METHODS

All email messages covering a 10 month period (3 October 1999 to 27 July 2000) were analysed retrospectively. Data describing the date, time of day, method of call out, case description, and medical interventions performed at the scene were collated and are presented.

There were no data that would permit classification of patients into “serious” or “non-serious” categories using conventional trauma scoring. A serious accident was defined as one which contained a patient with more than one long bone fracture, a suspected fractured pelvis, or an ambulance crew reporting difficulty with treating patient injuries.

RESULTS

Seventy five prehospital events were reported by the 12 doctors in a 10 month period, this is an average response once every four days. The types of incidents are presented in figure 1.

The majority of calls, 40 (53%) were to road traffic accidents. Of these, 19 (48%) were patients in “serious” accidents. The call for assistance from a prehospital doctor was thought to be appropriate by the doctor concerned in 14 of the remaining 21 cases by virtue of significant history (massive vehicle damage or a potentially dangerous situation). The remaining seven calls were deemed to be inappropriate.

Motorcycles were involved in five road traffic accidents and each was associated with at least one death.

Six road traffic accidents involved a pedestrian, five of these had serious injuries, one later died.

A tree was involved in six road traffic accidents. In four of these cases, patients had serious injuries. There were two on scene fatalities among this group.

There were nine calls “intercepted” by doctors monitoring ambulance radio. A doctor can tune in to the ambulance radio frequency and monitor the incidents being tasked to the ambulance crews. If any of the incidents appear appropriate that doctor can offer assistance. These group of calls were: one asystolic drowning (that survived subsequent to the doctor's interventions), two serious road traffic accidents (one with a patient dead at scene, the other with a multiply injured patient), one hoax shooting, a cardiac arrest, a hanging, and four minor road accidents with no serious injuries.

Times of calls

There was a trend towards more activity at the weekends and early evenings. The time and day of the week on which doctors were called are presented in figures 2 and 3. The number of calls was too small to determine the statistical significance of the distribution.

Medical interventions

Interventions were performed at 45 of 75 (60%) cases. These are presented in figure 4.

Ten different drugs were used: midazolam, ketamine, atropine, lignocaine (lidocaine) as local anaesthetic, three types of opioids, chlorpromazine, entonox and oxygen.

Analgesia was administered in 23 of 75 (31%) of all cases, most of these for road traffic accident victims. Opioids were used five times; ketamine 11 times; midazolam was added to an analgesic agent five times; a nerve block was used once; and entonox was give to one patient. Analgesia and anaesthesia were commonly administered to trapped patients (four of seven cases).

Midazolam was used eight times; seven times for sedating agitated patients and once purely for anxiolysis. Among the agitated group it was used to sedate patients whose agitation was attributable to pain four times and for psychoses three times. It was used at two RTAs. On three occasions it was used with ketamine.

Ketamine was used 13 times by four doctors, 11 times for analgesia and twice to induce anaesthesia. It was used in 17% of RTAs (7 of 40). The two times it was used for anaesthesia were among this group, both with prolonged on scene times because of entrapment (on scene anaesthesia >1 hour). The remaining 11 cases were for analgesia (10 patients with fractures and one impaled patient).

Seven deaths were certified by doctors; five at three RTAs, one at a factory, and one for a patient found hanging.

In four cases doctors reported that they had influenced time at the scene; encouraging prompt evacuation to hospital after recognising time critical injuries. No scene times were recorded.

DISCUSSION

Immediate care doctors are a limited resource and are of potential benefit in only a minority of ambulance work. Further work is required to optimise the call out thresholds and procedures. The high rates of morbidity (and indeed mortality) identified in the “intercepted” radio calls (when a doctor was not activated by the ambulance service) suggest that at present, immediate care doctors are not used to their full potential. In this study, we were unable to collate accurate data on scene times when prehospital doctors were deployed. Clearly, this needs to be examined in future studies and investigated as part of the ongoing evaluation of prehospital medical activity.

To optimise the call out rate, a good relationship with the local ambulance service is essential. They need to be made aware of the potential of immediate care doctors in different scenarios. Similarly, they need to understand when the presence of a doctor is unlikely to be of additional benefit.

In this series it seems that a doctor was of benefit in road accidents where there were entrapped casualties, and in those involving trees, pedestrians, and motorcycles. Other predictors of high morbidity and mortality were accidents involving high velocity impacts, car disintegration, car roll, severe intrusion, and ejection from the vehicle. Where of benefit, the doctors either provided care beyond the remit of the paramedic or influenced scene management. Further work, and more scene information is required to identify other scenarios that should initiate the activation of a prehospital doctor. This will lead to an evidence based protocol for call out criteria.

The data for this series were collected by freehand email. It is clear that a lot of on scene activity was not reported in this way. A standard computer based proforma is required to collate this additional information. A proposed form for all prehospital doctors is presented in appendix 1. Use of such a form on email groups could facilitate a national audit and in turn would enable BASICS to identify the nature and extent of prehospital activity around the country. This would assist in determining the contribution of prehospital doctors in different scenarios and would identify training and funding needs. It would assist in monitoring the difference that training to different standards confers on doctors. Funding will be dependent upon proving our worth.

During the period that this email review was conducted, prehospital doctors in the schemes were dispatched by the ambulance service only after an initial assessment of the scene by an ambulance crew, thus often wasting valuable time. The scheme subsequently entered into an agreement with the ambulance service that doctors would be called out after receipt of an emergency 999 call by virtue of the reported mechanism of the event, and not after scene assessment by an ambulance crew. Initially, it has been agreed that doctors will be called to accidents where there are reports of entrapped patients. This agreement was in part facilitated by email group awareness of the nature of the scheme's current activity mediated by email discussion.

The majority of SoliCare and Centre Care doctors do not work in the same institution or live close to one another. They do not meet on a regular basis. An email forum was established to facilitate discussion and audit. In an age of clinical governance and accountability, we need to prove value, worth, adherence to standards, and a difference to the outcome. We need to define the role of the prehospital doctor in Britain and to maximise patient care and minimise unnecessary call outs. The collation of standardised data is essential to this task. Email provides an invaluable medium for this purpose.

In this study we have presented an overview of recent prehospital medical activity in one area of the country. This is an important first step in auditing this activity. Clearly information detailing scene times, patient scoring, and patient outcomes is required to establish a more meaningful audit cycle. Future work will examine these areas. This requires greater communication between receiving hospitals (particularly those that enter data into National Trauma Audit and Research Network) and prehospital groups. Established hospital centred audit programmes need to feed back information to prehospital groups to disseminate relevant information about patients who received prehospital care back to the prehospital groups. Email can facilitate this process. This will be of great importance in an age of accountability and clinical governance. Prehospital doctors therefore need to collate and submit data in an honest and accurate manner. Communication links need to be established between prehospital groups and hospital audit coordinators.

Appendix1: Proposed proforma for logging prehospital activity

Date: Weather conditions: dry/wet/icy, etc

Day: Contact method:

Time of call: Access difficulties:

Time at scene:

Time clear of scene:

Description of case as given by ambulance control:

Description of case and events:

Equipment used (where appropriate please state which and how much):

Airway adjuncts Oxygen

IV access Fluids

C-spine collar

Drugs:

Other: RSI, surgical procedure, etc

Influenced on scene time? How?

Hospital alerted Y/N

Accompanied patient to hospital Y/N

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