Paramedics' knowledge, attitudes, and practices regarding the use of personal protective equipment against COVID-19.

The risk of novel coronavirus disease (COVID-19) transmission in the confined mobile ambulance compartment is increased during aerosol-generating procedures and close proximity. Paramedics are encouraged to increase body-surface-isolation by donning additional personal protective equipment (PPE) during patient encounters. This study aimed to better understand paramedics' knowledge, attitudes, and practices related to PPE use during the COVID-19 pandemic in the prehospital setting with a focus on mitigating risks associated with infection control. This prospective quantitative study collected descriptive data using a specifically designed data collection tool. The survey data was then cleaned and analyzed with Microsoft Excel® and the latest version of the Statistical Package for Social Sciences. One thousand frontline paramedics employed by the Hamad Medical Corporation Ambulance Service (HMCAS) were invited via email to participate in the study. A total of 282 (28.2% of frontline paramedics) paramedics completed the online survey, of which 80.1% completed the mandatory HMCAS online infection control training program within the last year, and 17.0% between one to two years ago. Approximately 83% of the participants had completed an N95 mask fit test at HMCAS within the past five years, and 91.5% completed the hand hygiene training. The study found that 98.2% of the paramedics were knowledgeable about COVID-19 and its transmission, while 96.1% agreed that aerosol-generating procedures increased airborne transmission. The paramedics' attitudes were mainly positive toward the use of PPE to prevent the spread of the virus, which was synchronous with their practice. The sample population demonstrated a strong knowledge of COVID-19 and its transmission. Their overall positive attitudes and good infection control practices were demonstrative of efforts to mitigate risks associated with the spread of the virus.

Prehospital conversion of paroxysmal supraventricular tachycardia using the modified Valsalva maneuver: A case report.

The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.

Hospital Mortality Based on the Mode of Emergency Medical Services Transportation.

OBJECTIVE: We assessed the presentations and outcomes of trauma patients transported by helicopter emergency medical services (HEMS) versus ground emergency medical services (GEMS). METHODS: A retrospective analysis of trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Data were analyzed and categorized based on the mode of transportation. RESULTS: A total of 4,596 trauma patients were admitted to the hospital with a mean age of 31 ± 15 years. Injured patients were transported to the trauma center by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and falls (25%). Compared with GEMS, patients transported by HEMS were characterized by having a greater injury severity, more proportion of traumatic brain injury, on-scene intubation, and a 2.5-fold higher mortality. However, the impact of mode of transportation on the hospital mortality among severely injured patients has disappeared after adjusting for potential confounders. CONCLUSION: Patients transported by HEMS may have different characteristic features and outcomes when compared with GEMS. However, further work is needed to identify the subgroups of trauma patients who clearly benefit from the use of HEMS.

Comparison of two training programmes on paramedic-delivered CPR performance.

OBJECTIVE: To compare CPR performance in two groups of paramedics who received CPR training from two different CPR training programmes. METHODS: Conducted in June 2014 at the Hamad Medical Corporation Ambulance Service, the national ambulance service of the State of Qatar, the CPR performances of 149 new paramedic recruits were evaluated after they had received training from either a traditional CPR programme or a tailored CPR programme. Both programmes taught the same content but differed in the way in which this content was delivered to learners. Exclusive to the tailored programme was mandatory precourse work, continuous assessments, a locally developed CPR instructional video and pedagogical activities tailored to the background education and learner style preferences of paramedics. At the end of each respective training programme, a single examiner who was blinded to the type of training paramedics had received, rated them as competent or non-competent on basic life support skills, condition specific skills, specific overall skills and non-technical skills during a simulated out-of-hospital cardiac arrest (OHCA) assessment. RESULTS: Paramedics who received CPR training with the tailored programme were rated competent 70.9% of the time, compared with paramedics who attended the traditional programme and who achieved this rating 7.9% of the time (p<0.001). Specific improvements were seen in the time required to detect cardiac arrest, chest compression quality, and time to first monitored rhythm and delivered shock. CONCLUSIONS: In an OHCA scenario, CPR performance rated as competent was significantly higher when training was received using a tailored CPR programme.

