British Paramedic Journal

A service evaluation of the recognition, care and management of functional seizures within a UK Ambulance Service

David Williams — 2026-06-01

Introduction – Functional seizures, a subtype of functional neurological disorder, are frequent presentations within the emergency department and wider hospital setting. There is a lack of research exploring pre-hospital care for this patient group. The aim of this service evaluation was to explore ambulance staff recognition, care and management of functional seizure presentations within a UK ambulance service trust.

Methods – An online survey was conducted using a convenience sample of clinical staff from South Western Ambulance Services NHS Foundation Trust. Respondents were asked a mixture of distinct and free-text answers exploring questions around identification, care and management of functional seizure presentations. Results were analysed using a mix of descriptive statistics and qualitative content analysis.

Results – There were 96 responses to the survey. 82% (n=81) of respondents reported they attend functional seizures at least once monthly, with 18% (n=17) of those attending functional seizures weekly. Ambulance staff confidence in the recognition and management of functional seizures is high, but notably 66% (n=63) have received no previous training or education for functional seizure care. Definitions and causes of functional seizures reportedly relied predominantly on a psychological component. Identification was based on history, seizure features and clinical guidelines. Management of functional seizures focused on reassurance. Challenges identified by ambulance staff included stigma, perceived diagnostic complexity, fear and limited education.

Conclusion – Ambulance staff frequently attend functional seizures but receive limited training, leading to misconceptions, stigma, and diagnostic challenges. Identification relies on unreliable signs and complex histories. Management aligns with clinical guidance, yet uncertainty remains for prolonged events. Fear of misdiagnosis, harmful attitudes, and poor education highlight urgent need for targeted education and future research.

Advanced Airway Management in Out-of-Hospital Cardiac Arrest

Andrew Cole — 2026-06-01

Introduction: Following national changes to airway management practice in out-of-hospital cardiac arrest (OHCA), endotracheal intubation (ETI) is no longer a core paramedic skill in many English ambulance services. This service evaluation assessed current airway practice and success rates in OHCA, focussing on supraglottic airways (SGAs) and ETI use following the restriction of ETI to specialist roles within a regional ambulance service.

Methods: This retrospective observational service evaluation included all OHCA incidents between April and September 2024 where resuscitation was attempted. Data were extracted from structured and free-text fields from the participating ambulance service’s OHCA registry. Variables analysed included the type of airway device used, whether the ETI was successful and how many attempts were undertaken before succeeding or changing to a different airway management approach,, SGA outcomes, and basic demographic and survival data were also analysed. A sub-analysis explored documented SGA difficulties and associated themes.

Results: SGAs were used in 85.8% of incidents with an overall success rate of 84.3%. Success was higher in paramedic-led cases (91.4%) compared to those involving clinicians in specialist roles (77.8%). ETI was performed in 37.1% of enhanced care-attended incidents with overall success of 97.7% and first pass success of 92.6%. Higher ETI success was seen when utilised following return of spontaneous circulation (ROSC) compared to intra-arrest patients (99.0% and 96.8% respectively). In 8.6% of incidents, SGAs were documented as successful but subsequently replaced. SGA failure was commonly associated with airway contamination requiring suction in 67.3% of those incidents. ETI was more common in younger patients and those surviving to 30 days, though findings may reflect service evaluation limitations rather than outcome driven benefit.

Conclusion: SGAs remain an effective first-line airway device in OHCA, particularly for non-specialist clinicians, though success may be reduced in contaminated airways. ETI success has improved under a specialist practitioner model, with regular exposure and robust clinical governance, supporting the decision to remove it as a core paramedic skill.

A survey of UK emergency medical services approach to incidental identification of atrial fibrillation

Laura Blair — 2026-06-01

Introduction

Atrial fibrillation (AF) is a condition associated with increased risk of stroke. The risk of stroke can be reduced by oral anticoagulation (OAC) medication but as AF is often asymptomatic, it can go unrecognised. Given the move away from face-to-face consultations, it is important to take advantage of any opportunities for AF detection and onward evaluation for potential OAC prescription. Emergency Medical Services (EMS) provide face-to-face assessments which can provide the oppportunity to identify incidental AF.

However, little is known about how EMS manage patients with incidently detected AF, or what the optimum approach may be. The aim was therefore to describe current practice within UK EMS for the detection and response to incidental AF.

Methods

Interview delivered surveys were conducted by the lead researcher, between June and August 2023, with participants from 12 UK ambulance trusts. Participants were emailed directly to ask if they would agree to be interviewed.

