Paramedics' perceptions of their role in palliative care : analysis of focus group transcripts

Paramedics play an important role in out-of-hospital health care. They provide unscheduled care, assisting both patients with minor injuries and those experiencing life-threatening emergencies. Increasingly, paramedics are called on to manage chronic and complex health needs, including symptom relief for patients at the end of life. However, paramedics may not be well prepared to offer palliative care, as practice guidelines and education tend to focus on the management of acute medical emergencies and major trauma. Emergency medical services that employ paramedics rarely have practice guidelines or protocols that deal specifically with palliative care.

Pilot evaluation of an adolescent risk and injury prevention programme incorporating curriculum and school connectedness components

School connectedness is an important protective factor for adolescent risk-taking behaviour. This study examined a pilot version of the Skills for Preventing Injury in Youth (SPIY) programme, combining teacher professional development for increasing school connectedness (connectedness component) with a risk and injury prevention curriculum for early adolescents (curriculum component). A process evaluation was conducted on the connectedness component, involving assessments of programme reach, participant receptiveness and initial use, and a preliminary impact evaluation was conducted on the combined connectedness and curriculum programme. The connectedness component was well received by teacher participants, who saw benefits for both themselves and their students. Classroom observation also showed that teachers who received professional development made use of the programme strategies. Grade 8 students who participated in the SPIY programme were less likely to report violent behaviour at six-month follow-up than were control students, and trends also suggested reduced transport injuries. The results of this research support the use of the combined SPIY connectedness and curriculum components in a large-scale effectiveness trial to assess the impact of the programme on students’ connectedness, risk-taking and associated injuries.

A Review of potential countermeasures for motorcycle and scooter safety practices across APEC for project : Compendium of Best Practices on Motorcycle and Scooter Safety

Motorcyclists and scooter riders are among the most vulnerable road users, across APEC. This report assesses the potential road safety measures that can be used to address these issues and selects measures that could feasibly and effectively be implemented across the Asia Pacific Economic Communities (APEC). The scope of the report is confined to on-road motorcycle riding. While the numbers of injuries resulting from off-road riding (including as part of farm work) are likely to be substantial based on data from other states, many of the issues and measures to reduce trauma in off-road riding would be quite different. A previous report described important motorcycle and scooter safety issues across APEC economies and any current barriers that might exist in implementing potentially effective countermeasures.

Comparing child product safety concerns with injury incidents : does the evidence support the response?

Background Efficient effective child product safety (PS) responses require data on hazards, injury severity and injury probability. PS responses in Australia largely rely on reports from manufacturers/retailers, other jurisdictions/regulators, or consumers. The extent to which reactive responses reflect actual child injury priorities is unknown. Aims/Objectives/Purpose This research compared PS issues for children identified using data compiled from PS regulatory data and data compiled from health data sources in Queensland, Australia. Methods PS regulatory documents describing issues affecting children in Queensland in 2008–2009 were compiled and analysed to identify frequent products and hazards. Three health data sources (ED, injury surveillance and hospital data) were analysed to identify frequent products and hazards. Results/Outcomes Projectile toys/squeeze toys were the priority products for PS regulators with these toys having the potential to release small parts presenting choking hazards. However, across all health datasets, falls were the most common mechanism of injury, and several of the products identified were not subject to a PS system response. While some incidents may not require a response, a manual review of injury description text identified child poisonings and burns as common mechanisms of injuries in the health data where there was substantial documentation of product-involvement, yet only 10% of PS system responses focused on these two mechanisms combined. Significance/contribution to the field Regulatory data focused on products that fail compliance checks with ‘potential’ to cause harm, and health data identified actual harm, resulting in different prioritisation of products/mechanisms. Work is needed to better integrate health data into PS responses in Australia.

Challenges for rural and remote road safety

The growing national and international awareness of the increased representation of serious injuries and fatalities in rural and remote areas is the focus of this paper. Australia was one of the earliest countries to try to address this issue with a targeted national action plan in 1996. This was an important document but the most recent national plan fails to dedicate attention to developing countermeasures for the particular problems of improving road safety in these regions. The findings of a major program of research in Northern Queensland are discussed to stimulate interest and research into potential countermeasures. Specifically, the need to monitor clusters of crashes as a focus for intervention and local ownership is advocated. Taking action towards a national reduction of speed limits on rural roads and investment in proactive research based trials of drink driving countermeasures such as courtesy buses is strongly advocated.

