAHWs (n = 198) from the two Cambodian provinces of Kampong Cham and Pursat. This study identified that VAHWs generated less than 22% of their annual household incomes from animal health services. Less than one-third had vaccinated livestock against foot-and-mouth disease (FMD), with none having vaccinated cattle every 6 months during the study period, and nearly half of the VAHWs having never vaccinated their own cattle against FMD. As no privately provided FMD vaccination services occurred in these communities, with all vaccines delivered through the government-subsidized programme, the findings confirmed that VAHWs only vaccinated animals against FMD when vaccines were made available by the Government. The desktop review found that the number of VAHWs in 2020 declined by more than 24% since 2017, and the proportion of female VAHWs was consistently low, with a mean of 8.26 (±1.019). These findings confirm findings from previous studies that identified considerable weaknesses in the VAHW system in Cambodia, particularly in contributing to FMD control. Cambodian animal health authorities require more effective policies to strengthen the current VAHW system, improving their services delivery; their retention as 'active'; their development of more sustainable roles with lower 'dropout' rates and the prolonged gender inequity. With the limited availability of government-subsidized FMD vaccination currently, extension programmes that engage VAHWs and farmers in seeking privately funded and delivered FMD vaccination that incorporates appropriate multivalent FMD serotype vaccines of high quality, delivered in small dose vials from a robust cold chain, is suggested. This strategy would assist VAHWs to contribute to the provision of private livestock vaccination services that are likely essential for sustainable FMD prevention and control in Cambodia.

Exploring the Socioeconomic Importance of Antimicrobial Use in the Small-Scale Pig Sector in Vietnam.

Antimicrobial resistance (AMR) is influenced by antimicrobial use in human and animal health. This use exerts selection pressure on pathogen populations with the development of resistance and the exchange of resistance genes. While the exact scale of AMR in Vietnam remains uncertain, recent studies suggest that it is a major issue in both human and animal health. This study explored antimicrobial use behaviors in 36 pig farms in the Nam Dinh Province (North) and the Dong Nai Province (South) of Vietnam (with a median of 5.5 breeding sows and 41 fattening pigs). It also estimated the economic costs and benefits of use for the producer. Data were collected through a structured face-to-face interview with additional productivity data collected by farmers during a six-week period following the initial interview. Overall, antimicrobial use was high across the farms; however, in-feed antimicrobial use is likely to be under-reported due to misleading and imprecise labelling on premixed commercial feeds. An economic analysis found that the cost of antimicrobials was low relative to other farm inputs (~2% of total costs), and that farm profitability was precariously balanced, with high disease and poor prices leading to negative and low profits. Future policies for smallholder farms need to consider farm-level economics and livestock food supply issues when developing further antimicrobial use interventions in the region.

The Costs, Benefits and Human Behaviours for Antimicrobial Use in Small Commercial Broiler Chicken Systems in Indonesia.

There are growing concerns over the threat to human health from the unregulated use of antimicrobials in livestock. Broiler production is of great economic and social importance in Indonesia. This study used a structured questionnaire approach to explore the human behaviours and economic drivers associated with antimicrobial use in small commercial broiler systems in Indonesia (n = 509). The study showed that antimicrobial use was high with farmers easily able to access antimicrobials through local animal medicine, however, it was difficult for farmers to access veterinary advice on responsible antimicrobial use. The most significant finding was that the relative cost of antimicrobials was low, and farmers observed improvements in productivity rates from routine antimicrobial administration. However, farmers seldom kept detailed records on farm productivity or economic costs; this is a hurdle to undertaking a more detailed economic analysis of antimicrobial use. There is a need for further research on the cost-effectiveness of alternative methods of preventing disease and ensuring that feasible alternatives are easily available. Farm-level economics and securing the food supply chain need to be central to any future policy interventions to reduce antimicrobial use in broiler systems in Indonesia and this observation is relevant at a regional and global level.

Characterizing Antimicrobial Use in the Livestock Sector in Three South East Asian Countries (Indonesia, Thailand, and Vietnam).

A framework was developed to characterize the antimicrobial use/antimicrobial resistance complex in livestock systems in Indonesia, Vietnam, and Thailand. Farm profitability, disease prevention, and mortality rate reduction were identified as drivers toward antimicrobial use in livestock systems. It revealed that antimicrobial use was high in all sectors studied, and that routine preventative use was of particular importance to broiler production systems. Misleading feed labeling was identified as a hurdle to the collection of accurate antimicrobial use data, with farmers being unaware of the antimicrobials contained in some commercial feed. Economic analysis found that the cost of antimicrobials was low relative to other farm inputs, and that farm profitability was precariously balanced. High disease and poor prices were identified as potential drivers toward economic loss. The research indicates that antimicrobial use in small-scale poultry production systems improves feed conversion ratios and overall productivity. However, data were limited to quantify adequately these potential gains and their impacts on the food supply. During the study, all countries embraced and implemented policies on better management of antimicrobial use in livestock and surveillance of antimicrobial resistance. Future policies need to consider farm-level economics and livestock food supply issues when developing further antimicrobial use interventions in the region.

