Downloaded from http://emj.bmj.com/ on July 1, 2015 - Published by group.bmj.com
PostScript
LETTERS
Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Extended skills for critical care paramedics (CCPs) in UK based systems have been extensively evaluated in recent times.1 2 Autonomous administration of ketamine for analgesia and conscious sedation has been identified as a core skill for CCPs but concerns have been raised about the level of exposure required to maintain competence.3 To date there have been no reports in the literature detailing the experience of ketamine administration by CCPs in the UK. Midlands Air Ambulance operates a fleet of three helicopters within the newly established West Midlands Major Trauma Network. Two platforms are CCP-led with the remaining aircraft employing physician-CCP teams as part of the regional Medical Emergency Response Incident Team. A land based platform also operates outside of daylight hours staffed by a physician-CCP team. CCPs within the MAA/Medical Emergency Response Incident Team structure rotate across the different platforms on a regular basis. A Patient Group Directive (PGD) was launched in September 2012 to support the autonomous administration of ketamine for analgesia and conscious sedation by CCPs within the West Midlands Major Trauma Network. All administrations of ketamine within the service are subject to detailed peer review as part of a wellestablished clinical governance structure. During the 1st year following the launch of the PGD ketamine was administered by 10 different CCP-led teams a total of 29 times. While there were no violations of the PGD and no recorded adverse events following drug administration, less than 4% of all scene attendances by CCP-led teams during this period required ketamine. A further 100 cases of ketamine administration by physician-CCP teams occurred during the same period. Our experience in a prehospital system with high levels of tasking to cases of traumatic injury is that CCPs can autonomously administer ketamine safely, in accordance with a PGD, but that it is rarely required. The structure of our
service is reasonably unique in UK practice allowing CCPs to work across a variety of different platforms independently and as part of physician-CCP teams. Without the added experience afforded by operations on physician-CCP platforms in our system, the level of exposure that CCPs receive may be insufficient to maintain standards of competence in the administration of ketamine. Further collaborative research between UK based services in which CCPs administer ketamine autonomously is required to accurately assess levels of exposure and identify suitable frameworks to support skill retention. Carl McQueen,1 Nicholas Crombie,2 Stef Cormack,3 Steve Wheaton4 1 Warwick Medical School—Clinical Trials Unit, University of Warwick Coventry, Coventry, UK 2 Training Programme Director PHEM—West Midlands Deanery, Birmingham, UK 3 Midlands Air Ambulance—HEMS paramedic, Birmingham, West Midlands, UK 4 West Midlands Ambulance Service NHS Foundation Trust, Birmingham, West Midlands, UK
Correspondence to Dr Carl McQueen, Warwick Medical School—Clinical Trials Unit, University of Warwick Coventry, Coventry CV4 7AL, UK; [email protected] Contributors SC and CMcQ analysed the data and prepared the manuscript. SW and NC reviewed the manuscript prior to submission. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite McQueen C, Crombie N, Cormack S, et al. Emerg Med J 2014;31:1029. Accepted 21 May 2014 Published Online First 12 June 2014
▸ http://dx.doi.org/10.1136/emermed-2013-202721 ▸ http://dx.doi.org/10.1136/emermed-2013-202895 Emerg Med J 2014;31:1029. doi:10.1136/emermed-2014-204022
REFERENCES 1
2
3
von Vopelius-Feldt J, Benger J. Critical care paramedics in England: a national survey of ambulance services. Eur J Emerg Med 2013. Published Online First doi:10.1097/MEJ.0000000000000085 von Vopelius-Feldt J, Wood J, Benger J. Critical care paramedics: where is the evidence? a systematic review. Eur J Emerg Med 2014;31:1016–24. von Vopelius-Feldt J, Wood J, Benger J. Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics
Emerg Med J December 2014 Vol 31 No 12
and prehospital physicians. Eur J Emerg Med 2014;31:1009–13.
