I suppose you're looking at setting up the ambulance as a mobile ITU. Seems
sensible therefore that whoever accompanies the patient should have relevant
skills (i.e. regular ITU experience, not just some training in the past).
Not sure that many of us in A and E have appropriate airway skills either
(i.e. ability to deal with a dislodged or blocked ETT in a difficult
intubation in the back of an ambulance without an ODA)- simple airway
manoeuvres can be done on the move better by paramedics. The specific skills
and level of experience needed for a transfer will vary from patient to
patient.

> Such a person is often
> present in an
> A&E department, but probably not present in most departments
> 24/7.  Indeed
> can A&E departments afford to denude themselves of such a doctor when
> present ?

If your department has staff it can afford to lose to do transfers you're
doing pretty well. Maybe in hospitals with resident middle grades and
consultants on call from home it would be possible to send the middle grade
out and use the consultant (who would presumably usually be in dealing with
the patient anyway) in to cover- as some anaesthetic departments do, but
that's potentially a lot of night time hours up and working for the
consultant. Alternatively in larger departments, send the consultant on the
transfer and have a second on consultant to cover to on call. We may find
ourselves pushed towards this as the EWTD hits anaesthetic juniors- I can
see anaesthetists wanting to pull out of the transfer duties.

>
> And what of critically ill (but stable) patients, say:
> 1) aortic tear,
> 2) grade 2 subarachnoid haemorrhage,
> 3) unstable high cervical spine fracture with normal neruology
>
> Should junior A&E staff (ever) transfer such patients ?

Depends on what you're planning on doing with the patients. I can't see any
advantage of sending a doctor or nurse unless they have skills not possessed
by the paramedics and which they may reasonably be called on to use during
the transfer (and the definition of how frequent 'may reasonably be' is an
economic one). Personally I'm not sure I (let alone one of my juniors) could
contribute anything if a patient with an aortic tear or unstable spine
deteriorated during transfer. SAHs where you thought deterioration might
occur I'd probably go for intubation prior to transfer rather than
transferring with someone with intubation skills (mind you, I haven't done a
RSI in anger for about 10 years, so that probably counts me out on that one
as well).
In general I can't see a circumstance in which it would be appropriate to
send an SHO.

>
> BAEM and the Faculty do not have a position statement on this
> issue, should
> we ?

Yes

Interhospital transfer seems to be left a bit to chance. In my experience
there's a lot of wasting of resources (often a doctor or nurse is sent when
there is nothing useful that that particular person could do in any likely
circumstances- my first transfer was as a JHO with a patient with bleeding
varices- I think the idea was that the patient needed a doctor rather than
needing anyone with any specific skills).
The best transfers I've seen have been where the receiving rather than the
referring hospital provides the team. From your figures it looks like a
typical DGH will be doing around 10 transfers a week. Seems sufficient to
support a separate specialisation of 'transfer medicine' (whether as a
subspecialisation of A and E, anaesthetics, prehospital care or whatever);
particularly if run on a regional or even supraregional basis (possibly with
use of helicopters to transport the transfer team to the referring hospital
in some cases). I don't think A and E can take this on within existing
resources and with our existing levels of training and ongoing experience.

Matt Dunn
Warwick


This email has been scanned for viruses by NAI AVD however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicitly stated.
If you have received this email in error, please notify the sender.