Airborne medics save lives

[Heliport]

From the Health Service Journal

Airborne medics save lives claim helicopter charities

A charter for air ambulances is fuelling debate over the future roles of air and land ambulances. Four independent air ambulance charities have signed up to new standards including a commitment to 'pre-hospital care doctors' on flights.

The first UK helicopter emergency medical service charter covers skills, additional training and supervision. It has been adopted by Great North Air Ambulance and services for London, Essex and Hertfordshire, and Kent, Surrey and Sussex.
The charities believe on-board doctors will help save lives and cut costly hospital transfers.

Conventional crews such as London Ambulance Service trust are trialling new ways of working, including taking some patients with coronary symptoms straight to specialist treatment centres. Most land ambulances do not have on-board doctors.

Kent, Surrey and Sussex Air Ambulance chief executive David Philpott told HSJ that fewer emergency departments and increased traffic, combined with efforts to improve patient care, will mean a move away from simple 'swoop and scoop' air ambulance services.

Doctors at the scene can refer severely injured patients directly to specialist centres rather than the nearest hospital. He called on the government to increase funding to reflect this shift in practice.
Mr Philpott estimated each on-board doctor costs up to £300,000 a year, which would mean an annual bill of nearly £7m to fund doctors on all 23 air ambulance helicopters operating in the UK. All 15 UK air ambulance services operate as charities.

London's Air Ambulance chief executive Andrew Cameron said services will increasingly be about getting senior medics to patients at trauma scenes to stabilise the injured.

A Department of health spokeswoman said the DoH recognised air ambulances could be 'an effective way of getting better and faster access to hospitals and valuable in supporting inter-hospital transfers', and added that the NHS already met the cost of most clinical staff. She said: 'It remains for NHS trusts to decide whether they provide any additional funding to air ambulance charities.'

A spokesman for the Ambulance Service Association said it was unrealistic to have doctors on all land ambulances but paramedics would welcome the chance to play a greater role in referring cases to a specialist service rather than the nearest district hospital.
'Our mandate is to take people to the nearest hospital. If paramedics were properly trained and skilled then certainly they could play an increased role in deciding where a patient should be taken.'

[TeeS]

Well said TripleT

TeeS

[Bertie Thruster]

estimated each on-board doctor costs up to £300,000 a year,


Not sure exactly how this figure was arrived at. Does it mean 3 consultant anaesthetists per unit per year or one GP working on his days off? :E

[Whirlygig]

One GP working on his day off :}. The amount will also include employers NI, pension contributions and the cost of the extra fuel required to lift his weight! :E

Seriously (!), that figure is too high; I cannot see how it's derived.

Cheers

Whirls

[Another Old Git]

Oh well, I really should know better but here goes. Head above parapet....begin.
The word Doctor can be a little generic in use as can the term Pilot.
I am sure that I could find enough PPL pilots to fly my aircraft for 365 days of the year on their days off at a cost to me of....Nil (Well no, but bear with me for the sake of example). Some of their standards might be very high.
Alternatively I might just pay for 3 full time CPL or ATPL holders with the right background and experience such as is often debated on this forum.
The cost to me has to include not just 3 line pilot salaries but the training, equipment, CP, TRE etc. The total costs to me are pretty high, but you get what you pay for.
Now, when that gynaecologist approaches me with their latex gloves twanging on their wrist I might just welcome their approach depending on my situation. Alternatively, if it is to remove my brain tumour, then thanks but I would rather the neuro surgeon started from the north pole and not the south!
The figure of up to £300,000 per anum is the estimated total cost to a charity to employ a full time, fully HEMS and Pre Hospital Care trained doctor who is supervised on a 1:1 ratio of clinical governance by a qualified PHC HEMS Consultant with guaranteed immediate advisory access, HEMS crewmember qualified and PPE equiped, 365 days a year.
As with the line pilot, 3 times basic salary is not the final figure, its all the other on costs.
The launch of the charter is an attempt to try and suggest a gold standard to work to. No one claims it is the only one, or even the right one, but it is a start.

BTW I totally agree with TTT whose conclusion was spot on.

I have had the privilege of working with a whole variety of HEMS teams that include many mixtures.
Police Observer /Paramedic
Technician / Paramedic
Basics Doctor / Paramedic
HEMS Doctor / Paramedic
Perhaps I should include Winchman / Paramedic to complete the possibilities.

If my life were hanging on a thread then I would be a lucky person to see any of those teams turn up, who all make a valuable contribution to the HEMS world.

IMHO the strongest team of all would be a trained HEMS Doctor partnering a HEMS Paramedic, (or very soon CCP) who had the abilty to intervene when needed and fly me straight to the most appropriate place for treatment (not the nearest DGH please!). That combination of skills is world class.

Now back below the parapet. I really should have known better.

[Whirlygig]

Alternatively, the figure of £300k could have just been journalist nuisance sorry, licence!

