I'm really not trying to say that you don't know how to work in the
pre-hospital environment. What I am saying is that suitably trained
doctors who work outside of hospital have more to offer patients with
critical problems than paramedics. They will encounter times when they
cannot succeed in what they try to do. The questions that must be asked
every time are "Would this patient have been better without an
intervention?" "Was the attempt at intervention justified" and "Could
someone with more skill have done better".

Sometimes the answer is the more experienced person could have done
better, but they weren't there at the time. When all anaesthetists are
prepared to give their spare time to riding on ambulances then I will
hang up my green helmet. Till then I reckon the guy in the car wreck has
a better chance with me than without me.

Vic Calland
Eventmed UK Ltd
Training & Development beyond First-Aid
Visit the website: http://www.eventmed.co.uk

-----Original Message-----
From: [log in to unmask]
[mailto:[log in to unmask]] On Behalf Of Fiona Wallace
Sent: 26 March 2003 21:37
To: [log in to unmask]
Subject: Re: The New GMS contract, GPwSI's, Immediate Care and the
Countryside Alliance


The patient who cannot be ventilated by any means turns up more
frequently
than you would expect; I had one and was bailed out by a senior
anaesthetist, within a couple of months the same happened to another SHO
in
a nearby hospital - with no senior available. That patient died.

I have no quibble with intubating patients prehospital - most of them
are
cold intubations, without drugs, in which case I'd estimate that the
average paramedic is at least as well trained as the average GP.
Castigating doctors for being 'frightened' outside the hospital
environment
avoids considering the fact that it may be a well founded fear of an
inappropriate intervention (RSI) performed by a practitioner with little
opportunity to maintain skills in such intervention and assess the risk
and
predict difficulty.

I find it strange that those GPs wanting to perform such prehospital
procedures have such contempt for colleagues with experience of
anaesthetics/critical care/A&E/prehospital care expressing caution.

Fiona.

>
>The patient who cannot be ventilated by any means available is almost
>non-existant. For some patients cricothyrotomy with a cuffed tube
before>
>you flatten them is the sensible approach. For others you may need a
>Combitube, AMD or LMA. For those with laryngeal fractures you may need
t>o
>resort to needle jet insufflation at the traditional tracheotomy site
of
>the 4th ring, but your old anaesthetist friend presumably didn't bother
>about the secondary brain injury that results from an ambulance journey
>whilst hypoxic. The "experts" in intubation in hospital are often
terrif>ied
>about pre-hospital airway management because they are terrified of the
>environment, not because of the technique that is required.
>
>Any competent pre-hospital care doctor will not play on scene
>unnecessarily, but failing to secure A's & B's pre transport is
>unforgivable. If you actually review the studies done, then the failure
>rate is low, and the benefits definitely outweigh the risks.
>
>Vic Calland
>
>Original Message:
>-----------------
>From:  [log in to unmask]
>Date: Sat, 22 Mar 2003 22:32:23 GMT
>To: [log in to unmask]
>Subject: Re: The New GMS contract, GPwSI's, Immediate Care and the
>Countryside Alliance
>
>
>
>An old anaesthetist/intensivist once told me...
>
>'I'd much rather manage a patient with an aspiration lung injury than
one
>whose airway was lost at the side of the road during a RSI'
>
>Paramedics/techs can support an airway and hand ventilate. An
experience>d
>intubator with an A&E team might choose RSI, when intubation w/o drugs
(my>
>preferred option) isn't available. I had a paralysed, unintubatable,
>unventilatable patient once. That sort of thing scars you (and scares
yo>u).
>
>Very few situations where BVM is inadequate. Even fewer in urban areas
w>ith
>short transport times. These are some of the worst airways in the worst
>circumstances, and I'm sorry, but I'm of the firm opinion that GPs
should
>not be managing them.
>
>MBBS does not a skilled intubator make (nor does a 10 year old
DipAnaes)
>
>Fiona.
>
>
>>Since I started this off I might butt in that airway management in the
>GCS>
>>challenged was exactly what I thought medical input was for.
>>
>>Vic Calland
>>
>>Original Message:
>>-----------------
>>From: Danny McGeehan [log in to unmask]
>>Date: Tue, 18 Mar 2003 22:09:58 +0000
>>To: [log in to unmask]
>>Subject: Re: The New GMS contract, GPwSI's, Immediate Care and the
>>Countryside Alliance
>>
>>
>>
>>> None the less, I think few of us would advocate victims being
bundled
>in>to
>>> the back of the nearest taxi/police car and driven to A&E by
untrained
>>> passers by.
>>>
>>Well there was the famous Yellow Cab study published I think in 1996
by
>>Demetriades from the University of Southern California which showed
that
>>the latter group.  the yellow cab and police car patients did better
th>a>n
>>the group transported to hospital by paramedics.  It was almost
>>sacriligious at the time.
>>
>>Best wishes
>>
>>Danny McGeehan
>>
>>--------------------------------------------------------------------
>>mail2web - Check your email from the web at
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>>
>>
>>
>>
>
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