Safety culture in supply chains : 'Customer is king'

Despite the presence of many regulations governing the operation of heavy vehicles and supply chains in Australia, the truck driving sector continues to have the highest incidence of fatal injuries compared to all other industries. The working environment has been the focus of attention by safety researchers during the past few decades, with particular consideration been given to the concept ‘safety culture’ and how to maintain, modify and advance responses to occupational risk. One important aspect of the heavy industry which sets it apart is the existence of cultural or sub-cultural influences at an industry wide and occupation-specific level rather than organisational level. This paper reports on the findings of stakeholder’s perceptions of the influences of power and control, and culture on industry safety. In-depth structured interviews were conducted during 2011 with Australian industry stakeholders (n=31). The questioning surrounded decision-making processes with regards to identifying risks, self-monitoring and reducing risky activities; as well as how power-affected relationships may influence the operational performance of supply chains and impacts on driver safety. One of the most significant findings from these interviews relates to the notion of power. The perception that the ‘Customer is King’ was widely viewed, with the majority of stakeholders believing that there exists a ‘master slave mentality’ in the industry. There appears to be great frustration in the industry as to the apparent immunity of customers (particularly retail supply chains) to their responsibilities. There was also a strong perception that the customer holds the balance of power by covertly employing remuneration-related incentives and pressures. Smaller trucking companies are perceived as being more vulnerable to the pressure of customer expectations.

A new model to study healing of a complex femur fracture with concurrent soft tissue injury in sheep

High energy bone fractures resulting from impact trauma are often accompanied by subcutaneous soft tissue injuries, even if the skin remains intact. There is evidence that such closed soft tissue injuries affect the healing of bone fractures, and vice versa. Despite this knowledge, most impact trauma studies in animals have focussed on bone fractures or soft tissue trauma in isolation. However, given the simultaneous impact on both tissues a better understanding of the interaction between these two injuries is necessary to optimise clinical treatment. The aim of this study was therefore to develop a new experimental model and characterise, for the first time, the healing of a complex fracture with concurrent closed soft tissue trauma in sheep. A pendulum impact device was designed to deliver a defined and standardised impact to the distal thigh of sheep, causing a reproducible contusion injury to the subcutaneous soft tissues. In a subsequent procedure, a reproducible femoral butterfly fracture (AO C3-type) was created at the sheep’s femur, which was initially stabilised for 5 days by an external fixator construct to allow for soft tissue swelling to recede, and ultimately in a bridging construct using locking plates. The combined injuries were applied to twelve sheep and the healing observed for four or eight weeks (six animals per group) until sacrifice. The pendulum impact led to a moderate to severe circumferential soft tissue injury with significant bruising, haematomas and partial muscle disruptions. Posttraumatic measurements showed elevated intra-compartmental pressure and circulatory tissue breakdown markers, with recovery to normal, pre-injury values within four days. Clinically, no neurovascular deficiencies were observed. Bi-weekly radiological analysis of the healing fractures showed progressive callus healing over time, with the average number of callus bridges increasing from 0.4 at two weeks to 4.2 at eight weeks. Biomechanical testing after sacrifice showed increasing torsional stiffness between four and eight weeks healing time from 10% to 100%, and increasing ultimate torsional strength from 10% to 64% (relative to the contralateral control limb). Our results demonstrate the robust healing of a complex femur fracture in the presence of a severe soft tissue contusion injury in sheep and demonstrate the establishment of a clinically relevant experimental model, for research aimed at improving the treatment of bone fractures accompanied by closed soft tissue injuries.