Exploration of difficult conversations among Australian paramedics.

Previous studies indicate that healthcare professionals find it challenging to engage in difficult conversations regarding concerning behavior of colleagues. As a result, these conversations are often avoided. The inability to have these difficult conversations is associated with poorer patient outcomes, staff commitment, discretionary effort, and employee satisfaction. This descriptive study used an online questionnaire to examine responses of paramedics employed by Ambulance Victoria (Australia) regarding difficult conversations between colleagues about concerning behavior of co-workers. The results suggest that, like other healthcare professions, many paramedics find it challenging to raise these concerns. To the best knowledge of the authors, this is the first study of its type to be undertaken within the paramedic profession and provides a platform for further research within this and other health professions.

Improvement in the prehospital recognition of tension pneumothorax: the effect of a change to paramedic guidelines and education.

INTRODUCTION: An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation. This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment. METHODS: Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System. RESULTS: In 2001-2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006-2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics. CONCLUSION: A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.

Cross-cultural validity of the Self-Stigma of Seeking Help (SSOSH) scale: examination across six nations.

Researchers have found that the stigma associated with seeking therapy--particularly self-stigma--can inhibit the use of psychological services. Yet, most of the research on self-stigma has been conducted in the United States. This is a considerable limitation, as the role of self-stigma in the help-seeking process may vary across cultural groups. However, to examine cross-cultural variations, researchers must first develop culturally valid scales. Therefore, this study examined scale validity and reliability of the widely used Self-Stigma of Seeking Help scale (SSOSH; Vogel, Wade, & Haake, 2006) across samples from 6 different countries (England, Greece, Israel, Taiwan, Turkey, and the United States). Specifically, we used a confirmatory factor analysis framework to conduct measurement invariance analysis and latent mean comparisons of the SSOSH across the 6 sampled countries. Overall, the results suggested that the SSOSH has a similar univariate structure across countries and is sufficiently invariant across countries to be used to explore cultural differences in the way that self-stigma relates to help-seeking behavior.

Individuals and environments: Linking ability and skill ratings with interests.

Holland's (1997) theory of corresponding person and work environment structures was evaluated by comparing the integration of individual and occupational ratings of interests, abilities, and skills. Occupational ratings were obtained from the U.S. Department of Labor's O*NET database (U.S. Department of Labor, 2007). College students (494 women, 526 men) provided self-ratings of their interests, abilities, and skills. Property vector fitting was used to embed ability and skill ratings into the Realistic, Investigative, Artistic, Social, Enterprising, and Conventional (RIASEC) interest structure, and bootstrapping was used to generate confidence intervals for the angles of the vectors and the magnitude of their fit to the Holland model. Across the individual and occupational ratings, 18 of 45 (40%) ability vectors and 41 of 48 (85%) skill vectors were fit into the RIASEC model. No significant gender differences were found in the integration of self-rated abilities and skills into the RIASEC circumplex; however, some differences were found between individual and environmental ratings. Obtained results highlight the potential utility and limitations of using Holland's model for representing both individual and occupational data in a common structure.

Theoretical and methodological issues with testing the SCCT and RIASEC models: Comment on Lent, Sheu, and Brown (2010) and Lubinski (2010).

The current article replies to comments made by Lent, Sheu, and Brown (2010) and Lubinski (2010) regarding the study "Interpreting the Interest-Efficacy Association From a RIASEC Perspective" (Armstrong & Vogel, 2009). The comments made by Lent et al. and Lubinski highlight a number of important theoretical and methodological issues, including the process of defining and differentiating between constructs, the assumptions underlying Holland's (1959, 1997) RIASEC (Realistic, Investigative, Artistic, Social, Enterprising, and Conventional types) model and interrelations among constructs specified in social cognitive career theory (SCCT), the importance of incremental validity for evaluating constructs, and methodological considerations when quantifying interest-efficacy correlations and for comparing models using multivariate statistical methods. On the basis of these comments and previous research on the SCCT and Holland models, we highlight the importance of considering multiple theoretical perspectives in vocational research and practice. Alternative structural models are outlined for examining the role of interests, self-efficacy, learning experiences, outcome expectations, personality, and cognitive abilities in the career choice and development process.

Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial.

