Prehospital care for road traffic casualties
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7346.1135 (Published 11 May 2002) Cite this as: BMJ 2002;324:1135All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
In their recent article (1), Coats and Davies imply that all victims
of motor vehicle collisions require spinal immobilization. This is not
true. Although immobilization has been the "standard procedure" in the
United States, Great Britain and many other counties, it is not the
standard world wide. Examples of areas where spine immobilization is not
the standard are Malaysia and large portions of Australia.
Spinal immobilization is not a benign procedure. It is uncomfortable
and adds time and expense to both prehospital and emergency department
care. Many patients are transported to the hospital only because they
are immobilized. Many of these patients receive radiographs only because
they arrive immobilized or develop back pain as a result of the
immobilization. We agree with the authors' point that we still do not know
if this is a beneficial procedure even in those patients with known or
high suspicion of spinal injury.
There is a growing body of literature which indicates that trauma
patients may be individually selected for immobilization by prehospital
care providers on the basis of simple criteria (2-5). These criteria
include neck pain or tenderness, reliability of the clinical exam, and
neurological deficit. The National Association of EMS Physicians has
endorsed these criteria through a position paper and they are steadily
gaining acceptance in U.S. EMS systems (6).
It is time that we scrutinize the widespread practice of immobilizing
all trauma patients and adopt the more reasonable approach of selective
immobilization.
Darren Braude, MD, MPH, EMT-P
Assistant Professor of Emergency Medicine
University of New Mexico
Robert M. Domeier, MD, FACEP
Saint Joseph Mercy Hospital
Ann Arbor, Michigan
References:
1. Coats TJ and Davies G. Prehospital care for road traffic casualties.
BMJ 2002;324:1135-1138
2. Domeier RM, Evans RW, Swor RA, Rivera-Rivera EJ, Frederiksen SM.
Prehospital Clinical Findings Associated with Spinal Injury. Prehospital
Emergency Care 1997;1:11-15.
3. Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J,
Frederiksen SM, Shork MA: The reliability of prehospital clinical
evaluation for potential spine injury is not affected by the mechanism of
injury. Prehospital Emergency Care 1999;3(4):332-337.
4. Stroh G, Braude D: Can an out-of-hospital cervical spine clearance
protocol identify all patients with injuries? An argument for selective
immobilization. Ann Emerg Med 2001;37(6):609-15.
5. Domeier RM, Swor RA, Evans RW, Krohmer J, Hancock JB, Fales W,
Frederiksen SM, Shork MA: Multicenter Prospective Validation of
Prehospital Clinical Spinal Clearance Criteria. Journal of Trauma 2002;in
press.
6. Domeier RM. Position Paper, National Association of EMS Physicians:
Indications for prehospital spinal immobilization. Prehospital Emergency
Care 1999;3(3):251-253.
Competing interests: No competing interests
The quality of the advice for doctors at the scene of road traffic
crashes offered by Davies and Coats1 speaks for itself and I am sure will
be welcomed by all doctors who may be involved in such incidents in either
a planned or an unscheduled way.
Their collective experience has been derived from a now established
pre-hospital medical care system that is hospital based but successfully
integrated within the London Ambulance Service. This has been key to its
effective tasking, deployment and operational effectiveness.
The “golden hour” is predominantly a pre-hospital event for many
injured patients in urban environments1, however, it not infrequently
takes closer to 2 hours to get injured and trapped patients to hospital in
rural areas such as mine. This is a very vulnerable time for these
patients.
The authors are right to emphasise that road traffic crashes are the
major cause of blunt injury in the UK associated with substantial
morbidity and mortality - involving significant numbers of children and
young adults – but these incidents do occur predictably in terms of
frequency, timing, location and circumstance.
