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Commentary from the RCA
  1. Royal College of Anaesthetists

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    Timely pre-hospital interventions by doctors, which cannot be undertaken by paramedics, may improve the outcome for some patients; however, we should recognise that this assertion lacks robust scientific evidence. In comparison with several other European countries, the involvement of doctors in pre-hospital care in the UK is variable; in some regions, pre-hospital involvement is negligible. In many areas, the response to ambulance personnel requesting medical assistance at the scene of a motor vehicle crash, for example, comprises a mobile medical team dispatched from the nearest hospital. The doctor on this team may be a trainee in emergency medicine or anaesthesia who has received little or no training in pre-hospital care.

    Doctors who commit to providing pre-hospital care should be trained appropriately. In line with other medical specialities, such training should be competency based and subject to revalidation. In an attempt to improve and standardise pre-hospital care by doctors in the UK, Mackenzie and Bevan propose the establishment of the new sub-specialty of pre-hospital and retrieval medicine. It is suggested that the curriculum for this subspecialty would be agreed by the Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh, the Faculty of Accident and Emergency Medicine (FAEM), the Royal College of General Practitioners (RCGP), and the British Association for Immediate Care (BASICS). As rapid sequence induction of anaesthesia and tracheal intubation is considered to be one of the key pre-hospital interventions that can be undertaken by a properly trained doctor, but not a paramedic, it would seem sensible to include the Royal College of Anaesthetists (RCA) in these discussions. Recently, collaboration between the RCA and FAEM has resulted in the development of an emergency airway course, which introduces emergency physicians and anaesthetists to the skills and decision making needed for rapid sequence induction and intubation.1 This course will be relevant to the pre-hospital practitioner. If pre-hospital practitioners are to acquire and maintain advanced airway skills they will benefit from the co-operation of anaesthetists.

    There are several challenges that emerge from the proposal to form a subspecialty of pre-hospital and retrieval medicine. The need for a doctor on scene is comparatively rare (precise data would be valuable) and acquiring the appropriate skills and experience may be difficult outside of helicopter emergency medical services that cover a large population. Having acquired the skills necessary for pre-hospital practice, it is difficult to see how adequate ongoing experience could be achieved unless the individual has the opportunity to practice in another setting—that is, in hospital. How does the general practitioner with a pre-hospital interest acquire and maintain skills in advanced airway management? Are primary care trusts (PCTs) prepared to fund a pre-hospital programme of training and supervised experience lasting for up to 2 years? Will the PCTs have resources to fund increasing involvement of doctors in pre-hospital practice?

    With appropriate training, pre-hospital practitioners could become involved in the transfer of critically ill patients between hospitals. These practitioners are more likely to be those with an in hospital primary specialty, such as emergency medicine. Regionalisation of specialist services such as trauma will necessitate more patient transfers from the receiving hospital to the regional centre. The receiving hospitals often struggle to release skilled personnel (usually anaesthetists) to undertake prolonged transfers. By taking on this transfer work, the pre-hospital specialist would have the opportunity to maintain skills at the same time as creating a more viable business case for PCTs.

    Timely pre-hospital interventions by doctors, which cannot be undertaken by paramedics, may improve the outcome for some patients; however, we should recognise that this assertion lacks robust scientific evidence. If a subspecialty of pre-hospital and retrieval medicine were to be developed, audit and research would be one of its important functions.

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    • Competing interests: none declared

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