Having worked in the NHS as an accountant, I would have said TTT's was much more realistic. Only a difference of £100k but that's still a 33% error.

Cheers

Whirls

[mini]

As an organisation the Medical profession appears a strange place to outsiders, AOG's point about a HEMS doc being supervised 1:1 by a dickie bow is a valid point, remember - all docs are considered to be "training" except Consultants...

Is there any research out there on the skills & equipment level of responders vis a vis the stay & stabilise or scoop & scoot argument? Given the relatively short transport times this would appear to be especially relavant to HEMS ops and the costs involved.

[S76Heavy]

I think the Dutch modelled their service after the German system (operated by the automobile club and university hospitals) but performed a study to demonstrate that even in a country with many ambulances available, the doctor on board made a significant difference in the cost of treatment for the patient and therefore it was deemed economically viable to continue the project.

That study should be available.

[FlyerFoto]

I don't see why the monetary figure should be relevant - what is relevant is that Air Ambulance services have to rely on charity!

When you look at the complete and utter cr*p that tax payers' money is spent on, surely there must be a very strong case for services to be publicly funded?

http://paulcoulthread.fotopic.net/p44089317.html

http://angliaone.org.uk

[Whirlygig]

There are arguments for and against Government funding of air ambulances. The most obvious one against is that of control.

Currently air ambulance units can decide where best to spend their resources and, with a smaller management structure, can make quicker changes if circumstances change. Having air ambulances as part of the NHS will force them to operate under that regime with long, drawn-out procurement processes, a myriad of reports and forms to complete and probably an extra tier of management.

Cheers

Whirls

[FlyerFoto]

Thanks Whirls - i must admit, I was thinking that after I'd made the post, the problems of control

Got to admit, though, it does seem ridiculous that, if the support of the public, or other benefactors were to dry up, these services would not be able to operate and yet OUR money is being squandered on all kinds of ridiculous, excessive scemes that don't benefit us at all?

[unstable load]

I am a relative outsider to the AAir Ambo scene, but I am going to toss in my tuppence worth.

The Golden Hour is critical to any trauma and IMHO it would be essential to get the patient stable eneough to transport, then transport them to a facility that has the necessary resources, ie CAT scan, ER, neuro/ortho etc surgeons and that is best achieved by the guys who know that field best, the Advanced Life Support Paramedics.
Unless the doctor is a specialist trauma doctor then he does not belong in the helicopter, and if he IS a specialist trauma doctor then he is best utilised in an environment where he has access to the resources he needs because unless the ambo is a Chinook or S61 he will not be able to access what he needs to best make use of his skills and abilities.

That is my tuppence worth, I will now crawl back under my stone and leave them what knows (or thinks they do) to continue this debate.

[Thud_and_Blunder]

Unstable Load, your post would suggest that your experience of the medical profession is limited in the ways Another Old Git suggested. I've seen Paramedic-only ops and now I've seen pre-hospital-medicine-specialist doctor plus Paramedic ops; the latter is enormously more capable. You can underline all you like, but the standard comment from highly-qualified HEMS paramedics and nurses who now operate with the above-mentioned doctors is "I didn't know how much I didn't know 'til I started working with them!". As an aside, if the doctors and paramedics are part of the crew, not just medical passengers, then their own love of learning new skills and providing feedback to the pilots turns the whole thing into something of a virtuous spiral.

TTT, your points on unnecessary treatment are well made - there is reportedly one paramedic, for example, who is claiming to have done something like 98 RSIs in 7 years. Sounds almost as if its worth investigating for assault charges...

- also, remember that not all helicopters are operated by the Ambulance Service. Those that are operated by the charity on behalf of the Ambulance Service are deciding their own (usually streamlined, politics-free) management systems!

Finally, FlyerFoto: If the system of emergency services being run by charities is so wrong, what would your reaction be to nationalisation of the RNLI?

[FlyerFoto]

Good question Thud!

Not something I've particularly thought of, either!

My main point, however, is still why do essential services have to rely on charity, when money is wasted elsewhere?

[Whirlygig]

why do essential services have to rely on charity, when money is wasted elsewhere?

Probably because we elected the Government we deserve? :ooh:

Cheers

Whirls

[FlyerFoto]

:eek::eek::eek::eek::eek:

Surely not Whirls???

[HillerBee]

In countries like Germany, Austria and the Netherlands there is a doctor on board. Germany and Austria have had air ambulance services much longer than the UK and so a lot of experience. If it wasn't of any advantage they would surely drop it, because they're NOT goverment funded as well. If the ADAC or ÖMTC can save a euro they will.

[unstable load]

Thus and blunder,

Guilty as charged with regard to the experience bit, but I do have some mates who are ALS Paramedics and they have a rather negative view on some of the EMS doctors they have worked with.

Cheers,
UL

[Bertie Thruster]

1......believe only the scottish operations are not charities.

2.....Why do immediate care doctors generally think that they are better at HEMS than HEMS paramedics?