The authors and their colleagues, who have been instrumental in
establishing a unique medical service for London, are to be congratulated
for their vision and commitment to prehospital care. By successfully
recruiting and training experienced doctors from a broad range of
predominantly hospital based specialities delivering critical care,
supported by experienced and highly trained paramedics rotating from the
London Ambulance Service, has enabled advanced medical care (i.e.
resuscitation room interventions) to be effectively and safely delivered
at the incident scene. For patients with life threatening and time
critical injury patterns, this may not only be life saving but may also
reduce the burden of lengthy and costly rehabilitation by significantly
reducing the risk of secondary neurological injury. The direct triaging of
patients requiring multi-disciplinary care to hospitals resourced to
deliver such care, thus avoiding the need for time consuming secondary
transfer, has enabled such patients with time critical injury patterns to
benefit maximally from timely specialist surgical intervention. Such
triage decisions may not be straightforward and on occasions require fine
judgement by an experienced clinician.
There has in recent years been significant investment nationally in
air ambulances throughout the United Kingdom but other than in London they
are not currently operationally medically supported full time for primary
missions2.
The NHS is about to benefit from a level of investment that has not
been realised for a generation. There is now an opportunity to further
evolve pre-hospital care for critically ill and injured patients
throughout the UK using the medical model established by the authors. This
could be readily achieved by further integration of Ambulance Service NHS
Trusts with acute (Regional) Hospital NHS Trusts, coordinated and funded
by Strategic Health Authorities.
John JM Black FRCS Ed FIMCRCS Ed FFAEM
Consultant in Emergency Medicine
Emergency Department,
John Radcliffe Hospital,
Oxford OX3 9DU
john.black@orh.nhs.uk
References:
1. Coats TJ, Davies G. Prehospital care for road traffic casualties.
BMJ 2002;324:1135-1138.
2. National Association of Air Ambulance Services.
http://www.naaas.co.uk/
Competing interests: No competing interests
Dear Sir
We read with interest the article in the 11 May issue of the BMJ,
reflecting the dramatic social and ecomonic effects of road traffic
accidents.
We applaud the article by Coates and Davis, emphasising the need for
training for doctors who may, by chance or intention, attend a road
traffic accident.
We would, however, like to emphasise the work of the Royal College of
Surgeons of Edinburgh and its Faculty of Pre-Hospital Care. In 1988, the
Royal College of Surgeons of Edinburgh introduced the first Diploma in
Immediate Medical Care examination, initially for doctors, which covered
all aspects of the previously neglected area of immediate medical care,
and not just road traffic accidents. This examination set standards which
have now become internationally accepted, and candidates have travelled
from as far afield as Australia to sit the examination. The examination
initially was only open to medical practitioners, but in 1998 College
Council agreed that paramedics and nurses involved with the practice of
pre-hospital care should be allowed to take the exam. This was a most
significant step, and it also meant that a Royal Surgical College was
inviting those who were not medical practitioners to partake of its
examination, and thereby was improving the integration of those other
providers of pre-hospital care.
The Fellowship in Immediate Medical Care was introduced in 2001 by
conversion for doctors already holding the DipIMC, and will now be
followed by a full Fellowship by examination next year. This will be the
first examination at this level in immediate medical care in the world.
The Faculty was founded in 1996, with 4 aims:
To set and maintain standards of practice in pre-hospital care.
To promote education in and teaching of pre-hospital care.
To initiate technical developments and research in pre-hospital care.
To integrate effectively the efforts of all participants in pre-hospital
care, and to harmonise and facilitate the onward management of the sick
and injured.
Since then its activities have developed rapidly in support of these
aims, and in particular the integration of all pre-hospital care
providers, from the bystander to the most experienced doctor.
The Faculty's Research Committee has produced evidence-based reports
dealing with spinal injuries, fluid replacement in trauma, burns
management, and will shortly be reviewing advanced airway care and other
important topics. Involvement with the Emergency Medical Journal is
developing integration, with the interface to accident and emergency
medicine.
A variety of other activites include working with Emirates Airline to
enhance their cabin crew training, and producing generic core training
material, which will be used as the basis for approval and accreditation
by many other organisations giving training in pre-hospital care,
including specialist niche areas, as for example mountain rescue. In
conjunction with the Institute of Health Care Development and EDEXCEL,
First Person on Scene courses are starting later this month in a number of
centres.
