If your going to do a *quick* introduction to pre-hospital care then there
are 3 areas I would look at where pre-hospital care differs from
in-hospital.  (I'm assuming this is a general discussion, but I've included
comments relevant to hospital away team members in brackets).

1.  Safety
2.  Kit (and how it differs from hospital equipment)
3.  Stay and play or scoop and run

Most doctors have come across a road accident at some time in their career,
and most find it quite traumatic to suddenly and unexpectedly be thrust into
an unfamiliar environment.

If you ask the group about their experiences of this (in a Pendelton sort of
way...) then this should bring out issues from the 3 areas above.

1.  Dealing with safety is paramount - last year an off duty nurse was badly
injured and an off duty paramedic was killed by being struck by passing
traffic at the scene of two separate incidents on the M6.
  
So safety of self, safety of scene, safety of casualties.
All doctors should have at least a reflective vest in their car (£35 SP
Services 0500 676999) and two warning triangles.
 
Consider where to park your car so as to protect the scene if you are first
there but beyond (or within) the scene if the police are already there. Use
the "fend off" position by parking at an angle to maximise your visibility.
Lay out your warning triangles if necessary.  If you do end up tempted to
get involved in an extrication at the very least borrow a hard hat with face
mask.

Make your casualties safe by turning off their car ignition, etc.

Remember the Scottish Ambulance Service say "Dead Heroes Don't Save Lives"
and the Confucious saying "Blight jacket and flashing lights not make man
immortal".

(From a hospital team point of view reinforce that the PHC environment is a
hazardous one and they should have a squad suit with knee pads, heavy duty
gloves, hard hat and visor and heavy boots.)


2. Kit - you can only carry so much so you have to make compromises, oxygen
runs out at the most inappropriate times, suction is often hand operated,
finding stuff in a rucksack at night is a nightmare.  You are limited to how
many of each item you can carry, so when something breaks you can be stuck.
Improvisation and lateral thinking can be required.

Keep it simple.  Minimum kit for any doctor's car - latex gloves, tuff cut
scissors a set of OP and NP airways, a pocket mask and dressings to stop
heamorrhage.  

(Hospital kits should be standardised and - like defibs - you should have
familiarised yourself with it before you need to use it.  You can see my
equipment list at http://www.coull.net/equip.html)


3.  Scoop and Run/Stay and Play - in fact common sense needs to be applied
to each case (this is the really difficult part about PHC, there are so many
variables that it is impossible to provide hard and fast rules).

Keep it simple at the scene.  Each intervention takes time and needs to be
justified.  Remember, the risks of many procedures are higher in a more
chaotic environment with less equipment and staff.  In general airway and
breathing problems you sort out at the scene, circulation problems can wait
until you are mobile in the vehicle.

(Hospital team members - consider alternative airway kit for difficult
access situations - combitubes / LMS.  Practice intubating mannequins from
odd angles to simulate access from a sunroof or patients trapped on their
side etc..)

My best advice is that anyone who is going to be doing PHC should arrange a
ride-along with the local ambulance service as this is invaluable in
familiarising yourself with the environment and the way ambulance crews
operate.

I can't think of any good web sites with teaching material off the top of my
head, but I'll post your request to the 999 list to see what they come up
with.



Robbie Coull

email: [log in to unmask]             website: http://www.coull.net


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