All interviews were conducted via Microsoft Teams. The survey was developed by the co-authors, refined during this project and included all aspects of the patient pathway. Content analysis was used by the lead researcher to analyse the interviews.

Results

There were variations in clinical aspects such as pulse palpation and only five trusts had a clear process about managing incidental findings. Methods for information sharing with primary care varied between in- and out-of-hours periods, according to the services that were available locally, leading to heterogeneity of care.

Discussion

An EMS encounter can provide an opportunity to identify incidental AF and instigate ongoing care for modification of stroke risk, however there is variability in practice across the UK. To ensure that opportunities for stroke risk reduction are maximised, a robust mechanism for clinical information sharing with primary care regarding incidental AF is required.

Resuscitation Attempts in Patients with Do Not Attempt Cardiopulmonary Resuscitation Decisions Attended by Emergency Medical Services: Contributing Factors and Predictors

Jack William Barrett — 2026-06-01

Introduction: Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which ambulance clinicians must rapidly decide whether to initiate resuscitation. In the United Kingdom, up to 30% of OHCA patients also have a documented Do Not Attempt Resuscitation (DNACPR) decision. Despite these advance care plans, patients may still receive cardiopulmonary resuscitation (CPR), potentially causing distress to patients, relatives, and clinicians; and increasing resource use. The frequency and predictors of such events in UK ambulance services remain poorly described.

Methods: A retrospective observational cohort study using one regional ambulance service’s OHCA registry (January–December 2024). Adults with a valid DNACPR form or ReSPECT form recommending against CPR, which was available to crews either electronically or physically at the time of the incident (or crews were informed by another HCP of the presence of a valid form), who suffered an OHCA and were attended by a regional emergency medical services (EMS) were included. The primary outcome was the commencement of any resuscitation attempt, defined as either over-the-phone CPR instructions or on-scene clinical intervention. Descriptive statistics compared cases with and without resuscitation. Univariable and multivariable logistic regression identified factors associated with a resuscitation attempt.

Results: Between 1^st January 2024 and 31^st December 2024, there were 7,809 OHCAs, of which 1,827 patients had a DNACPR; resuscitation by the ambulance service or bystanders occurred in 377 (20%) cases. Call handlers initiated most attempts (87%), and 36% received on-scene interventions. Median age was 80 years (IQR 70–90), and 51% were female. Multivariable analysis showed that each additional clinician on scene was associated with increased odds of resuscitation by 69% (adjusted odds ratio [aOR] 1.69, 95% CI 1.55–1.84; p<0.001). A public location carried a six-fold higher likelihood of resuscitation compared with assisted-living or nursing homes (aOR 6.08, 95% CI 1.47–27.4; p=0.013). Home OHCAs were common and associated with a resuscitation attempt (aOR 1.41, 95% CI 1.00–2.01). Where dedicated end-of-life care single points of access were available in an area, there were lower odds of a resuscitation attempt (aOR 0.32, 95% CI 0.12–0.81). Patient age, gender, and response time were not independent predictors of the outcome.

Discussion: One in five patients with a recorded DNACPR received a resuscitation attempt. This likely reflects the real-world complexities of DNACPR recognition in time-critical emergencies, including delayed access to documentation and potentially reversible presentations. Larger on-scene teams and public locations were associated with resuscitation, whereas a dedicated end-of-life care hub was associated with reduced attempts. Improving real-time visibility of advance care plans and strengthening end-of-life care pathways may help ensure care remains aligned with patient preferences.

Evaluation of Three Mechanical Chest Compression Devices – A Simulation-Based, Mannequin Study

Mads Kjeldsen — 2026-06-01

Introduction: High-quality chest compressions are essential when treating out-of-hospital cardiac arrest patients but may be compromised due to fatigue. Therefore, mechanical chest compression devices (MCCDs) are used, but the choice of device is a matter of debate. This study aimed to compare the quality of chest compressions along with usability of three commercially available devices.

Methods: We prospectively designed a protocol for testing LUCAS 3, AutoPulse, and Corpuls CPR on the AmbuMan Advanced simulation mannequin in four different scenarios, including mounting of device, patient transport via stairs and ambulance, and re-packing. We evaluated the quality of chest compressions as according to current guidelines, movement of device, and usability through a predefined questionnaire.