There is no doubt that improvement in all aspects of pre-hospital
care, dealing with both trauma and medical problems, will reduce morbidity
and mortallity, and this Faculty and this College would strongly support
all efforts to improve training and standards, and not just for doctors.
Yours faithfully
Brian G Steggles FRCSEd FIMC RCSEd
Chairman, Faculty of Pre-Hospital Care
Keith M Porter FRCSEd FIMC RCSEd
Honorary Secretary, Faculty of Pre-Hospital Care
Competing interests: No competing interests
Coats and Davies make the point in their article that the pre-
hospital arena is not an area where untrained and inexperienced doctors
can be expected to perform at a high level. However the point is also made
that all doctors may expect to pass or come across motor vehicle accidents
during their life time and should be able to provide at least good quality
first aid until other emergency services arrive at the scene. What
equipment is required to enable the inexperienced doctor to provide this
first aid?
The majority of preventable trauma deaths occuring before the
emergency services arrive are caused by an obstructed airway. Many doctors
carry ad-hoc pieces of equipment and kit "just in case", intra-venous
canulae or drips for example but in reality surprisingly little equipment
is actually required.
-A high visibility jacket is essential.
-A supply of latex gloves will enable airways to be cleared and opened and
pressure to be applied to bleeding points.
-A pocket mask will enable ventilatory support to be given to the apnoeic
patient (whether due to trauma or medical causes).
The medical practitioner can rely on all other supplies coming in the
ambulance response. This equipment will enable a doctor to save the vast
majority of salvagable trauma patients likely to expire in the time
between an accident occuring and an ambulance arriving and I would
recommend it as being cheap, easily aquired and with a long life.
Mark J Coates FIMC RCSEd
Member of Med-ALERT (All Lancashire Emergency Response Team)
Competing interests: No competing interests
Dear Sir,
Coats and Davies are to be congratulated on their review of pre-
hospital care for road traffic casualties. This is a long neglected area
of care within mainstream medical training. Provision of care is extremely
variable across the country from highly organised systems such as the
urban HEMS-London and the more rural BASICS setup MAGPAS to areas with
much more rudimentary or absent provision such as my own area South
Yorkshire.
In many areas the doctors called out to provide forward aid / pre-
hospital care from hospitals will have little or more likely no pre-
hospital experience and are rarely part of an organised pre-hospital
scheme. In addition composition of these mobile medical teams can vary and
often those called upon to go into the field may not even be aware that
that is part of their role.
Of the “alphabet soup” of very useful pre-hospital care courses
should be added the Anaesthesia Trauma and Critical Care (ATACC) course
run by a varied faculty and based at the Lancashire International Fire and
Rescue training centre in Chorley. While not solely concerned with pre-
hospital care the ATACC course covers the continuum from initial injury
and forward aid through resuscitation, surgery and on to the critical care
facility reinforcing the message that quality care should be started as
soon as possible after injury and its delivery maintained throughout. It
also emphasises and puts into practice the need for close cooperation
between medical staff and the emergency services and the course is run
with active participation from fire and rescue experts as well as medical
faculty specialising in pre-hospital and trauma care.
The ATACC course which has been running since 1998 has been
predominantly taken by anaesthetists as an addition or alternative to ATLS
but also by A&E doctors and nurses, operating department
practitioners, paramedics and even the odd orthopaedic trainee. I can
recommend the ATTAC course as a useful addition and development in the
training for managing trauma in the UK and for preparing individuals for
when they may have to work in the pre-hospital phase either as part of
their normal duties or as good Samaritans.
Further and more detailed information about the course may be gained at
the course website www.anaesthetic-trauma.org .
Competing Interests: I was a specialist registrar in pre-hospital
care with HEMS-London 1999-2000 and am currently about to start as an
instructor on the ATACC course.
Competing interests: No competing interests
I concur whole-heartedly with the praise that has been made of Tim
and Gareths' excellent article.