The effects of cold air (-110°C) and water (8°C) cryotherapy on knee skin temperature

Exposure to cold air, whole body cryotherapy (WBC), is a novel treatment employed by athletes. In WBC individuals dressed in minimal clothing are exposed to a temperature below -100°C for 2-4 min. The use of WBC has been advocated as a treatment for various knee injuries. PURPOSE: To compare the effects of two modalities of cryotherapy, -110°C WBC and 8°C cold water immersion (CWI) on knee skin temperature (Tsk). METHODS: With ethical approval and written informed consent 10 healthy active male participants (26.5±4.9 yr, 183.5±6.0 cm, 90.7±19.9 kg, 26.8±5.0 kg/m2, 23.0±9.3% body fat (measured by DXA), 7.6 ± 2.0 mm patellar skin fold; mean±SD) were exposed to 4 min of CWI and WBC. The treatment order was randomised in a controlled crossover design, with a minimum of 7 days between treatments. During WBC participants stood in a chamber (-60±3°C) for 20 s before entering the main chamber (-110°C±3°C) where they remained for 3 min and 40 s. For CWI participants were seated in a tank filled with cold water (8±0.3°C) and immersed to the level of the sternum for 4 min. Right knee Tsk was assessed via non-contact, infrared thermal imaging. A quadrilateral region of interest was created using inert markers placed 5 cm above and below the most superior and inferior aspect of the patella. Tsk within this quadrilateral was recorded pre, immediately post and every 10 min thereafter for 60 min. Tsk changes were examined using a two-way (treatment x time) repeated measures analyses of variance. In addition, a paired sample t-test was used to compare baseline Tsk before both treatments. RESULTS: Knee Tsk was similar before treatment (WBC: 29.9±0.7°C, CWI: 29.6±0.9°C, p>0.05). There was a significant main effect for treatment (p<0.05) and time (p<0.001). Compared to baseline, Tsk was significantly reduced (p<0.05) immediately post and at 10, 20, 30, 40, 50 and 60 min after both cooling modalities. Knee Tsk was lower (p<0.05) immediately after WBC (19.0±0.9°C) compared to CWI (20.5±0.6°C). However, from 10 to 60 min post, knee Tsk was lower (p<0.05) following the CWI treatment. CONCLUSION: WBC elicited a greater decrease in knee Tsk compared to CWI immediately after treatment. However, both modalities display different recovery patterns and Tsk after CWI was significantly lower than WBC at 10, 20, 30, 40, 50 and 60 min after treatment.

Changes in Knee Biomechanics After a Hip-Abductor Strengthening Protocol for Runners With Patellofemoral Pain Syndrome

Context: Very few authors have investigated the relationship between hip-abductor muscle strength and frontal-plane knee mechanics during running. Objective: To investigate this relationship using a 3-week hip-abductor muscle-strengthening program to identify changes in strength, pain, and biomechanics in runners with patellofemoral pain syndrome (PFPS). Design: Cohort study. Setting: University-based clinical research laboratory. Patients or Other Participants: Fifteen individuals (5 men, 10 women) with PFPS and 10 individuals without PFPS (4 men, 6 women) participated. Intervention(s): The patients with PFPS completed a 3-week hip-abductor strengthening protocol; control participants did not. Main Outcome Measure(s): The dependent variables of interest were maximal isometric hip-abductor muscle strength, 2-dimensional peak knee genu valgum angle, and stride-to-stride knee-joint variability. All measures were recorded at baseline and 3 weeks later. Between-groups differences were compared using repeated-measures analyses of variance. Results: At baseline, the PFPS group exhibited reduced strength, no difference in peak genu valgum angle, and increased stride-to-stride knee-joint variability compared with the control group. After the 3-week protocol, the PFPS group demonstrated increased strength, less pain, no change in peak genu valgum angle, and reduced stride-to-stride knee-joint variability compared with baseline. Conclusions: A 3-week hip-abductor muscle-strengthening protocol was effective in increasing muscle strength and decreasing pain and stride-to-stride knee-joint variability in individuals with PFPS. However, concomitant changes in peak knee genu valgum angle were not observed.