ProCESS trial recalls Sir William Osler’s advice Dear Editor, The ProCESS study1 brings to mind the observation by Sir William Osler that (to paraphrase) one should use a new therapy as often as possible while it still works. I have used Swan Ganz catheters, aminophylline, bretyllium, MAST trousers, nasal intubation, ipecac and neonatal suction bulbs while they worked and abandoned them when they no longer worked. I told parents to put children on their stomachs so they wouldn’t aspirate, and later to put them on their backs so they wouldn’t suffocate. I breathed for patients during basic cardiopulmonary resuscitation (CPR) and now wouldn’t because they do better without respiratory support. In asthma, I have used magnesium because it worked. I stopped using it because it no longer worked, and now occasionally use it because it now sometimes works. I still use sorbitol even though it never has worked because too many people believe it works. I smile benignly at all those who regard orthostatic vital signs as highly useful and, with apologies to Robert Knopp who demonstrated their frequent misuse,2 say nothing because there are too many ‘true believers’. I complied with the 4 h pneumonia guidelines while they worked. I am complying with the sepsis guidelines while they still work. The biggest improvement in patient care in the ED in my 32 years on the University of California San Francisco (UCSF) emergency medicine faculty has been the low-tech addition of the Discharge Coordinator in our ED to help patients arrange follow-up. The Lancet chose the development of the oral rehydrating solution for children as the single most important medical therapy of the 20 century with an estimated 40 million lives saved.3 In medicine, scepticism and humility will always work. Charles Edward Murphy Correspondence to Dr Charles Edward Murphy, Department of Emergency, UCSF, 505 Parnassus, San Francisco, CA 94143, USA; [email protected], [email protected] Competing interests None.
1029
Downloaded from http://emj.bmj.com/ on July 1, 2015 - Published by group.bmj.com
Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Carl McQueen, Nicholas Crombie, Stef Cormack and Steve Wheaton Emerg Med J 2014 31: 1029 originally published online June 12, 2014
doi: 10.1136/emermed-2014-204022 Updated information and services can be found at: http://emj.bmj.com/content/31/12/1029.2
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript
LETTERS
Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Extended skills for critical care paramedics (CCPs) in UK based systems have been extensively evaluated in recent times.1 2 Autonomous administration of ketamine for analgesia and conscious sedation has been identified as a core skill for CCPs but concerns have been raised about the level of exposure required to maintain competence.3 To date there have been no reports in the literature detailing the experience of ketamine administration by CCPs in the UK. Midlands Air Ambulance operates a fleet of three helicopters within the newly established West Midlands Major Trauma Network. Two platforms are CCP-led with the remaining aircraft employing physician-CCP teams as part of the regional Medical Emergency Response Incident Team. A land based platform also operates outside of daylight hours staffed by a physician-CCP team. CCPs within the MAA/Medical Emergency Response Incident Team structure rotate across the different platforms on a regular basis. A Patient Group Directive (PGD) was launched in September 2012 to support the autonomous administration of ketamine for analgesia and conscious sedation by CCPs within the West Midlands Major Trauma Network. All administrations of ketamine within the service are subject to detailed peer review as part of a wellestablished clinical governance structure. During the 1st year following the launch of the PGD ketamine was administered by 10 different CCP-led teams a total of 29 times. While there were no violations of the PGD and no recorded adverse events following drug administration, less than 4% of all scene attendances by CCP-led teams during this period required ketamine. A further 100 cases of ketamine administration by physician-CCP teams occurred during the same period. Our experience in a prehospital system with high levels of tasking to cases of traumatic injury is that CCPs can autonomously administer ketamine safely, in accordance with a PGD, but that it is rarely required. The structure of our