As an instructor in casualty handling at MVA's to a wide range of
professional groups such as Consultants from varying specialities, Fire
and Rescue service personnel and paramedics I feel that one very important
issue is team - work and being aware of each others skills and
capabilities to provide an integrated response to casualty care.
Training on courses in pre-hospital care needs to be directed to this end
with all groups of professionals working together in realistic, real time
scenarios.
Encouraging fire service personnel to take on additional skills in
casualty care allows them to make a rapid assessment of the time scale
needed to remove the casualty from the car, and provide good quality basic
interventions to prevent further deterioration within the first 5- 10
minutes of arriving on scene. In some cases the Fire Service may actually
be first in attendence at many MVA's; this extended knowledge allows them
to start the extrication process early and to confidently report back
their findings to paramedics when they arrive.In Lancashire the fire
service are in attendance first on scene at over 60% of MVA's. All Fire
Service MVA Instructor courses now provides Doctors and Nurses skilled in
casualty care as part of the teaching faculty, to allow this dissemination
of knowledge.Infact now-a-days you are 4 times more likely to see a
fireman at an MVA than at a fire!
Safety at scene courses are invaluable to BASICS doctors as it allows
them to assess the danger to themselves and the casualty.I feel it is
important for them to learn glass management strategies to allow them
rapid access to the casualty in the absence of the fire service.
Multi - disciplinary team working should be considered as mandatory
for Medical Rescue Teams, as in the event of multi - casualty scenarios it
allows each team member to provide appropriate and immediate care to
trauma victims.
Our medical rescue team includes fire - fighters, who are infact team
leaders who will triage the accident scene, Consultant Anaesthetists, and
Anaesthetic Assistants. We believe that the team approach is beneficial to
the casualty and provides a rapid response to each individual casualties
needs. All team members are trained in Airway management techniques, i.v.
cannulation and a rapid primary survey.
I would urge all doctors who are providing pre- hospital care to
attend safety at scene courses and to work in tandem with the emergency
services. Providing medical training to the fire service has given the
team the added advantage of being trained in scene safety and also
provided us with a knowledge of vehicle cutting techniques and the science
of space creation which allows us a better understanding of what is
acheivable on scene.
This symbiotic relationship is one which benefits the casualty which
is after all the very purpose of our pre- hospital role.
Competing interests: No competing interests
I must congratulate Tim and Gareth on their excellent review of pre-
hospital care in the UK. They make some very valuable points and present
the current injury statistics in some very real terms, yet they also
describe the severe deficiencies in the provision of medical care for
these casualties.
Doctors do have a duty of care and many are very keen to get involved
at the scenes of accidents, yet because of a basic lack of 'safety at
scene'knowledge they fall at the first hurdle and run the risk of at best
being excluded from the scene by the Incident Officer, or at worst
becoming a victim themsleves!
The skills and equipment required to ensure safety in these
situations are relatively simple yet potentially life saving (yours and
that of the casualty)and more doctors should be encouraged to attend such
courses, before exposing thesemlves to the risks. I am often horrified to
see hospital forward aid teams of untrained staff arrive at serious
incidents with ill-fitting, poor quality clothing that barely meets health
and safety standards, who are then asked in their 'expert opinion', how to
extricate the casualty.
Our Rescue Team trains closely with Lancashire Fire and Rescue
Service and we regulalry reverse roles during training to increase
understanding of what each emergency service requires 'on scene'. This not
only improves safety, but also greatly facilitates the extrication
process. Only by increasing such training can we hope to improve National
standards of trauma care as poor airway mananagement, over-zealous fluid
resuscitation and prolonged on-scene time, may well affect mortality far
more than any subsequent care in hospital.
BASICS and many other teams of doctors work voluntarily to provide a
higher standard of care in such situations, but sadly in many areas such
as ours these schemes have an uphill struggle against local ambulance
services and enthusiasm is lost. We should strive to support such schemes
and use BASICS or equivalent to pull all of these satellite programmes
together in a nationally supported system.
