Tranexamic acid versus oxytocin for primary postpartum Haemorrhage in the out-of-hospital setting: A systematic review with implications for rural practice.

INTRODUCTION: Primary postpartum haemorrhage causes approximately 25% of global maternal deaths and accounts for significant maternal morbidity. While high certainty evidence demonstrates that tranexamic acid reduces comparative blood loss in postpartum haemorrhage in hospital settings, limited data exist on the specific pharmacological management of this condition in out-of-hospital settings, and the implications for rural communities. OBJECTIVE: To determine the efficacy of oxytocin compared to tranexamic acid in women suffering postpartum haemorrhage in the out-of-hospital environment. DESIGN: A systematic review comparing evidence containing patients with postpartum haemorrhage in the out-of-hospital and/or rural setting, in which oxytocin/tranexamic acid were used. Outcome measures were comparative blood loss/haemorrhagic shock, the need for further interventions and maternal/neonatal morbidity/mortality. FINDINGS: No randomised control trials have been conducted in an out-of-hospital environment in relation to oxytocin/tranexamic acid. In this setting, there is no difference in outcome measures when using oxytocin compared to no intervention, or oxytocin compared to standard care. Data are lacking on the effect of tranexamic acid on the same outcome measures. DISCUSSION: Rural and out-of-hospital management of postpartum haemorrhage is limited by resource availability and practitioner availability, capacity and experience. In-hospital evidence may lack transferability, therefore direct evidence on the efficacy of pharmacological management in these contexts is scant and requires redress. CONCLUSION: There is no difference in blood loss, neonatal or maternal mortality or morbidity, or need for further interventions, when using oxytocin or TXA compared to no intervention, or compared to standard care, for PPH. Further studies are needed on the efficacy of these drugs, and alternate or co-drug therapies, for PPH in the out-of-hospital environment and rural clinical practice.

Emergency Medical Service responses as latent social capital toward Deliberate Self-Harm, Suicidality and Suicide.

Escalation in Deliberate Self-Harm (DSH) is indicative of a rise in poor mental health and/or a failure of social and health services. The phenomenon of DSH exacerbates mental illness sequela, while being an essential indicator of suicide risk. Globally, about 800 000 people commit suicide yearly, averaging almost one suicide every 40 s. Based on a Retrospective Cross-Sectional Study, the aim sought to establish the scope of the DSH, suicidality and suicide case-load from a Western Cape Emergency Medical Services (EMS) prehospital perspective. A census of 3 years of EMS Incident Management Records (IMR) from a large rural district with seven local municipalities was undertaken using a novel data collection instrument. The 2976 (N) mental health-related incidents that met the inclusion criteria (from 413 712 cases) suggest a presentation rate of 7 per 1000 EMS calls. Sixty percent (n = 1776) were regarded to have deliberately self-harmed, attempted suicide or committed suicide. Overdose/deliberate self-poisoning accounted for 52% (n = 1550) of all the DSH caseload of the study. Attempted suicide accounted for 2.7% (n = 83) and Suicide for 3.4% (n = 102) of the suicidality case-load from the study, respectively. Suicide averaged 2.8. suicides per month in the Garden Route District over the 3-year period. Men were five times more likely to commit suicide than women, commonly using strangulation, while women mostly ingested household detergents and poison, and overdosed on chronic medication. Understandably, the EMS needs to assess its own capability to respond, treat, and transport health-care users with DSH and suicidality. This study demonstrates the EMS 'everyday' exposure to DSH, suicidality and suicide case-load. It represents a critical first step in the problem-space definition upon which a determination of the need for EMS responses can be based, to interrupt suicidality by removing methods of harm and strengthening the mental health economy through social capital investment.

Screening tools for sepsis identification in paramedicine and other emergency contexts: a rapid systematic review.

