Editorials

Prehospital emergency care

Many of the people who die of trauma, heart attacks, or stroke die within the first hour. Many do not reach hospital. People have thus long recognised the need to improve the emergency services offered to patients before they reach hospital. But research on what happens at that critical time is hard to do. Many questions remain about who should offer the care and how it can best be offered. In an attempt to encourage research into prehospital emergency care and to develop the services offered, the Royal College of Surgeons of Edinburgh has established a multidisciplinary faculty of prehospital care. Now BASICS (British Association for Immediate Care) and the BMJ Publishing Group are launching a new journal--Pre-hospital Emergency Care Journal.*

BASICS was begun by Ken Easton in 1966 after he had seen serious road accidents poorly managed. It now comprises 1700 doctors around Britain, most of them general practitioners, who are prepared to offer immediate care. Ambulance staff have meanwhile greatly improved their skills. Some ambulance services believe that prehospital care belongs to paramedics,¹ but there is evidence that results are better in a rural setting if a trained general practitioner is called.²

Arguments continue over who is the best person to provide care, and research is limited. Defibrillators undoubtedly improve the outcome from cardiac arrest,³ and first aiders can be trained to use them.⁴ The advantages of a paramedic (who can intubate and give drugs) over a technician (who can defibrillate) have been challenged.⁵ Trained doctors can do all those things. Doctors also have an advantage in that they are allowed to give thrombolytic treatment, which improves the outcome of patients who have had heart attacks.⁶ The relative advantages of different staff is unclear in the case of trauma,⁷ and two American studies have shown that patients with penetrating injuries attended by either the police⁸ or the public⁹ had as good or a better outcome than those attended by trained ambulance crews. Patients with severe head injuries often need to be paralysed and ventilated, which usually can be undertaken only by doctors.¹⁰

The research is inconclusive, but well trained doctors undoubtedly have a role in prehospital emergency care. Yet undergraduate medical training is poor preparation, and that is why the Royal College of Surgeons has established a specialist examination in prehospital care. BASICS also offers training and has proposed a system of accreditation so that ambulance services can be sure that doctors are adequately trained. The new faculty is open to doctors, ambulance staff, nurses, first aiders, and others interested in prehospital care, and undoubtedly this difficult work needs teamwork. The roles of first aider, ambulance person, and doctor are complimentary.

Research is lacking not only on who should deliver care but also on the best care to offer. Guidelines cannot be automatically transposed from hospital practice to emergency prehospital care. An important element of all prehospital work is the decision of when to transport the patient. Will an intravenous infusion help an exsanguinating patient or simply delay definitive treatment by a surgeon? Giving fluid to patients with blunt chest trauma before transport to hospital increases mortality,¹¹ as does delaying the transfer to hospital of patients with penetrating trauma in order to wait for the arrival of paramedics.¹² Some types of care can be given safely only in hospital.

Further research is also needed on the best equipment for prehospital emergency care. Some forms of equipment--for instance, extrication devices--are unique to prehospital care, and they have not been adequately assessed. Some equipment may worsen the patient's predicament: pneumatic antishock garments may increase mortality, probably because they compromise respiratory function¹³; and semirigid collars used for immobilising the neck may raise intracranial pressure (G Davies, personal communication). New forms of telemetric equipment are also being proposed that will allow doctors to assist from a remote location. Their use will need evaluation and audit.

The research and audit that are necessary to underpin prehospital emergency care will appear in the new journal. A new body has been proposed to regulate paramedics, and the new faculty is collaborating with BASICS on training and accreditation. All the professional groups need to work together, and the journal will be for them all. These initiatives should ensure better outcomes for patients who need emergency care.

Editor Chairman, editorial board Prehospital Emergency Care, London WC1H 9JR

Editor BMJ, London WC1H 9JR

Matthew Cooke, Tim Hodgetts, Richard Smith 

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