Tim and Gareth have made some excellent points for every doctor to
appreciate. I would welcome any parties in the North West that may wish to
join ATACC and SMART (Manchester) to support their ideas and improve pre-
hospital care.
Finally, remember that all of your skills should be aimed at simple
things: airway/oxygenation, haemorrhage control/clot preservation and
rapid safe transport to hospital.
Competing interests: No competing interests
In 'real life' I am doctor of pharmacy, but at the roadside I am also
a well trained first-aider and have crewed ambulances for the Bristish Red
Cross. I have had many years of first aid and ambulance experience and
even lead a British First AId team in international work. I would
therefore ask all readers to consider the following points when
approaching the roadside scene(s) described by Coats and Davies:
1. Every public/roadside incident I remember attending has also had
one or more GPs/medical practitioners pass by and offer help. (Thank you!)
2. In almost every instance, such help is declined in the first
instance.
3. This doesn't mean you should immidiately leave the scene.
Regardles of any bravado from the first-aider or ambulance crew, an extra
pair of hands is almost always welcome. However, someone must assert
control/authority at any trauma scene - an effiecient first-aider or
ambulance crew will do this as a matter of course.
4. However, if they really don't want to see you, accept the fact
gracefully. Every crew with more than a day's experience could tell the
story of 'the doctor who got in the way'.
5. Most importantly - remember your own safety - most ambulance crews
will have a spare reflective garment, but you will need to request it.
(Remember, we're focusing on the patient(s), not you!)
6. Accept that the crew deal with similar situations every day -
their judgement is almost certainly sound, but in cases of real doubt do
not be afraid to question.
7. It may look messy, but our main concern is still the patients
breathing/airway, followed by arresting heamorrhage, treating breaks
(include spinal work here) and handling burns. All else is 'trivia' at the
roadside.
8. Remember that all casualties deteriorate over time. With the
exception of (suspected/certain) spinal trauma we would like to move
everyone to hospital as soon as possible.
Competing interests: No competing interests
I applaud Coates and Davies for their informative article which
includes practical advice for doctors (untrained in pre-hospital care)
assisting at the scene of a road traffic crash.
They correctly state that personal safety is key, and that the emergency
services should be requested (by telephoning 999 or 112) if they are not
already in attendance. They further highlight the need to give precise
location details to assist the emergency services.
I would like to supplement their advice with the following practical
suggestions:
1) Consider obtaining a high visibility jacket and a doctor's green
flashing beacon as additions to any medical kit you already carry in your
car. These are, however, only an adjunct to safety, and should not imbue
the user with a false sense of security.
2) When assessing personal safety at an incident:
a) If the emergency services are present - the incident scene may well be
being 'protected' by an emergency service vehicle using its flashing
warning lights - in this case it is worth driving past the scene and then
walking back to the incident (keeping out of the way of any traffic).
b) If the emergency services are not present - one should make an
assessment of whether it would be safer to use one's vehicle to 'protect
the scene' by stopping in front of the incident.
This is more likely to be advisable if the vehicle can be placed where
very visible (to avoid it being hit!), and if a warning device such as a
doctor's green flashing beacon can be used to increase the vehicle's
visibility. One needs to weigh up the risk of one’s vehicle being struck
(causing damage and a further crash) against the protection it may afford
to rescuers and the original incident scene.
3) At a motorway incident - using the emergency telephone on the
'hard shoulder' will indicate the location of the incident to the
emergency services by stating the telephone's identification number,
printed on the side of the housing of the emergency telephone.
4) When a mobile telephone is used:
a) Precise location details become even more relevant, as although the
number is passed to the emergency services, its location cannot be derived
from the telephone number unlike a fixed line telephone.
b) Whilst the memorable '999' has been in use in the UK for longer than
'112' - there is a theoretical advantage to using '112' from a mobile
telephone. If the cellular base transmission station (BTS) is in full use,
and a 999 call is attempted - the call will fail as the BTS has no
available space for it.