Normative and critical criteria for iliotibial band and iliopsoas muscle flexibility

Context: The Ober and Thomas tests are subjective and involve a "negative" or "positive" assessment, making them difficult to apply within the paradigm of evidence-based medicine. No authors have combined the subjective clinical assessment with an objective measurement for these special tests. Objective: To compare the subjective assessment of iliotibial band and iliopsoas flexibility with the objective measurement of a digital inclinometer, to establish normative values, and to provide an evidence-based critical criterion for determining tissue tightness. Design: Cross-sectional study. Setting: Clinical research laboratory. Patients or Other Participants: Three hundred recreational athletes (125 men, 175 women; 250 in injured group, 50 in control group). Main Outcome Measure(s): Iliotibial band and iliopsoas muscle flexibility were determined subjectively using the modified Ober and Thomas tests, respectively. Using a digital inclinometer, we objectively measured limb position. lnterrater reliability for the subjective assessment was compared between 2 clinicians for a random sample of 100 injured participants, who were classified subjectively as either negative or positive for iliotibial band and iliopsoas tightness. Percentage of agreement indicated interrater reliability for the subjective assessment. Results: For iliotibial band flexibility, the average inclinometer angle was -24.59 degrees +/- 7.27 degrees. A total of 432 limbs were subjectively assessed as negative (-27.13 degrees +/- 5.53 degrees) and 168 as positive (-16.29 degrees +/- 6.87 degrees). For iliopsoas flexibility, the average inclinometer angle was -10.60 degrees +/- 9.61 degrees. A total of 392 limbs were subjectively assessed as negative (-15.51 degrees +/- 5.82 degrees) and 208 as positive (0.34 degrees +/- 7.00 degrees). The critical criteria for iliotibial band and iliopsoas flexibility were determined to be -23.16 degrees and -9.69 degrees, respectively. Between-clinicians agreement was very good, ranging from 95.0% to 97.6% for the Thomas and Ober tests, respectively. Conclusions: Subjective assessments and instrumented measurements were combined to establish normative values and critical criterions for tissue flexibility for the modified Ober and Thomas tests.

Steps towards the validation of the Trendelenburg test : The effect of experimentally reduced hip abductor muscle function on frontal plane mechanics

Introduction: The Trendelenburg Test (TT) is used to assess the functional strength of the hip abductor muscles (HABD), their ability to control frontal plane motion of the pelvis, and the ability of the lumbopelvic complex to transfer load into single leg stance. Rationale: Although a standard method to perform the test has been described for use within clinical populations, no study has directly investigated Trendelenburg’s hypotheses. Purpose: To investigate the validity of the TT using an ultrasound guided nerve block (UNB) of the superior gluteal nerve and determine whether the reduction in HABD strength would result in the theorized mechanical compensatory strategies measured during the TT. Methods: Quasi-experimental design using a convenience sample of nine healthy males. Only subjects with no current or previous injury to the lumbar spine, pelvis, or lower extremities, and no previous surgeries were included. Force dynamometry was used to evaluation HABD strength (%BW). 2D mechanics were used to evaluate contralateral pelvic drop (cMPD), change in contralateral pelvic drop (∆cMPD), ipsilateral hip adduction (iHADD) and ipsilateral trunk sway (TRUNK) measured in degrees (°). All measures were collected prior to and following a UNB on the superior gluteal nerve performed by an interventional radiologist. Results: Subjects’ age was median 31yrs (IQR:22-32yrs); and weight was median 73kg (IQR:67-81kg). An average 52% reduction of HABD strength (z=2.36,p=0.02) resulted following the UNB. No differences were found in cMPD or ∆cMPD (z=0.01,p= 0.99, z=-0.67,p=0.49). Individual changes in biomechanics show no consistency between subjects and non-systematic changes across the group. One subject demonstrated the mechanical compensations described by Trendelenburg. Discussion: The TT should not be used as screening measure for HABD strength in populations demonstrating strength greater than 30%BW but reserved for use with populations with marked HABD weakness. Importance: This study presents data regarding a critical level of HABD strength required to support the pelvis during the TT.

iRAP Malaysia training course: Decade of Action for Road Safety. Report to Department of Foreign Affairs and Trade, Australia-Malaysia Institute

The International Road Assessment Program (iRAP) is a not-for-profit organisation that works in partnership with governments and non-government organisations in all parts of the world to make roads safe. The iRAP Malaysia pilot study on 3,700km of road identified the potential to save 31,800 deaths and serious injuries over the next 20 years from proven engineering improvements. To help ensure the iRAP data and results are available to planners and engineers, iRAP, together with staff from the Centre for Accident Research and Road Safety – Queensland (CARRS-Q) and the Malaysian Institute of Road Safety Research (MIROS) developed a 5-day iRAP training course that covers the background, theory and practical application of iRAP protocols, with a special focus on Malaysian case studies. Funding was provided by a competitive grant from the Australian-Malaysia Institute.