What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: a manikin study.

INTRODUCTION: Prompt airway management following a CBRN incident is linked to improved patient survival. However, responding rescuers will have to wear CBRN-PPE and treat patients positioned on the floor which will adversely impact on intubation skill performance. METHODS: 48 final year paramedic students intubated manikin's positions in 4 different positions; on an ambulance trolley (60 cm of the floor), lying prone, kneeling and sitting. Each skill was performed twice once wearing CBRN-PPE and once in normal clothes. Intubating order was randomised. RESULTS: Intubation performance when wearing standard clothing was similar in all four positions but this was not the case when intubation was performed while wearing CBRN-PPE. CBRN-PPE had a negative impact on intubation performance regardless of the position of the intubator. Intubation on the trolley while wearing CBRN-PPE was completed in 100% of attempts within 60s compared with 79.2% for kneeling, 75% for sitting and 43.8% for laying. After 120 s nearly 20% of intubation attempts using the kneeling and sitting position and nearly 40% of attempts with the intubator lying on the floor were still not completed. Intubation on an ambulance trolley, while wearing CBRN-PPE, was always successful compared with sitting (88.8%), kneeling (81.2%) and laying (62.5%). CONCLUSION: This manikin-based study serves to reaffirm that CBRN-PPE has an adverse impact on intubation performance as well as identifying the negative impact of patient position on the performance of intubation within a CBRN environment. Elevating the patient off the floor, prior to intubation, could improve intubation success when wearing CBRN-PPE as well as potentially improving safety of the intubator. In the immediate phase of a CBRN incident, intubation attempts should be delayed until optimal intubating conditions are available or at least until the patient is removed from the floor. Use of and intermediate airway devices should be considered as a 'stop gap'.

Comparison of six different intubation aids for use while wearing CBRN-PPE: a manikin study.

INTRODUCTION: Respiratory failure following chemical exposure can be fatal and although supraglottic airway devices have been evaluated for use in the management of CBRN casualties' intubation remains the gold standard airway. METHODS: This is a randomised cross-over study involving 66 paramedic students utilising the following intubating aids bougie, stylet, McCoy laryngoscope, Airtraq™, intubating laryngeal mask (ILMA) and standard intubation. Each participant performed intubation with each device while wearing standard uniform and CBRN-PPE. RESULTS: While wearing standard uniform all intubation aids, except the Airtraq™, resulted in at least a 90% successful intubation rate by 60s. The use of CBRN-PPE led to significantly longer intubation times (ranging from 14.3 to 20.7s) depending on intubation aid used (p<0.001) with a 90% successful intubation rate not being achieved by all devices even by 150s. While wearing CBRN-PPE standard intubation and intubation with a stylet were the fastest whereas the ILMA was deemed the easiest to use with the highest success rate. A marked deterioration in the number of intubation attempts completed within 30s was also noted with standard intubation deteriorating by 82%, stylet deteriorating by 96% and the McCoy by 100%. The deterioration in intubation success at 60s was less marked. CONCLUSION: In this manikin-based study all intubation aids evaluated while wearing CBRN-PPE were adversely affected by the loss of dexterity associated with wearing Butyl gloves. Standard intubation and intubation utilising a stylet resulted in the fastest intubation times; whereas the ILMA offers the highest intubation success rate and was deemed to be the easiest intubating aid to use. An important consideration with regards future research is the impact of a learning curve with regards to different intubation aids and whether preassembling all the intubation aids prior to the intubation attempt may improve intubation speed. The impact of intubator familiarity with regards to individual intubation aids is also an important consideration but established intubation aids like the Bougie are more difficult to use when dexterity is reduced due to CBRN-PPE.