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How much to do at the accident scene?
British Medical Journal, April 8, 2000 v320 i7240 p1005.
John Warwick, Charles D Deakin, Hans Okkels Birk and Lars Onsberg Henriksen
       Full Text COPYRIGHT 2000 British Medical Association
Paramedic agrees with most of comments about prehospital care
EDITOR--I agree with most of Cooke's comments about prehospital care by
paramedics in the United Kingdom[1] but would like to 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.
John Warwick paramedic/work based trainer London Ambulance Service NHS Trust,
London SE1 8SD john.warwick@virgin.net
[1] Cooke MW.. How much to do at the accident scene? BMJ 1999;319:1150. (30 October.)
[2] Cocks RA, Glucksman E. What does London need from its ambulance service?
BMJ 1993;306:1428-9.
[3] Joint Royal Colleges and Ambulance Liaison Committee-Ambulance Service
Association. The future role and education of paramedic ambulance service
personnel. London: JCALC, 2000.
[4] Deakin CD, Hicks IR. AB or ABC: pre-hospital fluid management in major
trauma. J Accid Emerg Med 1994;11: 154-7.
[5] Royal College of Surgeons of England. The management of patients with
major injuries. London: RCS, 1988.
Anaesthetists are best people to provide prehospital airway management
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 280/0 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 patients with trauma.
Charles D Deakin consultant anaesthetist Shackleton Department of
Anaesthetics, Southampton General Hospital, Southampton SO16 
6YDcdeakin@compuserve.com
[1] Cooke MW. How much to do at the accident scene? BMJ 1999;319:1150. (30 October.)
[2] Hussain LM, Redmond AD. Are prehospital deaths from accidental injury
preventable? BMJ 1994;308:1077-80.
[3] Nicholl J, Hughes S, Dixon S, Turner J, Yates D. The costs and benefits of
paramedic skills in pre-hospital trauma care. Health Technol Assess 1998;2.
Prehospital interventions prolong prehospital time
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?
Hans Okkels Birk health economist syhob@ra.dk
Lars Onsberg Henriksen chief medical officer Department of Hospitals, County
of Roskilde, Postboks 170, 4000 Roskilde, Denmark
[1] Cooke MW. How much to do at the accident scene? BMJ 1999;319:1150. (30 October.)
[2] Callaham M. Quantifying the scanty science of prehospital emergency care.
Ann Emerg Med 1997;30:785-90.
[3] Feero S, Hedges JR, Simmons E, Irwin L. Does out-of-hospital time affect
trauma survival? Am J Emerg Med 1995;13:133-5.
[4] Skelton MB, McSwain NE. A study of cognitive and technical skill
deterioration among trained paramedics. JACEP 1977;6:436-8.
                                -- End --