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Debate for Debate…: a License to Practise Pre-Hospital and Retrieval Medicine Rmackenzie,Dbevan

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Debate for Debate…: a License to Practise Pre-Hospital and Retrieval Medicine Rmackenzie,Dbevan 286 .................... PREHOSPITAL CARE Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from Debate For Debate…: A license to practise pre-hospital and retrieval medicine RMackenzie,DBevan he provision of on scene medical support to from simple first aid and basic resuscitation to ambulance services in the UK is fragmented, high stakes critical care interventions. The Tdisorganised, and largely unregulated. development of modern ambulance services has Recent and evolving educational, professional, further polarised this activity. At one end of the and regulatory developments in medical practice spectrum, there clearly remains a need for basic now provide an opportunity to remedy this first response capabilities in rural areas. This has situation and ensure that ‘‘immediate care’’ is been recognised through initiatives such as the governed and regulated in the same way as any NHS Scotland Remote and Rural Areas Resource other specialist undertaking within the NHS. Initiative (which provides funding for standar- Immediate care has been defined as the dised training for remote and rural medical provision of skilled medical help at the scene of practitioners)12 and immediate care scheme an accident or medical emergency and during involvement in development of community transportation to hospital.1 Well before the based lay response systems. At the other end of development of modern ambulance services and the spectrum, there also remains a need for the recognition of accident and emergency specialist on scene and in transit medical (A&E) medicine as a specialty, general practi- support. The most common examples in our tioners (GPs) were required to deal with increas- experience are the patient with immediately life ing numbers of critically injured patients in the threatening asthma and respiratory failure who pre-hospital environment. Their response, in is remote from hospital, and the seriously injured most parts of the UK, was to form themselves vehicle occupant who is trapped at the scene. The into voluntary associations and create a frame- relative infrequency of such patients does not work within which their training, equipment, diminish their critical care needs or the impact and operational activity could be organised and that they have on NHS resources. There seems funded.1–3 These ‘‘immediate care schemes’’, in little doubt that the timely intervention of a stark contrast to the systems developed in the competent specialist with the full range of United States and elsewhere in Europe, were, critical care skills can have a major impact on and still are, funded almost entirely through such a patient’s journey, in terms of early charitable donations. diagnosis, meaningful interventions, triage, or In some parts of the country, hospital practi- advocacy.13–16 The care of such patients often tioners have also played a role in the provision of requires difficult clinical decisions that are likely http://emj.bmj.com/ immediate care, either through ‘‘flying squads’’ to remain beyond the scope of most healthcare or mobile medical teams or by individual professionals employed by ambulance services membership of immediate care schemes.23 for the foreseeable future.17–20 We would argue Some hospitals continue to deploy mobile teams that many of these decisions and interventions at the request of ambulance services. are likely to also be beyond the scope of the Unfortunately, the provision of such services ‘‘occasional’’ or ‘‘fringe’’ immediate care doctor. continues to be unpredictable, and there are very Given the emergence of ‘‘intermediate’’ care wide variations in availability, funding, training, and confusion surrounding the medical practi- on October 1, 2021 by guest. Protected copyright. experience, and equipment.4–6 There also appears tioner’s contribution to pre-hospital care, we . R Mackenzie, Consultant to be considerable uncertainty regarding the propose that the term ‘‘pre-hospital and retrieval . in Accident and composition, training, and role of hospital . Emergency Medicine medicine’’ be used as a more accurate description . mobile medical teams in incidents that are not . and Medical Director, of this area of specialist practice. In our current . MAGPAS, St Ives, declared as major incidents. practice, we frequently attend incidents in rural . Cambridgshire, UK . Regardless of their background, the core areas, provide on scene medical care, undertake . activities that define the clinical practice of . D Bevan, General procedural sedation or emergency anaesthesia at . immediate care have remained essentially the scene, and take responsibility for in transit . Practitioner and . Immediate Care Doctor unchanged over the last 40 years. They can be medical care for 30–60 minutes. We believe that . MAGPAS, St Ives, defined by scrutinising the activity of individual this represents a specialist function within the . Cambridgeshire, UK . schemes and doctors and ambulance service Ambulance Service spectrum of activity. The . 