Identifying Features of a System of Practice to Inform a Contemporary Competency Framework for Paramedics in Canada.

INTRODUCTION: Paramedic practice is highly variable, occurs in diverse contexts, and involves the assessment and management of a range of presentations of varying acuity across the lifespan. As a result, attempts to define paramedic practice have been challenging and incomplete. This has led to inaccurate or under-representations of practice that can ultimately affect education, assessment, and the delivery of care. In this study, we outline our efforts to better identify, explore, and represent professional practice when developing a national competency framework for paramedics in Canada. METHODS: We used a systems-thinking approach to identify the settings, contexts, features, and influences on paramedic practice in Canada. This approach makes use of the role and influence of system features at the microsystem, mesosystem, exosystem, macrosystem, supra-macrosystem, and chronosystem levels in ways that can provide new insights. We used methods such as rich pictures, diagramming, and systems mapping to explore relationships between these contexts and features. FINDINGS: When we examine the system of practice in paramedicine, multiple layers become evident and within them we start to see details of features that ought to be considered in any future competency development work. Our exploration of the system highlights that paramedic practice considers the person receiving care, caregivers, and paramedics. It involves collaboration within co-located and dispersed teams that are composed of other health and social care professionals, public safety personnel, and others. Practice is enacted across varying geographical, cultural, social, and technical contexts and is subject to multiple levels of policy, regulatory, and legislative influence. CONCLUSION: Using a systems-thinking approach, we developed a detailed systems map of paramedic practice in Canada. This map can be used to inform the initial stages of a more representative, comprehensive, and contemporary national competency framework for paramedics in Canada.

Feeling our place in the world: an active inference account of self-esteem.

Self-esteem, the evaluation of one's own worth or value, is a critical aspect of psychological well-being and mental health. In this paper, we propose an active inference account of self-esteem, casting it as a sociometer or an inferential capacity to interpret one's standing within a social group. This approach allows us to explore the interaction between an individual's self-perception and the expectations of their social environment.When there is a mismatch between these perceptions and expectations, the individual needs to adjust their actions or update their self-perception to better align with their current experiences. We also consider this hypothesis in relation with recent research on affective inference, suggesting that self-esteem enables the individual to track and respond to this discrepancy through affective states such as anxiety or positive affect. By acting as an inferential sociometer, self-esteem allows individuals to navigate and adapt to their social environment, ultimately impacting their psychological well-being and mental health.

Enacting Gender: An Enactive-Ecological Account of Gender and Its Fluidity.

This paper aims to show that genders are enacted, by providing an account of how an individual can be said to enact a gender and explaining how, consequently, genders can be fluid. On the enactive-ecological view we defend, individuals first and foremost perceive the world as fields of affordances, that is, structured sets of action possibilities. Fields of natural affordances offer action possibilities because of the natural properties of organisms and environments. Handles offer graspability to humans because of physical-structural properties of handles and the anatomical-physiological properties of humans. Although humans live in fields of bodily, action, and cultural affordances, our work focuses on cultural affordances, where action possibilities are offered to individuals because of the normative responses of individuals in that culture. Knocking on a door affords entrance because knocking provides cultured individuals on the other side of the door an affordance to which they themselves behave normatively. Usually, behaving normatively in response to cultural affordances brings about sequences of perception-action loops, which we will call "scripts": for instance, closed doors afford knocking, which affords the individual inside opening the door, which affords an interpersonal meeting, which (may) afford entrance. Although the notion of script has a strong cognitivist flavor, one of the aims of the paper to provide an ecological account of scripts, to show that what cognitivists viewed as representations (or representational structures) are in fact environmentally structured perception-action loops. On our account of gender, gendered cultures build and maintain gendered cultural affordance landscapes, that is, landscapes in which the action possibilities individuals face are normed according to a specific body type or situation; most often (assigned) biological sex. Individuals enact a given gender when they come to perceive the affordances reserved for one gender by their culture and respond in the culturally normative way, thus enacting gendered sequences of perception-action loops (i.e., gendered scripts). With the shifting landscapes of cultural affordances brought about by several recent social, technological, and epistemic developments in some cultures, the gendered landscapes of affordances offered to individuals in these cultures have become more varied and less rigid, thus increasing the variety and flexibility of scripts individuals can enact. This entails that individuals in such cultures have an increased possibility for gender fluidity, which may in part explain the increasing number of people currently identifying outside the binary.