Results: We invited 45 paramedics and 40 prehospital physicians, of which 9 paramedics participated. We observed significant mean total time differences in patient transport via stairs and re-packing. Significant differences in ratings of MCCDs regarding unpacking, mounting, and start of mechanical chest compressions as well as the overall usability and satisfaction, were observed. LUCAS 3 and Corpuls CPR had significantly higher mean proportions of compressions within the European Resuscitation Council’s recommendations as compared to AutoPulse (post hoc analysis). Most paramedics recommended Corpuls CPR for future use.

Conclusion: This study demonstrated superiority of LUCAS 3 and Corpuls CPR compared to AutoPulse regarding quality of chest compressions during cardiac arrest as compared to current guidelines and usability in a simulated setting. No distinction of LUCAS 3 and Corpuls CPR could be made.

Student paramedic sexual safety in ambulance placement: a critical exploration

Jennifer Dod — 2026-06-01

Sexually inappropriate behaviour within United Kingdom (UK) ambulance services has become an increasingly visible and pressing concern, yet little is known about how these behaviours impact student paramedics during practice-based learning. This article examines existing evidence relating to sexual misconduct, harassment, and sex-based discrimination in UK ambulance trusts, with specific attention to the likely under-reported experiences of student paramedics. Interest in this issue is grounded in the authors’ combined professional and personal experiences as educators, practitioners, and recent students who have directly observed or encountered these behaviours.

The culture in which these placements occur has been repeatedly characterised by entrenched misogyny, hierarchical structures, and normalisation of potentially inappropriate “banter”, all of which may mask or trivialise harmful behaviour. Existing literature and national reviews highlight substantial barriers to reporting such issues, including fear of reprisals, lack of confidentiality, distrust of management, and organisational cultures that minimise concerns. Although recent policy attention has improved recognition of sexual safety as a systemic problem within ambulance services, student paramedics remain largely excluded from major data sources such as the NHS Staff Survey. Early indicators, including National Education and Training Survey findings and professional body initiatives, suggest that paramedic students may be disproportionately exposed to sexualised behaviour yet lack safe mechanisms to disclose concerns.

To contextualise these issues, this article draws on sociological perspectives, particularly Social Identity Theory, to explore how group dynamics, power structures, and gendered norms may perpetuate inappropriate sexual behaviour and inhibit speaking up. This analysis underscores the need for evidence-based interventions that address both individual and organisational contributors to sexual misconduct. The article concludes by identifying a critical evidence gap regarding UK student paramedic experiences and outlining the authors’ forthcoming research study, which aims to provide the first in-depth exploration of this issue from the student perspective.

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Development of a national consensus guideline for termination of resuscitation in the out-of-hospital environment.

Mike Smyth — 2026-06-01

Background: Ambulance Services in the United Kingdom (UK) attempted resuscitation in over 34400 cases in 2022. Of these, 58% had the resuscitation attempt terminated at scene and only 7.8% survived to hospital discharge. The decision to stop resuscitation is informed by a national guideline that is over 20 years old. This study describes the development of a revised termination of resuscitation guideline.

Methods: This was a mixed methods study comprising a diagnostic test accuracy meta-analysis of termination of resuscitation (TOR) rules, modelling of multiple TOR rules using data from the Out of Hospital Cardiac Arrest Outcomes (OHCAO) registry, a survey of ambulance services combined including a review of national policy documents, qualitative interviews with ambulance and emergency department (ED) clinicians plus interviews with relatives of patients who did not survive a prehospital resuscitation attempt. These work packages informed a national consensus meeting with a wide range of stakeholders, employing nominal group techniques (NGT), to draft a revised TOR guideline.

Results: The systematic review identified very low certainty evidence from 43 studies indicating that TOR rules are unlikely to be suitable for implementation in the UK. When we modelled the performance of TOR rules, the 3 best performing were the Marsden, KOCARC 1 and GOTO1 TOR rules. We identified considerable variation in practice across UK ambulance services, however there was consistency across services with respect to perceived risks. Paramedics experienced tension when they felt guidelines restricted them from acting in the patient's best interests. ED staff felt paramedics should be empowered to stop resuscitation in some cases. Relatives felt paramedics did a good job and that they had information that was useful for paramedics. Multiple stakeholders participated in a consensus conference to develop a revised TOR guideline.

Conclusions: We iteratively derived updated termination of resuscitation and verification of death guidelines.

When Innovation Pootles Along: The Need for Clear Stop-Go Decisions in Ambulance-Based Service Evaluations

Cath Hodson — 2026-06-01