[Thud_and_Blunder]

Apologies for the delay - not everywhere has internet access.

TTT: Thud and Blunder – do you know which UK HEMS operations are charity and not Ambulance operated?

Actually T&B - I am making an assumption that you are in the UK, which on reading your post again, may not be the case.

...there's Kent and Surrey/Sussex, for starters. Not sure about London; I have no direct experience of their ops. Have a look at some of my pics on the HEMS photos thread to see some of the places I operate.

Bertie: 2.....Why do immediate care doctors generally think that they are better at HEMS than HEMS paramedics?

...sounds like bad experience(s) with particular personalities, possibly P****? (I love the smell of alliteration in the morning). Having now had the chance to see these docs work with proper oversight/governance, decent continuity and the full support of the paramedics, I think that the docs who're selected for the job have no difficulty showing that (deep breath) they really are better all-round than our green- (or red-) suited friends. Mind you, the ones that come in with the right attitude are always willing to acknowledge they can learn something from the folk who've been doing it all their working lives. So long as every sortie gets debriefed, there's no room for nastiness or snide behaviour - everyone gets to benefit (especially the patients).

[[email protected]]

The aspiration to have a doctor on board every AA is laudable but hardly cost effective - what percentage of the callouts actually require that extra level of anaesthesia?

I agree that if I was the patient, I would want the best care possible but for most casualties it is the rapid transport to hospital that makes the difference, not having a doctor plus paramedic plus technician etc. You might as well have a Chinook with a MASH team in it for every incident.

[a1w]

From the initial quote-
"Kent, Surrey and Sussex Air Ambulance chief executive David Philpott told HSJ that fewer emergency departments and increased traffic, combined with efforts to improve patient care, will mean a move away from simple 'swoop and scoop' air ambulance services."

Now if I remember correctly - wasnt the concept of the "Golden Hour" the pitch that was used for the fund raising in both Surrey and Sussex for the charity Air Ambulance??

[206 jock]

Another Old Git is about the closest....if you'd like a few facts, here you go:
The £300,000 is an estimate for fully qualified A&E doctors (about 2.5 are required per helicopter, to allow for rotation and to maintain their in-hospital skills too, to ensure their career does not suffer), with governance provided by - for example - Barts and St Thomas' senior clinician team ('the dicky bows'), as per London HEMS. So these guys are not GP's on their days off: they are the real deal when it comes to helping a seriously injured patient, at the point of injury. Of course, also built into the cost is the extra liability insurance required - once you take a doctor to the scene, it confers an extra level of responsibility and in today's litigious environment, you need to have cover. The trustees of each charity could open themselves up to - ultimately - liability for corporate manslaughter if you fail to have adequate cover.
Just remember: the Golden Hour isn't plural. a1W, are you saying the there is a disconnect somewhere in the logic? If there is, I'm blowed if I can see it!
Once a doctor has reached the scene, he (or she) may well be able to perform in-the-field surgery that then allows the patient to be transported by land ambulance. Here's a fact: three out of four seriously injured patients loaded into a 'swoop and scoop' Air Ambulance still die. A Paramedic may be skilled, but is no substitute for a doctor. The charities often have Medical consultants (in a case with which I am very familiar, the A&E consultant at Queens in Nottingham) to advise them: they are unanimous that spending the £300k will save lives. That's good enough for me.
Beleive me, the charities don't risk spending £300k a year on a series of whims!

[[email protected]]

206 - of the 3 out of 4 serious casualties who die, how many would have died regardless of any medical intervention, no matter how skilled? Exactly what 'in-field surgery' are you talking about and how often would it actually save lives as opposed to prolonging it until they died in hospital anyway.

To cater for every medical eventuality you would have to go for my Chinook plus full surgical team for every call-out concept - hardly fundable from charities.

I have learned many times that just because a doctor says something is so, doesn't mean it is. Does he mean that £300K may save a life or maybe 2 per year?

[a1w]

I would tend to agree with Crab -
Yes it is brilliant to have a Doctor at scene but surely the patient needs to get to a place of definitive care as quickly as possible as that is where all the facilites a Doctor would need are!

206 jock - re your comment " Here's a fact: three out of four seriously injured patients loaded into a 'swoop and scoop' Air Ambulance still die."

where did you get that information from??

[206 jock]

"I have learned many times that just because a doctor says something is so, doesn't mean it is"

Maybe you're right....a bunch of chattering helo pilots may just be a much better source of good, informed input than an A&E consultant:ugh:

Thud and Blunder has clearly worked with both just Paramedics and later with doctors on board. Just to remind you what he said:

"I've seen Paramedic-only ops and now I've seen pre-hospital-medicine-specialist doctor plus Paramedic ops; the latter is enormously more capable."

You may of course believe what you want to believe. I've been to meetings, where I have listened to the arguments presented to me and have been part of a team that has approved spending £300k of charity money on doctors on board. Nothing I have read on here has caused me a millisecond of doubt that I voted the right way.