OBJECTIVE: To determine whether paramedic rapid sequence intubation in patients with severe traumatic brain injury (TBI) improves neurologic outcomes at 6 months compared with intubation in the hospital. BACKGROUND: Severe TBI is associated with a high rate of mortality and long-term morbidity. Comatose patients with TBI routinely undergo endo-tracheal intubation to protect the airway, prevent hypoxia, and control ventilation. In many places, paramedics perform intubation prior to hospital arrival. However, it is unknown whether this approach improves outcomes. METHODS: In a prospective, randomized, controlled trial, we assigned adults with severe TBI in an urban setting to either prehospital rapid sequence intubation by paramedics or transport to a hospital emergency department for intubation by physicians. The primary outcome measure was the median extended Glasgow Outcome Scale (GOSe) score at 6 months. Secondary end-points were favorable versus unfavorable outcome at 6 months, length of intensive care and hospital stay, and survival to hospital discharge. RESULTS: A total of 312 patients with severe TBI were randomly assigned to paramedic rapid sequence intubation or hospital intubation. The success rate for paramedic intubation was 97%. At 6 months, the median GOSe score was 5 (interquartile range, 1-6) in patients intubated by paramedics compared with 3 (interquartile range, 1-6) in the patients intubated at hospital (P = 0.28).The proportion of patients with favorable outcome (GOSe, 5-8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% confidence interval, 1.00-1.64; P = 0.046). There were no differences in intensive care or hospital length of stay, or in survival to hospital discharge. CONCLUSIONS: In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.

BACKGROUND: Clinical handover between paramedics and the trauma team is undertaken in a time-pressured environment. Paramedics are often required to handover complex problems to a multitude of staff. There is evidence that information loss occurs at this transition. The aims of this project were to (1) develop a minimum dataset to assist paramedics provide handover; (2) identify attributes of effective and ineffective handover; (3) determine the feasibility of advanced data transmission; and (4) identify how to best display data in trauma bays. METHODS: Qualitative study of paramedics and trauma team members. A thematic analysis was undertaken using grounded theory. RESULTS: Ten paramedics and 17 trauma team members were interviewed. A minimum dataset modified on an existing template was developed to include fields required by the trauma team to inform immediate treatment. Respondents stated that an effective handover was one which was delivered succinctly and in a structured manner, and contained only vital data necessary to direct immediate treatment. Advanced transmission of data to the receiving hospital was widely supported. While computers carried by paramedics were capable of exporting data to the receiving hospital, barriers such as time constraints, workflow issues and infection control issues impeded the ability to do this in the current environment. DISCUSSION: There is support for the adoption and further evaluation of a handover template. It can provide valuable structure to the face-to-face handover, and experience from other specialties suggests it can reduce information loss. Strategies to enable information to be transmitted in advance of the patients' arrival must address concerns voiced by paramedics.

Assessing clinical handover between paramedics and the trauma team.

INTRODUCTION: The aim of effective clinical handover is seamless transfer of information between care providers. Handover between paramedics and the trauma team provides challenges in ensuring that information loss does not occur. Handover is often time-pressured and paramedics' clinical notes are often delayed in reaching the trauma team. Documentation by trauma team members must be accurate. This study evaluated information loss and discordance as patients were transferred from the scene of an incident to the Trauma Centre. METHODS: Twenty-five trauma patients presenting by ambulance to a tertiary Emergency and Trauma Centre were randomly selected. Audiotaped (pre-hospital) and videotaped (in-hospital) handover was compared with written documentation. RESULTS: In the pre-hospital setting 171/228 (75%) of data items handed over by paramedics to the trauma team were documented and in the in-hospital handover 335/498 (67%) of information was documented. Information least likely to be documented by trauma team members (1) in the pre-hospital setting related to treatment provided and (2) in the in-hospital setting related to signs and symptoms. While 79% of information was subsequently documented by paramedics, 9% (n=59) of information was not documented either by trauma team members or paramedics and constitutes information loss. Information handed over was not congruent with documentation on seven occasions. Discrepancies included a patient's allergy status and sites of injury (n=2). Demographic details were most likely to be documented but not handed over by paramedics. CONCLUSION: By documenting where deficits in handover occur we can identify points of vulnerability and strategies to capture this information.

The Victorian major trauma transfer study.

AIMS: To comprehensively examine the inter-hospital transfer of major trauma patients-including the reason for transfer, duration, escorts, interventions and unexpected events. METHODS: This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form. RESULTS: A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min. Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%). Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p<0.001). Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p<0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p<0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p<0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p=0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p=0.001). CONCLUSION: Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.

Men and things, women and people: a meta-analysis of sex differences in interests.