2 7–11 . Correspondence to: medical advisors and directors. In our concept of ‘‘pre-hospital and retrieval medicine’’ . Dr R Mackenzie, experience, this practice includes direct clinical . Mid Anglia General . care at the scene and during retrieval to hospital Abbreviations: A&E, accident and emergency; BASICS, . Practitioner Accident . (in transit care), scene management, major British Association for Immediate Care; CCT, Certificate of . Service (MAGPAS), . St Ives, Cambridgeshire incident management, clinical leadership (for Completion of Training; DoH, Department of Health; GP, . general practitioner; GPwSI, General Practitioner with . PE27 5WF UK; roderick. example, medical director functions) and sup- . mackenzie@magpas. porting professional activities such as training Specialist Interest (GPwSI); JCPTGP, Joint Committee on . Postgraduate Training in General Practice; PHEC, Pre- . org.uk and education of ambulance service personnel. hospital Emergency Care; PMETB, Postgraduate Medical . Accepted Doctors involved with immediate care have Education and Training Board; STA, Specialist Training . 30 December 2004 historically undertaken a spectrum of activities Authority www.emjonline.com For debate: A license to practise pre-hospital and retrieval medicine 287 .................... being considered as a specialist endeavour rather BASICS accreditation standards to doctors who than an occasional pursuit is not new.12122 The deliver a clinical service (box 1). Organisations Emerg Med J: first published as 10.1136/emj.2004.020636 on 23 March 2005. Downloaded from glaring inconsistency between the requirement that employ doctors, such as the London Debate for a predominantly consultant led emergency Helicopter Emergency Medical Service (HEMS) department phase compared to a paramedic or and Great North Air Ambulance (GNAS), do not technician led pre-hospital phase for the same require applicants to hold and/or maintain critically ill or injured patient is now, however, BASICS accreditation. Similarly, A&E depart- more difficult to defend other than on historical ments who routinely send doctors to incident grounds. It is clearly recognised that time to scenes do not require them to be BASICS meaningful intervention related to injury pattern accredited. The accreditation standards them- is probably the most important determinant of selves are also widely regarded as primarily survival following traumatic injury.23–25 There is aimed at the occasional practitioner in rural no doubt that short scene times and rapid areas (for example, completion of a 3 day Pre- transfer to the appropriately staffed and prepared Hospital Emergency Care (PHEC) course). Those hospital should be the norm for most patients, organisations that have applied standards tend but what of those who cannot be transported to use the Dip IMC as a benchmark. This has (entrapment) or who have urgent pre-hospital been recommended as the minimum qualifica- critical care needs that cannot be met from tion for doctors regularly called out by ambu- current paramedic or emergency care practitioner lance services by both BASICS and the Royal education and training? In addition, trauma care College of Surgeons.12627 Despite this, the Dip systems are changing, with the recognition that a IMC is not a minimum requirement for BASICS balance has to be struck between local hospital accreditation and it has not become a mandated access and the concentration of multispecialist prerequisite for operational activity supporting expertise in regional centres.26 A regional trauma ambulance services. system further increases the need for on scene medical care, selection of the most appropriate THE FACULTY OF PRE-HOSPITAL CARE facility to meet each patient’s needs, and safe The Dip IMC is administered by the Royal retrieval to that facility. There is currently no College of Surgeons of Edinburgh and its system, training stream, or workforce in place Faculty of Pre-hospital Care. The faculty was across the UK to ensure that the needs of these formed in 1996 with the central aim of setting patients are met in a consistent or organised and maintaining standards of practice in pre- manner. hospital care. The Dip IMC has undergone extensive development and is now open to BASICS nursing and paramedic professionals. The British Association for Immediate Care Paradoxically, the current regulations for the (BASICS) was formed in 1977 with the aim of Dip IMC require ‘‘documented evidence of becoming the national co-ordinating body
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