[ChrisGr31]

Not sure its 100% relevant but didn't the Kent Air Ambulance recently seek to deliver a patient direct to the Queen Vic at East Grinstead, to be told he had to go to a DGH to be referred from there. Then the next day he was transported (I think by land ambulance) to the Queen Vic. That might explain why Kent & Sussex/Surrey (aren't they effectively the same) might be so keen to get Docs on board to do immediate referrals.

Secondly with more A & E departments facing closure patient transfer time by road is going to take even longer. This is going to be a particular issue in Kent, Sussex and Surrey where the main road structure is north/South (Coast to London) rather than east/west. So it would seem that the air ambulance is going to be required more often to do quicker transfers from scenes of accidents to the nearest specialist centre which could be some distance away. Hence a greater need for doctors on board?

[[email protected]]

206 - doctors are just like helicopter pilots -ask 3 of them the same question and you will get 3 different answers (yes - even consultants!!!)

Your operation is very fortunate in that it can declare UDI and do what it wants (within reason) with the charity donations -In the NHS that £300K for a doctor in a helo to make a difference to 1 life set against drugs or treatment (for example to combat dementia) that changes many lives would have different consultants in differing specialities voting in different ways.

Your A and E consultant is looking for clinical excellence within his own train set which is fine but surely that £300K could be better spent.

Are you going to take your expensive and valuable APHLS/trauma specialist on every callout, most of which will be scoop and run anyway when he could be far better employed in the A&E dept where there are far more casualties.

[Thud_and_Blunder]

Crab, your worthy well-made arguments are veering into NHS-vs-everybody-else territory. Yes, in the ideal world the NHS would have the pick of the consultants and the beds for the patients. However, I take patients into hospitals where I've seen 6 ambulances waiting while beds become available for their patients (I was told in Wilts that on the shift before one of mine, they'd seen 11 vehicles in the stack outside the hospital in Bath). Not much point swoop-and-scooping when the patient joins a queue. Now, if a charity can afford to bring the golden hour to a close by effectively taking A&E to the patient then why shouldn't they be encouraged to do so? It's a bit like the debate about private medicine, although in this case the treatment is available to the people who most need it rather than those who can most easily afford it.

As for the suggestion that most calls would be "scoop and run", I've no access to any clinical audit so cannot provide an objective answer (subjectively, I'd say it's around 50-50 doc-skills-needed/not needed). However, with appropriate despatch skills an organisation which includes a HEMS aircraft should be perfectly capable of ensuring that the (exceptionally) highly qualified assets available are only sent to the appropriate tasks. Not, as I believe used to be the case in one county, sent to provide land-crew mealtime coverage in set areas because the despatchers were aware that aircrew are not allocated meal-breaks of their own. Another good reason for ensuring that the charity and not the Ambulance Service maintain operational control.

So, again subjectively - I've seen doctors achieve results not possible with paramedic/nurse-only crews, and look forward to continuing to do so. Those who don't approve need merely refrain from putting money into the appropriate collecting-tins (just be sure to refuse treatment should a helicopter turn up to look after you when it all goes horribly wrong one day).

[[email protected]]

Thud - as I said earlier the aspiration is laudable but the devil is in the detail. If the doctor is going to be sat with the crew on duty then you would be foolish not to take him for every callout because a. the casualty could deteriorate or b. you could be retasked in the air to a more serious accident.

Then if the doc provides the in-the field surgery for the cas who then has to go by land ambulance to join the queue outside the A&E dept, what have you gained?

If you are going to argue that good despatching will ensure that only the appropriate resources are sent to an incident - then all AA should operate from a hospital that has specialists on immediate call who can carry out other duties instead of wasting precious skills sitting in a portakabin drinking coffee.

I get the impression that the charity are trying to find uses for their surplus of cash donations - get another helicopter or operate 24/7, don't poach a valuable resource from an already overstretched NHS.

[206 jock]

Crab,
I think you've been watching too many episodes of ER! The A&E doctors seek the Air Ambulance role not for the coffee and daytime TV, but because it's a real chance to deal with serious trauma (which they've been trained for) not a series of 'little Johnny has stubbed his toe' incidents which is the stock-in-trade of A&E department.
If you're so convinced that you're right, join an AA charity as a trustee - they're often looking for volunteers who'd rather act than just chat about it;)
Maybe we could compare notes afterwards.

[[email protected]]

206 - you miss my point - an A&E doctor who spends a full shift sitting with the crew won't be getting to see serious trauma on every flight or even on every day, much of what he goes to will be the stuff that paramedics deal with at the moment (and extremely well). On one call, he might make the difference between life and death, but on that basis you should put a doctor in every land ambulance as well.

Maybe you have been watching too many episodes of the London HEMS where they do carry doctors on a regular basis - how often is the doctor used when a paramedic would give the same treatment.

I have carried enough doctors on enough jobs to know that on the odd ocassion they make a difference but on most they don't need to do anything that the paramedics can't and some just get in the way.