service is reasonably unique in UK practice allowing CCPs to work across a variety of different platforms independently and as part of physician-CCP teams. Without the added experience afforded by operations on physician-CCP platforms in our system, the level of exposure that CCPs receive may be insufficient to maintain standards of competence in the administration of ketamine. Further collaborative research between UK based services in which CCPs administer ketamine autonomously is required to accurately assess levels of exposure and identify suitable frameworks to support skill retention. Carl McQueen,1 Nicholas Crombie,2 Stef Cormack,3 Steve Wheaton4 1 Warwick Medical School—Clinical Trials Unit, University of Warwick Coventry, Coventry, UK 2 Training Programme Director PHEM—West Midlands Deanery, Birmingham, UK 3 Midlands Air Ambulance—HEMS paramedic, Birmingham, West Midlands, UK 4 West Midlands Ambulance Service NHS Foundation Trust, Birmingham, West Midlands, UK
Correspondence to Dr Carl McQueen, Warwick Medical School—Clinical Trials Unit, University of Warwick Coventry, Coventry CV4 7AL, UK; [email protected] Contributors SC and CMcQ analysed the data and prepared the manuscript. SW and NC reviewed the manuscript prior to submission. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite McQueen C, Crombie N, Cormack S, et al. Emerg Med J 2014;31:1029. Accepted 21 May 2014 Published Online First 12 June 2014
▸ http://dx.doi.org/10.1136/emermed-2013-202721 ▸ http://dx.doi.org/10.1136/emermed-2013-202895 Emerg Med J 2014;31:1029. doi:10.1136/emermed-2014-204022
REFERENCES 1
2
3
von Vopelius-Feldt J, Benger J. Critical care paramedics in England: a national survey of ambulance services. Eur J Emerg Med 2013. Published Online First doi:10.1097/MEJ.0000000000000085 von Vopelius-Feldt J, Wood J, Benger J. Critical care paramedics: where is the evidence? a systematic review. Eur J Emerg Med 2014;31:1016–24. von Vopelius-Feldt J, Wood J, Benger J. Who does what in prehospital critical care? An analysis of competencies of paramedics, critical care paramedics
Emerg Med J December 2014 Vol 31 No 12
and prehospital physicians. Eur J Emerg Med 2014;31:1009–13.
ProCESS trial recalls Sir William Osler’s advice Dear Editor, The ProCESS study1 brings to mind the observation by Sir William Osler that (to paraphrase) one should use a new therapy as often as possible while it still works. I have used Swan Ganz catheters, aminophylline, bretyllium, MAST trousers, nasal intubation, ipecac and neonatal suction bulbs while they worked and abandoned them when they no longer worked. I told parents to put children on their stomachs so they wouldn’t aspirate, and later to put them on their backs so they wouldn’t suffocate. I breathed for patients during basic cardiopulmonary resuscitation (CPR) and now wouldn’t because they do better without respiratory support. In asthma, I have used magnesium because it worked. I stopped using it because it no longer worked, and now occasionally use it because it now sometimes works. I still use sorbitol even though it never has worked because too many people believe it works. I smile benignly at all those who regard orthostatic vital signs as highly useful and, with apologies to Robert Knopp who demonstrated their frequent misuse,2 say nothing because there are too many ‘true believers’. I complied with the 4 h pneumonia guidelines while they worked. I am complying with the sepsis guidelines while they still work. The biggest improvement in patient care in the ED in my 32 years on the University of California San Francisco (UCSF) emergency medicine faculty has been the low-tech addition of the Discharge Coordinator in our ED to help patients arrange follow-up. The Lancet chose the development of the oral rehydrating solution for children as the single most important medical therapy of the 20 century with an estimated 40 million lives saved.3 In medicine, scepticism and humility will always work. Charles Edward Murphy Correspondence to Dr Charles Edward Murphy, Department of Emergency, UCSF, 505 Parnassus, San Francisco, CA 94143, USA; [email protected], [email protected] Competing interests None.
1029
Downloaded from http://emj.bmj.com/ on July 1, 2015 - Published by group.bmj.com
Prehospital use of ketamine for analgesia and procedural sedation by critical care paramedics in the UK: a note of caution? Carl McQueen, Nicholas Crombie, Stef Cormack and Steve Wheaton Emerg Med J 2014 31: 1029 originally published online June 12, 2014
doi: 10.1136/emermed-2014-204022 Updated information and services can be found at: http://emj.bmj.com/content/31/12/1029.2
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
