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From: [log in to unmask] <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>;
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Date: 10 June 1999 17:50
Subject: Pre-Hospital implications ....


>Pre-Hospital implications of the British Orthopaedic Association and the
>Royal College of Surgeons of England trauma reports 1997: an alternative
view
>McGeehan DF Pre-Hospital Immediate Care 1999;3:109-12
>
>Danny
>Congratulations on a well-reasoned response to this paper.
>
>Although I understand what Keith Porter and his colleagues are trying to
>achieve, I think that you have highlighted how much of the argument is
based
>on extrapolation of data from other systems, which come from a different
>paradigm (your comment on penetrating trauma in the UK is well-made).
>
>In the more remote parts of England and Wales, and certainly in the
Highlands
>of Scotland and Ireland, Hospitals serve much smaller populations, and are
>much more sparsely located. In Lincolnshire, we have 3 DGHs, covering the
>third-largest county in England, and the county with the highest road
>fatality rate per capita.
>
>Using the transfer and bypass approach would mean our casualties taking
>something like 2 hours to get to the Trauma Centre (or 30-60 minutes by
air).
>Our Air Ambulance Service (which, incidentally, often carries a Doctor, one
>of the few outside London so to do) operates under CAA guidelines, by day,
>and weather restrictions, such as lightning risk, often mean that the
>aircraft is unavailable. Even if it were, the flight time from its base in
>Lincoln, out to the Lincolnshire coast, is about 15 min. Add to that any
>on-scene time, and the return flight to a regional centre, adds up to
>something like 60-90 minutes from call to resuscitation.
>
>If we are to expedite the transfer of critically-ill patients to regional
>centres, where their injuries can best be treated (if, indeed that has ever
>been incontrovertibly established?), we must deploy the skills of BASICS
>Doctors, Paramedics, A&E Doctors/Nurses, and Intensivists together, rather
>than shouting at one another and protecting our own domains. If rural
>medicine teaches us nothing else, it is the value of teamwork.
>
>I know that few of my Paramedic friends will relish the responsibility of
>escorting unstable patients past the door of one A&E Dept, to drive 40
miles
>to another, for the sake of a 3.5% reduction in mortality.

This also highlghts a major problem that paramedics suffer. One set of
doctors wants us to do one thing and another set wants us to do something
else. We are pushed from pillar to post (such as fluid resuscitation - first
it is right then it is wrong). We can only do what we are told. When we do
what we are told, reports come out telling us we are not achieving anything
worthwhile and the report makes out that we are in the wrong.

I thought the report by Health Technology Assessment people was heavily
weighted in order to say what the authors wanted to say in the first place
and they blamed paramedics for the increased mortality and morbidity. I felt
that the data was collected in a very poor manner, with patients included
when they didn't quite fit the original criteria and patients with a certain
length of stay in hospital included when they shouldn't have been. They
couldn't even tell if the patients had been treated by paramedics or
technicians in one service as the information wasn't available.

As you say, urban and rural trauma are very different and most studies and
opinions seem to be based on the patient being round the corner from the
hospital. A great deal of the country is a long way from a DGH and with
centralisation, such as in Kent, more communities are becoming more isolated
in hospital terms.

The further you are from a hospital, the more you need a doctor.
Unfortunately, it seems to be harder and harder to get a doctor in rural
areas, especially at night and weekends. I am constantly being told that I
can't have this, that or the other equipment or drug because I don't have
the training. In that case, train me properly or get me somebody who does
have the training, ie a doctor. That way it wouldn't make quite so much
difference if the travel time to hospital was 45 minutes (which,
incidentally is common in the area I work).

If the doctors want distant pre-hospital care to improve, they should either
train the paramedics or get out there and do it themselves. (BASICS and
their doctor members are honourably excluded from this). Unfortunately,
there are far too few doctors to go around, so I think that one good
solution would be to provide more training for paramedics. But then I would
say that, because I am biased. :-)

Stephen Dolphin
Paramedic




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