[Thud_and_Blunder]

We're in danger of turning this into a 4-way exclusive discussion here! Crab, you paint a picture of standby duty in a Portacabin which might be relevant to current RAF SAR practice (sitting around, drinking coffee... your quote) but which is at total variance to my experience of a HEMS organisation with a doctor on board. They bring in a work ethic totally foreign to most pilots; the buggers never sit still. Along with the paramedics, who are like sponges for the new skills and information the doctors are always passing-on, these new arrivals appear not to stop from the moment they appear on duty - in my experience. Perhaps it's the people they choose, who as said before are doing the job (on a 12-month contract, readily renewable) as a means of increasing their breadth of skills for future jobs. Perhaps it's the selection process, which ensured in the unit I know that at least 1 candidate - who looked very good on paper but in person lacked the skills to work as part of the team - did not join. Interestingly, 2 out of the 3 docs on this particular unit aren't from the UK - they've brought their skills from other English-speaking countries having provided no drain on NHS resources in the process. Oh, and if the aircraft's down for maintenance or whatever then these docs do not kick their heels on the unit; they're off out somewhere useful. TTT - doctors who can only cope with patients brought to them already-stabilised and preferably on a hospital bed certainly don't get through.

Crab, another point of yours:
if the doc provides the in-the field surgery for the cas who then has to go by land ambulance to join the queue outside the A&E dept, what have you gained?
Well, at the very least you have a patient who's stabilised and anaesthetised, so you don't need to drag out the trauma team on arrival at hospital. Then, because the doc is in touch with the dedicated on-call consultant, precious time is saved en route to surgery 'cos most/all of the diagnosis is done. There are probably other advantages too, but because I only did well enough at school to become a ossifer and a pilot - not a doctor - I don't know enough about the system to list them here!

Overall, if your experience of doctors on helicopters is that they are an expensive luxury then I suggest you take a look at the system that put them there in the first place (for example, not all SMOs/UMOs in the RAF are equal. Some I'd happily take on a SAR shout, others are just so much talking ballast). If that system fails to select the right doctors, give them training, governance and immediate access to comms with a dedicated consultant then it is doomed to fail. However, if the system recognises which tasks would benefit from the presence of appropriate docs then puts them in place with the aforementioned structure then it will be an improvement on what went before (which is often already good, but that's no reason to stop improving things).

Finally, there may well be areas of the UK where a clinical review would show that doctors on HEMS can't be justified. For example, they're useful in London 'cos of the stabbings/shootings and in areas with high-speed roads 'cos of the potential nature and scale of the injuries. However, it might be that an area without these problem areas - and, perhaps, with excellent land access to spacious A&E units - might find HEMS doctors superfluous. I'm sure the charities in these areas would staff their helicopters appropriately.

[[email protected]]

Thud - you make some good points and as I have said already the aspiration to give the best possible care as quickly as possible is a very laudable one, and the main reason that air ambulances came into existence (golden hour, reduced time to specialist treatment etc.)

To clarify one of my points - I didn't mean that the docs would sit around because they were lazy, I meant that when not on a call out requiring their skills they are a wasted resource (notwithstanding the training benefit for the paramedics when on the ground). Therefore to justify their existence you must take them on all call-outs a. because they might be needed and b. because the other paramedics who they might train will have gone on the shout anyway.

A SAR crewroom ends up with long periods of quiet because we have a filter (ARCC) so we don't launch to every 999 call whereas many Ambulance controls scramble the air ambulance even when they have sent a land ambulance anyway ( a cycnic might say you have to justify your existence to the people that make the donations by having a large number of callouts each year)

[Rescue1]

Golly Gosh isn't it nice to have Crab back, Rotorheads is such a quite place when Crabs on his Holl's :)
Welcome Back M8 hope u had a good one;)

[FC1]

Unless ambulance control protocols have changed recently, a road ambulance will always be deployed before an air ambulance. In London it is more often than not the ground crew screaming for the air ambulance to attend!

And in London the air ambulance doc's and paramedics will see and deal with more trauma patients during a six month tour than most will see in a life time.

A wasted resource they are not. Just because they are not at a job does not mean they just waiting for a call. The job generates an enormous amount of paperwork, audit, data crunching, follow-ups and then there's the re-stocking and preparation of kit and ....................................

[Thud_and_Blunder]

Good reply, Crab. Yes, a cynic might say that. Someone who knows the ambulance service might know that a land ambulance with 2 technicians on board (not as highly trained as paramedics) might well merit top-cover from an air ambulance (with highly trained practitioners) with a slightly longer running time! I don't know of any AAmb which would launch just to keep the stats up (not that I have working knowledge of more than a few, mind); however, I well remember burning holes in the sky while in the military simply 'cos the boss' latest ego trip required it! Don't start me on the service which used to launch a rescue aircraft and another for the camera team ;)
BTW, it's often not "getting there first" where the air ambo provides value - it's sorting things out on scene then, when appropriate, evacuating the casualty faster than land crews where the advantage lies.

