Intended for healthcare professionals

Letters

How much to do at the accident scene?

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7240.1005/a (Published 08 April 2000) Cite this as: BMJ 2000;320:1005

This article has a correction. Please see:

Paramedic agrees with most of comments about prehospital care

  1. John Warwick, paramedic/work based trainer (john.warwick{at}virgin.net)
  1. London Ambulance Service NHS Trust, London SE1 8SD
  2. Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton SO16 6YD
  3. Department of Hospitals, County of Roskilde, Postboks 170, 4000 Roskilde, Denmark

    EDITOR—I agree with most of Cooke's comments about prehospital care by paramedics in the United Kingdom1 but would liketo raise a few points. As a paramedic in London, I realise that my remarks may not have national generalisability, but their essence should travel across regional boundaries.

    Cooke is correct in his assertion that “Changes are needed if the paramedic is to be an independent practitioner.” Paramedics are the product of doctors; we are what they made us. The idea of having extended role ambulance staff began during the 1970s and '80s. Unfortunately, the original aspirations of our worthy fathers were overtaken by political posturing.

    The original concept was for a small cadre of highly trained paramedics who would be targeted at the small percentage of 999 calls where the patient would benefit from extended skills before reaching hospital. The emphasis was initially on calls for patients with cardiac problems; later this was extended to patients with trauma. When the ambulance dispute in 1989 was eventually concluded a promise was made that there would be a paramedic in each vehicle. This went against the original concept of sending a paramedic to every call made about a life threatening condition—which would have required accurate and effective assessment and deployment.2

    Cooke is correct that paramedics need the underpinning knowledge to make appropriate decisions about patients' treatment. Degree programmes will help provide this knowledge, along with experiential learning. The proposed development of practitioners in emergency care will certainly address this issue.3 Education alone, however, will not alter some of the problems currently encountered in the prehospital phase:

    1. Paramedics need to question what more can reasonably be done for their patient after securing the airway and checking breathing at the scene. Problems with circulation should be dealt with on the way to hospital.4

    2. The choice of hospital needs to be addressed. Preventable deaths may be avoided by transporting the patient to the most appropriate multidisciplinary hospital, not the nearest hospital.5

    3. The fact that little direct communication occurs between the receiving hospital and the ambulance crew needs to be considered.

    Research into prehospital care is needed and should include input from paramedics; they could be part of the research team. The old maxims of “stay and play” and “load and go” could perhaps be replaced with “play while running” to the most appropriate hospital.That way we might be able to make a real, quantifiable difference.

    References

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    Anaesthetists are best people to provide prehospital airway management

    1. Charles D Deakin, consultant anaesthetist (cdeakin{at}compuserve.com)
    1. London Ambulance Service NHS Trust, London SE1 8SD
    2. Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton SO16 6YD
    3. Department of Hospitals, County of Roskilde, Postboks 170, 4000 Roskilde, Denmark

      EDITOR—Although I agree with Cooke's general conclusions that airway and breathing problems must be treated at the roadside and circulation ones in hospital, I disagree with his statement that the airway can be easily secured at the scene.1

      Two studies examining prehospital deaths from trauma in the United Kingdom have shown significant morbidity and mortality from airway obstruction. Hussain and Redmond concluded that up to 85% of patients who die with survivable injuries before reaching hospital may do so because of airway obstruction.2 In another study airway obstruction was thought to have contributed to death from major trauma in 28% of patients treated by ambulance crew.3 These figures do not support the assumption that the airway can easily be secured at the scene.

      The airway is often compromised because of limited skilled help; poor lighting; a difficult patient position; blood, vomit, and debris in the upper airway; and poor views at laryngoscopy due to stabilisation of the cervical spine; in addition, the patient must be managed in a moving ambulance. Prehospital airway management is therefore difficult, even for anaesthetists with extensive experience in airway management. Paramedics in the United Kingdom who start in this environment having performed just 20 intubations do not have sufficient training to manage many of the more difficult cases. Furthermore, because paramedics are not trained to use neuromuscular blocking drugs, the only patients with trauma who are sufficiently obtunded to tolerate endotracheal intubation by them have invariably got non-survivable injuries (G Davies, personal communication).

      Having completed training in endotracheal intubation, an average paramedic will intubate only about eight patients a year, and not all ambulance services undertake formal refresher training in airway management. Difficult clinical scenarios and limited training may explain why only 63% of attempts at intubation by paramedics are successful.3

      Paramedics do not have the necessary skills to deal with the airway in patients with major trauma. Prehospital airway management must be undertaken by those with much greater experience than 20 intubations. Graduate courses will not improve airway management; what is required is much more practical training in airway skills. Currently the only group able to provide advanced prehospital airway management are anaesthetists, who have practical experience and can use neuromuscular blocking drugs and induction agents. The United Kingdom is the only country in Europe that does not routinely employ this standard of prehospital care; until it changes its practice, inadequate airway management will continue to contribute to the unacceptable prehospital morbidity and mortality of patientswith trauma.

      References

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      Prehospital interventions prolong prehospital time

      1. Hans Okkels Birk, health economist (syhob{at}ra.dk),
      2. Lars Onsberg Henriksen, chief medical officer
      1. London Ambulance Service NHS Trust, London SE1 8SD
      2. Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton SO16 6YD
      3. Department of Hospitals, County of Roskilde, Postboks 170, 4000 Roskilde, Denmark

        EDITOR—The question of how much prehospital care to give to patients (“scoop and run” versus “stay and play”)1 is very relevant in Denmark, where the ministry of health is considering extending the ambulance technicians' curriculum. We have carried out a prospective study (unpublished) of the relation between prehospital interventions and time at the scene.

        The study was of all 5571 patients with acute conditions transported to hospital by ambulances from two ambulance stations in the county of Roskilde in 1998. No selection of patients took place. The ambulances cover a mixed urban/rural area with roughly 150 000 inhabitants. Prehospital interventions took place for a wide variety of indications: 2479 of the patients received oxygen at the scene or in the ambulance, and ambulance technicians carried out electrocardiography on 1131 patients. The median time at the scene was 8.0 minutes, and the median transport time to hospital was 12.0 minutes.

        Despite the variety of indications for prehospital interventions the technicians had relatively little experience. In 1998 each technician was present, on average, on 7.9 occasions when drugs were given for angina, on 4.0 occasions when drugs were given for asthma, at 3.4 cardiopulmonary resuscitations, and at 3.0 defibrillations.

        For most prehospital interventions there is little evidence of a positive effect on outcome,2 while shorter total prehospital time may be an important factor in survival for patients with trauma.3 We found that use of each kind of prehospital intervention implied a prolonged time at the scene and that there was a direct correlation between the number of basic prehospital interventions used and the time at the scene.

        When the scope of the ambulance technicians' curriculum is considered, several factors should be borne in mind: the limited experience of the technicians, the lack of evidence of a positive effect on outcome of most prehospital interventions, and the prolongation of the time at the scene. New interventions will usually be technically demanding, their use will rarely be indicated, and the skills requiring the most technical knowledge deteriorate the fastest.4

        References

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