Cell-type- and region-specific modulation of cocaine seeking by micro-RNA-1 in striatal projection neurons.

The persistent and experience-dependent nature of drug addiction may result in part from epigenetic alterations, including non-coding micro-RNAs (miRNAs), which are both critical for neuronal function and modulated by cocaine in the striatum. Two major striatal cell populations, the striato-nigral and striato-pallidal projection neurons, express, respectively, the D1 (D1-SPNs) and D2 (D2-SPNs) dopamine receptor, and display distinct but complementary functions in drug-evoked responses. However, a cell-type-specific role for miRNAs action has yet to be clarified. Here, we evaluated the expression of a subset of miRNAs proposed to modulate cocaine effects in the nucleus accumbens (NAc) and dorsal striatum (DS) upon sustained cocaine exposure in mice and showed that these selected miRNAs were preferentially upregulated in the NAc. We focused on miR-1 considering the important role of some of its predicted mRNA targets, Fosb and Npas4, in the effects of cocaine. We validated these targets in vitro and in vivo. We explored the potential of miR-1 to regulate cocaine-induced behavior by overexpressing it in specific striatal cell populations. In DS D1-SPNs miR-1 overexpression downregulated Fosb and Npas4 and reduced cocaine-induced CPP reinstatement, but increased cue-induced cocaine seeking. In DS D2-SPNs miR-1 overexpression reduced the motivation to self-administer cocaine. Our results indicate a role of miR1 and its target genes, Fosb and Npas4, in these behaviors and highlight a precise cell-type- and region-specific modulatory role of miR-1, illustrating the importance of cell-specific investigations.

Active Inference and Cooperative Communication: An Ecological Alternative to the Alignment View.

We present and contrast two accounts of cooperative communication, both based on Active Inference, a framework that unifies biological and cognitive processes. The mental alignment account, defended in Vasil et al., takes the function of cooperative communication to be the alignment of the interlocutor's mental states, and cooperative communicative behavior to be driven by an evolutionarily selected adaptive prior belief favoring the selection of action policies that promote such an alignment. We argue that the mental alignment account should be rejected because it neglects the action-oriented nature of cooperative communication, which skews its view of the dynamics of communicative interaction. We introduce our own conception of cooperative communication, inspired by a more radical ecological interpretation of the active inference framework. Cooperative communication, on our ecological conception, serves to guide and constrain the dynamics of the cooperative interaction via the construction and restructuring of shared fields of affordances, in order to reach the local goals of the joint actions in which episodes of cooperative communication are embedded. We argue that our ecological conception provides a better theoretical standpoint to account for the action-oriented nature of cooperative communication in the active inference framework.

At-a-glance - What can paramedic data tell us about the opioid crisis in Canada? / Aperçu - Que peuvent nous révéler les données des ambulanciers paramédicaux sur la crise des opioïdes au Canada?

The nature of Canada's opioid crisis necessitates additional data sources that can provide a more comprehensive picture of the epidemic, in order to provide public health officials and decision-makers with a robust evidence base. Paramedic data provide a conduit into the community where overdoses occur. Prehospital events and circumstances surrounding opioid-related overdoses provide unique opportunities to collect evidence that can contribute to prevention, harm reduction and health promotion efforts. Using data extracted from the Ottawa Paramedic Service (OPS), this proof-of-concept study demonstrated that paramedic response data were useful in providing near real-time epidemiological information (person, time and place) on the opioid epidemic and in assessing trends and opportunities to develop alert triggers. Between January and June 2017, the OPS responded to an average of four opioid-related calls each week. On average, 0.5 mg of naloxone was administered each time. For the study period, linear trends show a small but insignificant increase in calls (p = 0.18). A higher volume of calls occurred between April 16 and 29, 2017. According to local media reports, this spike in paramedic responses was due to the arrival of high-grade fentanyl in Ottawa. With further validation, paramedic data can potentially provide a novel data source to monitor opioid-related overdoses.

