Management of cardiac arrest by ambulance technicians and paramedicsBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7003.508a (Published 19 August 1995) Cite this as: BMJ 1995;311:508
- Andrew K Marsden, Consultant medical director,
- Stuart M Cobbe, Walton professor of medical cardiology
Paramedics have other uses beside attending cardiac arrests
EDITOR,--The paper by U M Guly and colleagues, of Edinburgh, shows the wisdom of the former managers of the Scottish Ambulance Service who in 1989, before the widespread introduction of paramedic training in Scotland, resolved to equip all frontline ambulances with defibrillators and train staff in their use.1 Since the start of the “Heartstart Scotland” programme about 1000 patients have recovered completely after a cardiac arrest outside hospital. The fact that the grade of staff using defibrillators does not materially influence such excellent results causes no great surprise because, in the chain of survival after cardiac arrest, the link of early defibrillation is the most positive discriminator and it matters little who provides it.
It might, however, be useful to analyse why paramedics in Edinburgh have not achieved significantly better outcomes for patients. Firstly, the study coincided with the deployment of paramedics in rapid response units; they could not transport patients. With successful defibrillation a delay often occurred before a vehicle became available for transport, resulting in the paramedics spending longer at the scene, as reported. Secondly, paramedics were often deployed as a secondary response when cardiac resuscitation was initiated by an ambulance technician because breathing and consciousness had not returned after defibrillation. Patients in such cases are less likely to survive. The paramedics' only relevant extended skill at the time of the study was tracheal intubation, which alone is unlikely to be of major benefit in these high risk patients. The immediate survival of such patients receiving a secondary response from the authors' hospital based medical team (a group of patients excluded from this analysis) may be little better than that ascribed to early defibrillation by ambulance technicians.
This study examined only cardiac resuscitation and in a city setting close to a major teaching hospital. It took no account of the contribution of paramedics to the management of other emergencies, including trauma, asthma, and diabetes, especially in remote localities. From the authors' narrow perspective, we fail to see how they can support their conclusion in the key messages box that “the outcome of patients treated by technicians v paramedics does not justify the government's plans.” Only a comprehensive review of all aspects of the delivery of services will be sufficient to justify or challenge the government's investment.