[edit] 'ere, summat strange just happened with PPRuNe. I typed and entered this reply; on returning to the board after half-an-hour I see the post 2 above this one (from Kent) has magically appeared. Good to see a poster who can put some facts in to support my rather-bare bones.

[[email protected]]

Rescue1 - all in the interests of healthy debate:)

I am encouraged by Unconflicted's post that the Air Ambulance Working Group (what happened to CHAS?) is going to co-ordinate this measure as a National improvement - I was concerned that the richer charities would outpace the poorer and a form of postcode (or should that be lat and long) lottery would ensue with some getting better care than others.

However, 2 of Unconflicted's points made the case for more helicopters (point 2 and the first part of point 4) not doctors in the existing ones. Paramedics can intubate (point 3) it is not a doctor specific skill.

More casualties arriving alive at hospital requires more doctors, nurses, beds, surgeons etc etc so I still believe any spare cash should address these shortfalls first. The charities were set up to provide services that were not funded by the NHS - why not spend the money on hospitals instead of doctors in helicopters?

[Another Old Git]

Glad to see some healthy debate, but I think there are some serious misconceptions creeping in. I could write an essay but I will just stick to comment on the last three points from Crab
I was concerned that the richer charities would outpace the poorer
A seemingly valid point but I would urge you to look a lot deeper. This has liitle to do with finances. The charities sit on a collective £30 million in reserves, not evenly spread I grant you. This has more to do with progress away from the status quo.
Paramedics can intubate
I urge you to have a quiet one to one with your local Paramedics. I know it wont be publicised on this forum but there is a truth that I am sure they will enlighten you on, that this statement is far from the whole story.
The charities were set up to provide services that were not funded by the NHS
Absolutely. I think you answer your own point.

To come back to a point that seems to be getting lost, I dont see this as one skill being replaced by a better or worse one, but two distinctly different skills (three if you count the pilot) coming together to form a best possible service to what might be the dying you or me. Dont ask me to choose between Doc or Paramedic. Give me both (and sweets for being brave and drugs and that cute one for reassurance and...

[[email protected]]

AoG - just think what that £30 million could do if it were used to improve other services that the NHS can't (or won't) fund. All the helicopters and doctors in helicopters in the world won't help if the hospitals they take the patients to are full/ undermanned/ closed. Pay for some more nurses first then gild your lily with an A&E consultant.

Needs of the many vs needs of the few..

PS I will ask my Winchman paramedic about tubing today but I suspect you mean conscious v unconscious patients and lack of anaesthesia.

[TorqueOfTheDevil]

I don't know of any AAmb which would launch just to keep the stats up


Oh, there's at least one!

Last year (or was it the year before) they flew over 50nm to attend a teenager with a broken arm at a weekend rugby match, when there was a Minor Injuries unit just over half a mile away by road! The Ambulance Service didn't ask for them, but it would seem that they heard of the incident and decided that there might be a good opportunity to show themselves off in front of lots of potential donors. Rather pointless, especially when you consider that the hospital the yoof was taken to was 45 mins drive away (handy for the parents!), when he could have been treated in his home town...

This isn't an isolated episode either. One definite benefit of central funding of Air Ambs would be that they wouldn't then feel any pressure to justify their existence by launching to every incident they hear of, no matter how inappropriate that incident may be for them to attend. Don't even get me started on Air Ambs having a go at mountain jobs and then having eventually to admit that they can't get the casualty and calling for SAR, enormously prolonging the casualty's stay on the crag/hillside...

[Thud_and_Blunder]

TorqueOTD,

Hmm - I've heard interesting stories from the area in your profile. No definitive evidence to back it up, but if true then they do the rest of the AAmb community no favours with their approach to the task.

It was with this in mind that I made absolutely sure, on a recent task in Yorkshire where people were trapped on a small island in the middle of a river with water rapidly rising, that the SAR folk really weren't available before we started shuttling them to the safety of the riverbank. Swift-water rescue is not something to be taken lightly, we acknowledge SAR as being by far the most effective method. In this case if we'd delayed any longer these folk would've been in grave danger. Just as we finished the last lift a Seaking arrived overhead (task in the Lake District now complete) and orbited a couple of times before heading home. I rang Leconfield after returning from task to make sure they didn't feel put out; very positive response - I also learned that with only 1 VHF box the SK won't always talk on Scene-of-Search if already chatting to ATC. Worth remembering.

Anyway - back to your point. Your example might not be an isolated incident, but I suspect it may be down to just one operation. The operations I've been involved with certainly don't feel the need to flaunt themselves unnecessarily.