RÉSUMÉ: La nature de la crise des opioïdes au Canada nécessite des sources de données supplémentaires aptes à dresser un portrait plus fidèle de l'épidémie, afin de fournir aux responsables en santé publique et aux décideurs une base de données probantes solide. Les données des ambulanciers paramédicaux sont un point d'accès aux collectivités où les surdoses surviennent. Les événements préhospitaliers et les circonstances entourant les surdoses d'opioïdes offrent des occasions uniques de recueillir des données probantes pouvant contribuer à la prévention, à la réduction des méfaits et aux efforts de promotion de la santé. À l'aide de données extraites du Service paramédic d'Ottawa (SPO), cette étude de validation de principe a démontré que les données d'intervention ambulancière paramédicale étaient utiles pour obtenir des renseignements épidémiologiques en temps quasi réel (personne, heure et lieu) sur l'épidémie d'opioïdes et pour évaluer les tendances ainsi que les possibilités d'élaborer des déclencheurs d'alerte. Entre janvier et juin 2017, le SPO a répondu à une moyenne de quatre appels liés aux opioïdes par semaine. À chaque fois, 0,5 mg de naloxone ont en moyenne été administrés. Pour la période à l'étude, les tendances linéaires montrent une faible augmentation des appels, non significative (p = 0,18). Le volume d'appels a augmenté entre le 16 et le 29 avril 2017. Selon les médias locaux, ce pic dans les interventions ambulancières paramédicales est attribuable à l'arrivée de fentanyl de qualité supérieure à Ottawa. Avec une validation plus poussée, ces données paramédicales pourraient potentiellement constituer une nouvelle source de données pour la surveillance des surdoses liées aux opioïdes.

Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention.

OBJECTIVES: This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems. BACKGROUND: It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown. METHODS: Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital. The primary outcome was all-cause mortality at 180 days. RESULTS: A total of 1,389 consecutive patients with STEMI were assessed by the emergency medical services (EMS) and referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first. Death at 180 days occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non-PCI-capable hospital (p < 0.0001. After adjusting for baseline characteristics in a multivariable logistic regression model, mortality remained lower among patients referred directly from the field to the PCI center (odds ratio: 0.52, 95% confidence interval: 0.31 to 0.88, p = 0.01). Similar results were obtained by using propensity score methods for adjustment. CONCLUSIONS: A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.

The role of paramedics in a primary PCI program for ST-elevation myocardial infarction.

Time to reperfusion is linked to survival in patients presenting with ST-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) is now considered the dominant strategy when it can be performed quickly. Because the number of cardiac catherization facilities is limited, health care workers have attempted to develop systems to ensure access to primary PCI for all patients with STEMI. The pre-hospital ECG has been shown to be a valuable tool to identify STEMI early and its use in the field has allowed paramedics to alert the medical team of an incoming patient with STEMI. Paramedics have come to play an important role in the early identification of patients with STEMI who make use of the emergency medical services. We review evidence that supports the role of the paramedics in patients presenting with STEMI.

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.

