I concur with the view of the evidence expressed by others on this list-
prehospital interventions other than simple airway manouvers have not been
shown to be of benefit in trauma. I would say, though that Dr Mattox's view
on permissive hypotension- that preoperative fluid resuscitation in trauma
is a bad thing- is an extreme view (just because I happen to agree with him
doesn't alter that fact). There have been a few RCTs comparing different
amounts of fluid in trauma (Cochrane review Kwan I, Bunn F, Roberts I, on
behalf of the WHO Pre-Hospital Trauma Care Steering Committee. Timing and
volume of fluid administration for patients with bleeding following trauma
(Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update
Software showed increased mortality with early fluid resuscitation, but with
the 95% CIs for RR just crossing 1.0). The main study that Dr Mattox quotes
(and the only one to hit significance) was confined to penetrating thoracic
trauma.


> before I go any further, I would need to know just what
> exactly GPs are
> doing 'at scene' that cannot be performed by a paramedic or
> forward A&E
> team, and that there is a firm evidence base that these interventions
> improve outcome.

Or indeed by a non paramedic ambulance crew

> >(iv) for immediate care and first responder services. Rural
> and remote
> >GP's are often more involved in the provision of emergency
> care outside
> >the setting of their surgery or a local community hospital. This work
> >requires extra training (e.g. BASICS) equipment, resource, commitment
> >and reward. Under the new contract, these services will be
> commissioned
> >and funded as an enhanced service. PCO's will normally wish to
> >commission such services where land ambulance response times are
> >relatively long or the practice is remote from the nearest
> appropriate
> >hospital.


It is a bit different. In London, West Midlands etc. it is usually possible
to get a land ambulance to the patient within 15 minutes of the call, and
rarely more than 30 minutes transfer time from scene to hospital. In parts
of rural Scotland (and to a lesser extent, Wales), the times are much
greater. There is a stronger case there for more prehospital intervention in
medical cases (although trauma remains arguable).

> >It does however also now mean that BASICS schemes will have an uphill
> >struggle to prove where Immediate Care really is needed. We
> really need
> >a national database for ALL medical call outs to pre-hospital care
> >incidents, analysed by post-code, so we have an evidence base for our
> >case. This really must be one of our highest priorities in BASICS.

As a prehospital care provider myself, I am in complete agreement. The
greatest priority is to lay a sound research basis for which patients should
be treated by which interventions delivered by people with which skills
(accepting that this may mean rejecting much of what we do, and may require
people with a higher level of training than currently found- and I include
my own training as quite possibly inadequate to deliver the rest)

Matt Dunn
Warwick


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