[Russell Sprout]

I think the problem stems from not singing off the same song sheet, I’ve been dispatched on quite a few HEMS tasks that lay closer to SAR bases than ours and have called Kinloss to suggest that it may be beneficial to send a Seaking. But in the long run it just confuses the whole issue by involving too many chiefs- Ambulance control, Police, RCC, Air ambulance control desks etc etc. and no one seems to have the balls to make decisions regarding helicopters as I’m sure to a control room operator dealing with aircraft it must be quite a major piece on the chess board to handle.. Still it always looks impressive when SAR, air ambulance and Police ASU turn up having been dispatched due to lack of coordination.

As for the suitability of SAR over air ambulances, I’ve also attended many incidents where we have arrived, packaged the patient and left the scene only to hear that a Seaking is inbound to the same incident after it is all over.

Once winches on air ambulances have been introduced and the multi million pound machines start spending more of the day out of the hanger than in (day/night VFR/IMC), I’m sure that emergency services helicopters in Britain will be a very effective force on par with our European counter parts operating in the Alps etc.....

Russell

P.s And before anyone starts harping on about winches again, just think of the flak that must have been encountered by suggesting we take people to hospital by helicopter in the first place, after all you could have a brand new fleet of land vehicles for the price of a helicopter….

[[email protected]]

Unconflicted - you support the addition of 3 A&E doctors per Air ambulance at a cost of £300k to each charity per year to gain a small benefit for one or 2 patients.

I believe the money would be better spent in other areas of the NHS, regardless of the fact the taxes are supposed to provide these services. The charities could donate funds or sponsor extra posts or provide buildings/renovations where the NHS trusts are overstretched.

It seems the charities are sitting on a huge pile of cash and are looking for ways to spend it quickly so people don't ask questions or stop donating.

The problem with allocating resources based on population is that it doesn't take into account the extra distances involved in less populated areas (the SW for example).


Thud - we have moaned about the avionics fit in the Mk 3 Sea King for years but to no avail - multiband radios are cheap as chips but getting someone in the IPT to fund them is impossible.

[MINself]

As a charity reliant on cash flow, the piles of cash you refer to are cash reserves and are there in the event of a problem with the helicopter requiring an immediate cash solution. These cash reserves prevent the air ambulance being taken off-line due to the unforseen and whilst to the ill informed these funds might seem to be better spent else where, the benefit of this is out weighed by the necessity of maintaining a contingency fund. I'm sure the generous folks who have donated these funds would prefer this rather than seeing a break in a vital service due to lack of financial planning. The millions we are talking about are spread over a couple of dozen charities.

I’ve also attended many incidents where we have arrived, packaged the patient and left the scene only to hear that a Seaking is inbound to the same incident after it is all over.

I have also experienced this, but I have also saved a precious SAR asset being dispatched because an air ambulance was able to deal with an incident and also recognised early on during an incident (on arrival at scene) the limitations of the air ambulance and tasked SAR. It depends on availability, the location of the incident the proximity of the nearest asset and of course the weather and daylight. SAR and air ambulances work perfectly well alongside each other (when the SK's VHF works and you don't have to relay messages through D & D), and when the several different control rooms speak to each other.

MS

[TorqueOfTheDevil]

Please do not see this as me having a go, I’m just want to know how we can overcome this, it annoys me turning up to a casualty who has been there suffering for hours needlessly or worse yet dead because the wrong asset was deployed.

Rasyob,

I think everyone of whatever outfit would agree with this - we're all on the same side, and all of us are familiar with the frustration of a casualty being compromised because the wrong (or less appropriate) asset was sent. Unless anyone has any better ideas, the best way to progress the issue is to liaise closely with the local Ambulance Control, to give them the best chance of understanding what the various types of helicopter (ie SAR, Air Amb, Police) bring to the party. It is also worth taking every opportunity to remind the emergency services control room staff that they won't be charged for requesting SAR to do a rescue - this myth still lives on (perpetuated by at least one Air Amb operator I could name - wonder why they'd do that?!), and it still causes delays in SAR being used - only time and patience will allow us to convince the relevant people that SAR can be a vital and free asset at many types of incident. Leconfield have been notably successful in spreading the message at training days with control room staff of their various local emergency services, and the amount of tasking they have received has rocketed this year as a direct result.

TOTD

[Thud_and_Blunder]

Crab,

Noted re the VHF fit and I do sympathise; after all, look how long it took MoD to give you FLIR/TI!

However, I still think your points about allocation of resources are more a "NHS vs Private" argument. This is not public funds we are talking about, it is money given to Air Ambulances by people who know precisely where it will be spent. Er, unless we're talking about the good folk of Wiltshire, but that's another story. Now, if all money spent in the UK on healthcare is going to be given to the NHS then fine, your argument holds sway. However, as long as people who wish to spend money on non-NHS resources are allowed to do so then I'm afraid your case doesn't work. Further, you might think only "one or two" people benefit - my own experience strongly indicates otherwise.

As for the points about "certain operator(s)" being economical with the actuality about SAR costs, capabilities and so forth - a bit of a theme seems to be appearing. In the police world the Home Office would assume the role of overseer and would have a quiet word with the unit(s) involved. Which agency has similar regulatory oversight of Air Ambulance operators?