OBJECTIVES: In the last several years, the National Association of EMS Physicians (NAEMSP) has called for better reporting on prehospital endotracheal intubation (ETI) and has provided guidelines and tools for better systematic review. We sought to evaluate the success of prehospital, non-drug-assisted ETI performed by Ottawa advanced care paramedics (ACPs) based on those guidelines. METHODS: A retrospective review was conducted on ETI performed by Ottawa ACPs over a 25-month period to determine the overall success rate of ETI. To qualify our results, descriptive analysis was conducted on demographic data. The relationships between success rate, patient demographic data, and preintubation conditions were examined. RESULTS: Overall success rate of ACP prehospital, non-drug-assisted ETI was 82.1% (95% confidence interval [CI]: 79.6, 84.3), representing a decreased value in comparison with the 90.7% of the previous study (p < 0.001). The study population comprised 1,029 intubated patients, the majority being adults (98.4%), with a mean age of 65.4 years (standard deviation [SD] 18.4). ETIs were successful for 64.6% (95% CI: 61.7, 67.5) of the first attempts; 79% of successful intubations were achieved within two attempts. ETI achievement was correlated with patients' age, with patients designated as vital signs absent (VSA), with those having a preintervention Glasgow Coma Scale (GCS) score of 3, and with those who were orally intubated (p < 0.05). Gender, weight, the nature (medical and trauma) of patient types, and locations of ambulance calls were found not to be related to the overall intubation success. CONCLUSIONS: This study reported the success rate of non-drug-assisted, prehospital ETI by ACPs in the Ottawa region. Our findings emphasize the importance of quality assessment for individual emergency medical services systems, to ensure optimum performance in ETI practice over time, and for intubation skill-retention training.

A citywide protocol for primary PCI in ST-segment elevation myocardial infarction.

BACKGROUND: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain. METHODS: We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians. RESULTS: Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001). CONCLUSIONS: Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital.

Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). We assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). We developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI). Outcomes of these patients were compared with those of a retrospective cohort of 225 consecutive patients with STEMI transported by ambulance to the nearest hospital emergency department. We treated 108 consecutive patients with STEMI using ambulance services according to the paramedic-referred primary PCI protocol. Primary PCI was performed in 93.5% versus 8.9% in the control group, and the median door-to-balloon time was 63 versus 125 minutes in the control group (p <0.0001 for 2 comparisons). Thrombolytic therapy was prescribed to 80.4% of the control group, with a median door-to-needle time of 41 minutes. In-hospital mortality was 1.9% in the paramedic-referred primary PCI group versus 8.9% in the control group (p = 0.017) and remained significantly lower after statistical adjustment for baseline risk. In conclusion, paramedic-referred primary PCI is a safe and feasible strategy for treating STEMI that is associated with rapid and effective reperfusion and very low in-hospital mortality.

Spectral shape sensitivity contributes to the azimuth tuning of neurons in the cat's inferior colliculus.

We recorded high-best-frequency single-unit responses to free-field noise bursts that varied in intensity and azimuth to determine whether inferior colliculus (IC) neurons derive directionality from monaural spectral-shape. Sixty-nine percent of the sample was directional (much more responsive at some azimuths than others). One hundred twenty-nine directional units were recorded under monaural conditions (unilateral ear plugging). Binaural directional (BD) cells showed weak monaural directionality. Monaural directional (MD) cells showed strong monaural directionality, i.e., were much more responsive at some directions than others. Some MD cells were sensitive to both monaural and binaural directional cues. MD cells were monaurally nondirectional in response to tone bursts that lack direction-dependent variation in spectral shape. MD cells were unresponsive to noise bursts at certain azimuths even at high intensities showing that particular spectral shapes inhibit their responses. Two-tone inhibition was stronger where MD cells were unresponsive to noise stimulation than at directions where they were responsive. According to the side-band inhibition model, MD cells derive monaural directionality by comparing energy in excitatory and inhibitory frequency domains and thus should have stronger inhibitory side-bands than BD cells. MD and BD cells showed differences in breadth of excitatory frequency domains, strength of nonmonotonic level tuning, and responsiveness to tones and noise that were consistent with this prediction. Comparison of these data with previous findings shows that strength of spectral inhibition increases greatly between the level of the cochlear nucleus and the IC, and there is relatively little change in strength of spectral inhibition among the IC, auditory thalamus, and cortex.