Immediate care: specialty or pastime?

Abstract

In many parts of the country doctors are providing a pre-hospital emergency service in the form of immediate care schemes. These schemes consist of volunteer doctors who are called out by the local ambulance service and aim to provide another tier of response beyond that of the paramedically trained ambulanceman. The recently published report of the British Medical Association (BMA) Board of Science and Education acknowledged the works of the British Association for Immediate Care (BASICS) as a valuable national resource and recognized that the doctor has an important role in the pre-hospital care of patients, beyond that given by the Level 2 paramedics in the UK (British Medical Association, 1993). The report recommended that central financing should be made available and that formal training and audit of immediate care is established. Some organizations consulted for the above report considered that there was a declining role for the doctor at the scene with the increase in the number of paramedics. Much of the evidence for the value of paramedics has been imported from North America. The British paramedic is only a Level 2 paramedic (infusion, intubation and limited drug therapy) as opposed to the Level 4 training for full paramedic status in the USA. Training and continuing education in the USA, including audit, far exceed those in the UK. Baxt demonstrated a 35 per cent improvement in mortality in a group treated by doctors rather than Level 4 paramedics (Baxt and Moody, 1987). It has been correctly stated that ‘it is unreasonable and unrealistic to expect a paramedic to exercise the degree of diagnostic acumen, clinical judgment and surgical skill’ of a doctor (Holden, 1993). The undertaking of any practical procedures is recognized to be the easy part. The skill lies in the decision to undertake it and the timing. More than in any other area, the decision on delaying a procedure is a key element in immediate care. Most procedures will have a higher morbidity in the field and will delay transfer to hospital. It takes considerable experience to decide on the relative benefits of early intervention versus rapid evacuation. A doctor has flexibility in management that can allow time to be saved at the scene; in contrast, paramedics work to fixed protocols which can result in unnecessary delay. It is, however, extremely difficult to audit this aspect of the medical contribution to patient care, and hence most studies look at the technical procedures that can be undertaken by medical staff that are beyond the skills of a Level 2 paramedic. The BMA report also highlighted some of the problems behind immediate care, including the lack of appreciation of the practice of immediate care by some experts. At present, immediate care suffers from the variability of the service. The geographical cover is patchy over the country. Some schemes can only offer cover on a part-time basis. The medical training of the individuals concerned is inconsistent. Some possess Advanced Trauma, Cardiac and Paediatric Life Support Certificates. Many have attended the specialist courses recognized by BASICS. The derogatory use of the term ‘general practitioner’ for an individual so-trained is inappropriate and inaccurate as many schemes also have hospital doctors as members. Unfortunately there are also general practitioners who have no specific immediate care training. It is these doctors who are open to the criticism that they may be no more skilled than an ambulance paramedic. There are, however, many skills that they will possess and use in their everday practice that will complement those of the paramedic. The major area of deficit in their training will, however, be pre-hospital trauma care.