School-based first aid training and the implications for traffic injury prevention : a randomised controlled trial

Adolescent injury remains a significant public health concern and is often the result of at-risk transport related behaviours. When a person is injured actions taken by bystanders are of crucial importance and timely first aid appears to reduce the severity of some injuries (Hussain & Redmond, 1994). Accordingly, researchers have suggested that first aid training should be more widely available as a potential strategy to reduce injury (Lynch et al., 2006). Further research has identified schools as an ideal setting for learning first aid skills as a means of injury prevention (Maitra, 1997). The current research examines the implications of school based first aid training for young adolescents on injury prevention, particularly relating to transport injuries. First aid training was integrated with peer protection and school connectedness within the Skills for Preventing Injury in Youth (SPIY) program (Buckley & Sheehan, 2009) and evaluated to determine if there was a reduction in the likelihood of transport related injuries at six months post-intervention. In Queensland, Australia, 35 high schools were recruited and randomly assigned to intervention and control conditions in early April 2012. A total of 2,000 Year nine students (mean age 13.5 years, 39% male) completed surveys six months post-intervention in November 2012. Analyses will compare the intervention students with control group students who self-reported i) first aid training with a teacher, professional or other adult and ii) no first aid in the preceding six months. Using the Extended Adolescent Injury Checklist (E-AIC) (Chapman, Buckley & Sheehan, 2011) the transport related injury experiences included being injured while “riding as a passenger in a car”, “driving a car off road” and “riding a bicycle”. It is expected that students taught first aid within SPIY will report significantly fewer transport related injuries in the previous three months, compared to the control groups described above. Analyses will be conducted separately for sex and socio-economic class of schools. Findings from this study will provide insight into the value of first aid in adolescent injury prevention and provide evidence as to whether teaching first aid skills within a school based health education curriculum has traffic safety implications.

Measuring mechanical properties of tendon in vivo

Introduction: Understanding the mechanical properties of tendon is an important step to guiding the process of improving athletic performance, predicting injury and treating tendinopathies. The speed of sound in a medium is governed by the bulk modulus and density for fluids and isotropic materials. However, for tendon,which is a structural composite of fluid and collagen, there is some anisotropy requiring an adjustment for Poisson’s ratio. In this paper, these relationships are explored and modelled using data collected, in vivo, on human Achilles tendon. Estimates for elastic modulus and hysteresis based on speed of sound data are then compared against published values from in vitro mechanical tests. Methods: Measurements using clinical ultrasound imaging, inverse dynamics and acoustic transmission techniques were used to determine dimensions, loading conditions and longitudinal speed of sound for the Achilles tendon during a series of isometric plantar flexion exercises against body weight. Upper and lower bounds for speed of sound versus tensile stress in the tendon were then modelled and estimates derived for elastic modulus and hysteresis. Results: Axial speed of sound varied between 1850 to 2090 m.s−1 with a non-linear, asymptotic dependency on the level of tensile stress in the tendon 5–35 MPa. Estimates derived for the elastic modulus ranged between 1–2 GPa. Hysteresis derived from models of the stress-strain relationship, ranged from 3–11%. These values agree closely with those previously reported from direct measurements obtained via in vitro mechanical tensile tests on major weight bearing tendons. Discussion: There is sufficiently good agreement between these indirect (speed of sound derived) and direct (mechanical tensile test derived) measures of tendon mechanical properties to validate the use of this non-invasive acoustic transmission technique. This non-invasive method is suitable for monitoring changes in tendon properties as predictors of athletic performance, injury or therapeutic progression.

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.