Background Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. Methods A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. Results Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. Conclusion Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.

IntroductionThe incidence of myocardial infarction is rising in Sub-Saharan Africa. In order to reduce mortality, timely reperfusion by percutaneous coronary intervention (PCI) or thrombolysis followed by PCI is required. South Africa has historically been characterised by inequities in healthcare access based on geographic and socioeconomic status. We aimed to determine the coverage of PCI-facilities in South Africa and relate this to access based on population and socio-economic status.MethodsThis cross-sectional study obtained data from literature, directories, organisational databases and correspondence with Departments of Health and hospital groups. Data was analysed descriptively while Spearman’s Rho sought correlations between PCI-facility resources, population, poverty and medical insurance status.ResultsSouth Africa has 62 PCI-facilities. Gauteng has the most PCI-facilities (n = 28) while the Northern Cape has none. Most PCI-facilities (n = 48; 77%) are owned by the private sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r = 0.01; p = 0.17) and insurance status of individuals (r = −0.4; p = 0.27).ConclusionFor many South Africans, access to PCI-facilities and primary PCI is still impossible given their socio-economic status or geographical locale. Research is needed to determine the specific PCI-facility needs based on geographic and epidemiological aspects, and to develop a contextualised solution for South Africans suffering a myocardial infarction.

This sample of Johannesburg-based paramedics had a greater prevalence of burnout compared with their international counterparts. Further research is needed to identify the true extent of this problem.

Background Motor vehicle collisions account for 1.3 million deaths and 50 million serious injuries worldwide each year. However, the majority of people involved in such incidents are uninjured or have injuries which do not prevent them exiting the vehicle. Self-extrication is the process by which a casualty is instructed to leave their vehicle and completes this with minimal or no assistance. Self-extrication may offer a number of patient and system-wide benefits. The efficacy of routine cervical collar application for this group is unclear and previous studies have demonstrated inconsistent results. It is unknown whether scripted instructions given to casualties on how to exit the vehicle would offer any additional utility. The aim of this study was to evaluate the effect of cervical collars and instructions on spinal movements during self-extrication from a vehicle, using novel motion tracking technology. Methods Biomechanical data on extrications were collected using Inertial Measurement Units on 10 healthy volunteers. The different extrication types examined were: i) No instructions and no cervical collar, ii) No instructions, with cervical collar, iii) With instructions and no collar, and iv) With instructions and with collar. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement, mean, standard deviation and confidence intervals are reported for each extrication type. Results Data were recorded for 392 extrications. The smallest cervical spine movements were recorded when a collar was applied and no instructions were given: mean 6.9 mm AP and 4.4 mm LAT. This also produced the smallest movements at the lumbar spine with a mean of 122 mm AP and 72.5 mm LAT. The largest overall movements were seen in the cervical spine AP when no instructions and no collar were used (28.3 mm). For cervical spine lateral movements, no collar but with instructions produced the greatest movement (18.5 mm). For the lumbar spine, the greatest movement was recorded when instructions were given and no collar was used (153.5 mm AP, 101.1 mm LAT). Conclusions Across all participants, the most frequently occurring extrication method associated with the least movement was no instructions, with a cervical collar in situ.

ObjectivesWhile prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa.DesignObservational study with a retrospective descriptive design.SettingCape Town metropole, Western Cape province, South Africa.ParticipantsAll patients with OHCA for the period 1 January 2018–31 December 2018 were extracted from public and private emergency medical services (EMS) and described.Outcome measuresDescription of patients with OHCA in terms of demographics, treatment and short-term outcome.ResultsA total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene.ConclusionTo our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.

Introduction: Emergency Medical Services (EMS) are designed to respond to and manage patients experiencing life-threatening emergencies; however, not all emergency calls are necessarily emergent and of high acuity. Emergency responses to low-acuity patients affect not only EMS, but other areas of the health care system. However, definitions of low-acuity calls are vague and subjective; therefore, it was necessary to provide a clear description of the low-acuity patient in EMS. Aim: The goal of this study was to develop descriptors for “low-acuity EMS patients” through expert consensus within the EMS environment. Methods: A Modified Delphi survey was used to develop call-out categories and descriptors of low acuity through expert opinion of practitioners within EMS. Purposive, snowball sampling was used to recruit 60 participants, of which 29 completed all three rounds. An online survey tool was used and offered both binary and free-text options to participants. Consensus of 75% was accepted on the binary options while free text offered further proposals for consideration during the survey. Results: On completion of round two, consensus was obtained on 45% (70/155) of the descriptors, and a further 30% (46/155) consensus was obtained in round three. Experts felt that respiratory distress, unconsciousness, chest pain, and severe hemorrhage cannot be considered low acuity. For other emergency response categories, specific descriptors were offered to denote a case as low acuity. Conclusion: Descriptors of low acuity in EMS are provided in both medical and trauma cases. These descriptors may not only assist in the reduction of unnecessary response and transport of patients, but also assist in identifying the most appropriate response of EMS resources to call-outs. Further development and validation are required of these descriptors in order to improve accuracy and effectiveness within the EMS dispatch environment.

BackgroundGiven the frequency of suicidal patients making attempts prior to a completed suicide, emergency access to mental health care services could lead to significant reduction in morbidity and mortality for these patients.AimTo describe the attitudes of prehospital providers and describe transport decision-making around the management of patients with a suicide attempt.SettingCape Town Metropole.MethodsA cross-sectional, vignette-based survey was used to collect data related to training and knowledge of the Mental Health Care Act, prehospital transport decision-making and patient management.ResultsPatients with less dramatic suicidal history were more likely to be discharged on scene. Few respondents reported the use of formal suicide evaluation tools to aid their decision. Respondents displayed negative attitudes towards suicidal patients. Some respondents reported returning to find a suicidal patient dead, while others reported patient attempts at suicide when in their care. Eighty per cent of respondents had no training in the management of suicidal patients, while only 7.0% had specific training in the Mental Health Care Act.ConclusionA critical lack in the knowledge, training and implementation of the Mental Health Care Act exists amongst prehospital providers within the Western Cape. A further concern is the negative feelings towards suicidal patients and the lack of commitment to transporting patients to definitive care. It is essential to urgently develop training programmes to ensure that prehospital providers are better equipped to deal with suicidal patients.