If '112' is dialled, the GSM (mobile phone) specification calls for the
BTS to drop one of its existing non-emergency calls, and carry the '112'
call instead, so a '112' call may succeed where a '999' call might fail.
5) Many paramedics are wary of doctors offering assistance 'in the
street'. I have found that when I offer assistance I am better received
if:
a) I offer my identification - confirming I am a doctor,
b) I give them some indication of my level of expertise, and
c) I make it plain I respect their skills and knowledge, and that they are
more specialised in pre-hospital care than I am. However, doctors will
have skills complementary to the paramedics - I try to present myself as a
resource they can use as an adjunct to their skills.
As an example I may be able to use a bougie at a difficult intubation
where their protocols do not allow for use of a bougie, or I can allow
ketorolac to be given for analgesia when it is not a drug usually
available for them to use.
Competing interests: None.
I am a member of a voluntary aid society, undertaking occasional duties
with them on an unpaid basis. I have in the past assisted on a voluntary
basis at incidents I have come across whilst driving.
Competing interests: No competing interests
Road traffic accidents: The Spanish experience
EDITOR- The edition of 11 May "War on the roads" presents new
evidence concerning road traffic accidents and analyses possible ways
forward. We would like to add our experience in Spain.
Firstly, we would like to say that driving under the influence of
alcohol is one of the main causes of traffic accidents. The possible
course of action, including the involvement of doctors, of telling drivers
not to drink and drive, and assessing whether patients involved in
accidents and/or infringements for driving under the effects of alcohol
suffer from alcohol related problems, is well known; as is that course of
action where patients with alcohol related problems are denied a licence
to drive, following the dictates of Directive 91/439/EEC. As the number of
alcohol-related accidents decreases in developed countries, the problem of
illicit drugs and medication requires more attention. In the case of
medication and driving, doctors should: i) Select the medicament that
least affects psychomotor performance and driving ability. ii) Avoid
polypharmacy, self-medication and joint consumption with alcohol. iii)
Provide adequate information for patients. Since 2001, Spain has
classified the main groups of medicaments in three levels, according to
whether they interfere not at all, moderately or seriously with the
psychomotor performance-fitness to drive, which facilitates the choice of
medication to be prescribed1.
Secondly, we would like to comment on the 'Programme on Traffic
Accidents: Prevention and Assistance'2, carried out by the 'Sociedad
Española de Medicina Rural y Generalista' SEMERGEN in collaboration with
various public and private bodies, including our University. More than
6,000 GPs are currently attending the course. It consists of a theoretical
module2 of 16 chapters which analyse the different aspects related to
traffic accidents. In the practical module (15 classroom hours), one
module looks at pre-hospital assistance at traffic accidents, a vital
question3, for which a specific video has been made4. Another is dedicated
to medical advice such as: The use of child seats in cars, seatbelts and
pregnant women, prescribing medicaments to drivers, the involvement of
doctors in the question of driving and alcohol, and the relation between
medical pathologies and driving, analysing cases of somnolence and ageing.
The practical work will begin in September 2002. The course is approved
and inspected.
F. Javier Alvarez lecturer
M. Carmen del Río assistant researcher
Department of Pharmacology and Therapeutics,
Faculty of Medicine, University of Valladolid, 47005 Valladolid, Spain
alvarez@med.uva.es and delrio@med.uva.es
1 Del Río MC, Alvarez FJ. González JC. Guía de prescripción
farmacológica y seguridad vial. Madrid: Dirección General de Tráfico,
2001.
2 Alvarez FJ, Blanco E, Buisan C, García E (Eds). Programa sobre
accidentes de tráfico: prevención y asistencia. Madrid: SEMERGEN, 2000.
3 Coats TJ, Davies G. Prehospital care for road traffic casualties. BMJ
2002;324:1135-8.
4 Toranzo T. Simulacro de Accidente de Tráfico: Asistencia prehospitalaria
en un accidente de tráfico con múltiples víctimas. Madrid: SEMERGEN, 2000.
Competing interests: No competing interests