BACKGROUND: Sepsis is a life-threatening condition that contributes significantly to protracted hospitalisations globally. The unique positioning of paramedics and other emergency care cadres in emergency contexts enable the prospect of early identification and management of sepsis, however, a standardised screening tool still does not exist in the emergency setting. The objective of this review was to identify and recommend the most clinically ideal sepsis screening tool for emergency contexts such as emergency departments and out-of-hospital emergency contexts. METHODS: A rapid review of five databases (Medline, Embase, the Cochrane Library, CINAHL, and ProQuest Central) was undertaken, with searches performed on February 10, 2022. Covidence software was used by two authors for initial screening, and full text review was undertaken independently by each reviewer, with conflicts resolved by consensus-finding and a mediator. Systematic reviews, meta-analyses, randomised controlled trials, and prospective observational studies were eligible for inclusion. Data extraction used an a priori template and focused on sensitivity and specificity, with ROBINS-I and ROBIS bias assessment tools employed to assess risk of bias in included studies. Study details and key findings were summarised in tables. The a priori review protocol was registered on Open Science Framework ( https://doi.org/10.17605/OSF.IO/3XQ5T ). RESULTS: The literature search identified 362 results. After review, 18 studies met the inclusion criteria and were included for analysis. There were five systematic reviews, with three including meta-analysis, eleven prospective observational studies, one randomised controlled trial, and one validation study. CONCLUSIONS: The review recognised that a paucity of evidence exists surrounding standardised sepsis screening tools in the emergency context. The use of a sepsis screening tool in the emergency environment may be prudent, however there is currently insufficient evidence to recommend a single screening tool for this context. A combination of the qSOFA and SIRS may be employed to avoid 'practice paralysis' in the interim. The authors acknowledge the inherent potential for publication and selection bias within the review due to the inclusion criteria.

Down with falls! Paramedicine scope regarding falls amongst older adults in rural and remote communities: A scoping review.

INTRODUCTION: Australian rural and remote areas are faced with the double burden of an ageing population paired with inequitable access to health resources due to the paradigm of major city centred health care. This complicates fall management within this space. Paramedics are a registered health profession, which provides mobile, equitable health care. However, this resource is not being effectively utilised in rural and remote areas where primary care access barriers may cause patient needs to go unmet. OBJECTIVE: To describe the existing literature and describe the international scope of current paramedicine practice in the out-of-hospital management of falls amongst older adults in rural and remote settings. DESIGN: Joanna Briggs Institute scoping review methodology was employed. CINAHL (EBSCO), MEDLINE (Ovid), EMBASE (Ovid), SCOPUS (Elsevier), Google Scholar and These Global were searched and Australian, New Zealand and the UK ambulance service guidelines were sought. FINDINGS: Two records met inclusion criteria. Currently, rural and remote paramedic fall management involves preventative health promotion through patient education, population-based screening and referrals. DISCUSSION: The use of paramedics to screen at-risk populations and refer is vital, as many rural adults had screened positive to fall risks and other unmet needs. There is poor recollection of physically printed education material and low acceptance of further in-home assessments following paramedic departure. CONCLUSION: This scoping review has highlighted a significant knowledge gap on this topic. Further research is needed to effectively utilise paramedicine within areas where access to primary care is not possible to achieve downstream, risk reducing care in the home.

A critical ethnographic study of discriminatory social practice during clinical practice in emergency medical care.

BACKGROUND: Post-apartheid, South Africa adopted an inclusive education system that was intended to be free of unfair discrimination. This qualitative study examines the experiences and perceptions of racial discrimination between Emergency Medical Care (EMC) students, clinical mentors, and patients within an Emergency Medical Service (EMS) during clinical practice. Understanding the nature of such discrimination is critical for redress. METHODS: Within the conceptual framework of Critical Race Theory, critical ethnographic methodology explored how discriminatory social practice manifests during clinical practice. Semi-structured interviews enabled thematic analysis. We purposively sampled 13 undergraduate EMC students and 5 Emergency Care (EC) providers. RESULTS: EMC student participants reported experiences of racial and gender discrimination during work-integrated learning (WIL) as they were treated differently on the basis of race and gender. Language was used as an intentional barrier to isolate students from the patients during WIL because EC providers would intentionally speak in a language not understood by the student and failed to translate vital medical information about the case. This conduct prevented some students from engaging in clinical decision-making. CONCLUSIONS: Unfair discrimination within the pre-hospital setting have an impact on the learning opportunities of EMC students. Such practice violates basic human rights and has the potential to negatively affect the clinical management of patients, thus it has the potential to violate patient's rights. This study confirms the existence of discriminatory practices during WIL which is usually unreported. The lack of a structured approach to redress the discrimination causes a lack of inclusivity and unequal access to clinical education in a public clinical platform.