The magnitude and variability of sex differences in vocational interests were examined in the present meta-analysis for Holland's (1959, 1997) categories (Realistic, Investigative, Artistic, Social, Enterprising, and Conventional), Prediger's (1982) Things-People and Data-Ideas dimensions, and the STEM (science, technology, engineering, and mathematics) interest areas. Technical manuals for 47 interest inventories were used, yielding 503,188 respondents. Results showed that men prefer working with things and women prefer working with people, producing a large effect size (d = 0.93) on the Things-People dimension. Men showed stronger Realistic (d = 0.84) and Investigative (d = 0.26) interests, and women showed stronger Artistic (d = -0.35), Social (d = -0.68), and Conventional (d = -0.33) interests. Sex differences favoring men were also found for more specific measures of engineering (d = 1.11), science (d = 0.36), and mathematics (d = 0.34) interests. Average effect sizes varied across interest inventories, ranging from 0.08 to 0.79. The quality of interest inventories, based on professional reputation, was not differentially related to the magnitude of sex differences. Moderators of the effect sizes included interest inventory item development strategy, scoring method, theoretical framework, and sample variables of age and cohort. Application of some item development strategies can substantially reduce sex differences. The present study suggests that interests may play a critical role in gendered occupational choices and gender disparity in the STEM fields.

The impact of ambulance practice on acute stroke care.

BACKGROUND AND PURPOSE: Few patients with acute stroke are treated with alteplase, often due to significant prehospital delays after symptom onset. The aims of this study were to: (1) identify factors associated with rapid first medical assessment in the emergency department after a call for ambulance assistance, and (2) determine the impact of ambulance practice on times from the ambulance call to first medical assessment in the emergency department. METHODS: During a 6-month period in 2004, all ambulance-transported patients with stroke or transient ischemic attack arriving from a geographically defined region in Melbourne, Australia (population 383,000) to one of 3 hospital emergency departments were assessed prospectively. Ambulance records including the tape recording of the call for ambulance assistance and hospital medical records, were analyzed. RESULTS: One hundred ninety-eight patients were included in the study. One hundred eighty-seven ambulance patient care records were complete and available for analysis. Factors associated with first medical assessment in the emergency department <60 minutes from the ambulance call and <10 minutes from hospital arrival were: Glasgow Coma Scale <13 (P<0.001 and P=0.021) and hospital prenotification (P=0.04 and P<0.001). Paramedic stroke recognition and hospital prenotification were associated with shorter times from the ambulance call to first medical assessment (P=0.001 and P<0.001). CONCLUSIONS: Paramedic stroke recognition and hospital prenotification are associated with shorter prehospital times from the ambulance call to hospital arrival and in-hospital times from hospital arrival to first medical assessment. This highlights the importance of including ambulance practice in comprehensive care pathways that span the whole process of stroke care.

Stroke symptoms and the decision to call for an ambulance.

BACKGROUND AND PURPOSE: Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. METHODS: For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. RESULTS: One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as "stroke." Factors independently associated with a call within 1 hour were: speech problems (P=0.009), caller family history of stroke (P=0.017), and the patient was not alone at symptom onset (P=0.018). CONCLUSIONS: Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment.

Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose.

OBJECTIVE: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting. DESIGN: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser. PARTICIPANTS AND SETTING: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria. MAIN OUTCOME MEASURES: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment. RESULTS: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%. CONCLUSION: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Call-to-needle times for thrombolysis in acute myocardial infarction in Victoria.

OBJECTIVE: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality. DESIGN: Cohort study. SETTING: 20 hospitals and two ambulance services in the State of Victoria, Australia. PARTICIPANTS: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis. MAIN OUTCOME MEASURES: CTN time, and in-hospital mortality. RESULTS: Median CTN time was 83 minutes (mean, 93.2 min; range, 29-894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0-853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3-2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes. CONCLUSION: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance-hospital communication. Prehospital thrombolysis may be appropriate for some regions.

The use of rapid sequence intubation by ambulance paramedics for patients with severe head injury.

OBJECTIVE: To determine the effects of rapid sequence intubation in patients with severe head injury performed by paramedics on a helicopter emergency medical service. METHODS: The patient care records for patients with severe head injury who underwent rapid sequence intubation between November 1999 and February 2002 (inclusive) were examined. Data were extracted on the demographics of the patients, as well as the physiological changes before and after rapid sequence intubation. RESULTS: There were 122 patients with severe head injury evaluated at the scene during the study period. Rapid sequence intubation was attempted in 110 patients and was successful in 107 (97%). Intubation was associated with improvements in systolic blood pressure, oxygen saturation and end-tidal carbon dioxide levels, compared with baseline levels. CONCLUSION: Rapid sequence intubation in patients with severe head injury may be safely undertaken by helicopter-based ambulance paramedics and is associated with improvements in oxygenation, ventilation and blood pressure. Further studies of this skill undertaken by road-based paramedics are warranted.