Trauma: we care. More for discussion

Abstract

I read with interest the recent letter by Zafar et al. [1] and felt that some of the issues raised required clarification. Firstly, there seems to be some confusion in the letter between transfer/retrieval medicine and pre-hospital medicine. Transfer and retrieval in civilian practice in the United Kingdom is concerned with delivery of patients between hospitals, i.e. patients who have already been admitted to a medical care facility. Pre-hospital medicine may include this role, but more commonly refers to ‘the provision of skilled healthcare at the site of a trauma incident or medical emergency’ [2]. Secondly, the authors also make reference to pre-hospital tracheal intubation, implying that paramedics intubate trauma patients. Paramedics in the United Kingdom currently do intubate patients, but only those who do not require pharmacological agents to assist intubation. This group of patients, in the context of trauma, have a near 100% mortality rate [3]. Rapid sequence induction of anaesthesia is only performed currently by pre-hospital doctors. This seems unlikely to change in light of a Joint Royal Colleges Ambulance Liaison Committee report of June 2008, which states ‘paramedic tracheal intubation cannot be recommended as a mandatory component of paramedic practice and should not be continued to be practiced in its current format’ [4]. The authors seem to suggest a retrieval system based on the military model, presumably referring to Medical Emergency Response Teams, currently operating in Afghanistan. A typical Medical Emergency Response Team setup will include a consultant or senior trainee anaesthetist. As the authors rightly state, medical treatment is started en route to base, in the back of the helicopter. Cramped as it may be, a CH-47 helicopter is still a great deal larger than the majority of civilian air ambulances. There are also restrictions on when civilian air ambulances may fly without an instrument rating; some may not carry passengers after dusk. Most are not based at the site of tertiary referral or trauma centres, necessitating a crew waiting at the airfield and removed from other clinical work. In particular, I find the suggestion regarding a Physician’s Assistant being utilised in retrieval particularly worrying. The Royal College of Anaesthetists explicitly states that Physician’s Assistants must not undertake initial airway assessment and management of acutely ill or injured patients and cannot work without a named consultant being both within the theatre suite and being immediately available [5]. The authors summarise by calling for raised standards for transfer training, which appears to be a perfectly reasonable aim. There are already many in the pre-hospital community who are working tirelessly towards raising standards in the field of pre-hospital care. It is important however that we don’t lose sight of the issues surrounding each speciality by confusing transfer/retrieval medicine with pre-hospital care.