[MINself]

It is also worth taking every opportunity to remind the emergency services control room staff that they won't be charged for requesting SAR to do a rescue

It might be because that particular rumour stems from misinformation? Please correct me, but for non rescue sorties, ie non critical inter hospital transfers, do the RAF charge as some air ambulance charities do for this service? I agree with Thud_and_Blunder, it is possibly the lack of standardization and oversight that is the achilles heel of the various air ambulance units.

MS

[[email protected]]

Minself - I fully agree with the contingency fund argument but if that is so important why blow £300K of it on doctors? The charities involved must be very sure of their projected donations if they can afford to run their helicopters and 3 doctors every year. Or do they already have such a huge surplus that they can afford such luxuries with ease? Of the medical professionals (including doctors) I have talked to, most seem to think that doctors on AA will have a limited and possibly negative effect (more likely to stay and play at the scene than scoop and run to the A&E).

As to charging - as far as I am aware the policy is that we do not ever charge. I have never done a non-critical inter-hospital transfer, they are usually critically ill patients needing specialist care unavailable at their primary hospital. Before the ARCC tasks a SAR asset for a medtransfer, the NHS has to show that there is no other way of transporting the patient available and that without the use of SAR, the patient's life is in danger.

The ARRC keep trying to get the message across to ambulance controls that we are free but even in the good ones we are 3rd on the list of call out priority behind land ambulances and air ambulances. We improved the knowledge in the Devon area by inviting 2 paramedics/technicians to fly with us every Friday so they understood our capabilities and limitations - but all the work seems to have to be done by the SAR units - there is precious little initiative taken by the NHS trusts or Ambulance authorities.

[MINself]

Crab, this does sound a huge amount of money for having a team of full time doctors on the air ambulance for the few of the units that have chosen to provide this option. These particular units might have a more comfortable financial situation than those that haven't chosen to employ a team of full time doctors but for the vast majority of air ambulances £300k would be an unacceptable expenditure, year on year. Some air ambulances rely on a pool of doctors who work free of charge and in their spare time in addition to the pramedics, admitedly providing doctors on air ambulances in this adhoc way possibly isn't the most efficient way of putting doctors on air ambulances but for the majority of air ambulance charities it is the only way. With regards to the argument of swoop and scoop Vs extended doctors intervention on scene, IMHO having seen both, both have their merits depending on the situation but if I was the patient I would want to be treated by the most medically qualified person at the scene.

As to charging - as far as I am aware the policy is that we do not ever charge. I am glad to hear it, it sounds like there is a lack of knowledge in some of the air and land ambulance control rooms on the subject of SAR, its use and importantly that it costs the ambulance service nothing.

[Thud_and_Blunder]

OK Crab, I'm beginning to realise that there are those that can't be persuaded and those that won't be persuaded.

You're using some pretty strong terms:
("why blow £300K of it on doctors?", "more likely to stay and play at the scene"),

relying on second-hand, subjective evidence:
("Of the medical professionals (including doctors) I have talked to, most seem to think that doctors on AA will have a limited and possibly negative effect", "a small benefit for one or 2 patients")

and indulging in some fairly heavy-handed unfounded speculation:
("It seems the charities are sitting on a huge pile of cash and are looking for ways to spend it quickly so people don't ask questions or stop donating").

Finally, you haven't moved from your stance that the whole thing is an NHS issue:
("I believe the money would be better spent in other areas of the NHS, regardless of the fact the taxes are supposed to provide these services. The charities could donate funds or sponsor extra posts or provide buildings/renovations where the NHS trusts are overstretched.")

From the top:

Charities are far more accountable to their donors than the NHS, or the MoD for that matter. Furthermore, if charities were to be seen to be frittering money away then people would simply stop donating. If only the same could be said for Gov't funded organisations like the 2 I've just mentioned...

Doctors working in the properly-structured environment that exists in places like London, Kent et al don't "stay and play" - they provide appropriate treatment and ensure that the casualty then gets the further care he/she requires.

Try talking to medical professionals who actually know, from first-hand experience, what working in such an environment involves. Better yet, try listening to what such doctors might have to say.

Charities have a responsibility to their donors, as alluded to above, to ensure that any surplus funds are allocated in the best manner possible. If a charity sees a way to improve an already-excellent service then it is their duty to do so.

Finally, they're called "Air Ambulance" charities 'cos that's where their money goes. People give them funds in the knowledge that they will specifically spend the money on a means of getting rapid intervention/treatment/extraction on the fortunately-rare occasions when things all go horribly wrong. Should the Charity Commission or whatever it's called this week catch such an organisation donating money to prop-up NHS building shortfalls or whatever there'd be hell to pay - quite rightly. If you haven't gripped the difference between medical services people expect from the Gov't (the NHS) and medical services funded through other means ( eg BUPA, Air Ambulance charities) then we're not going to get anywhere 'til you do.

OK - you think the NHS should have more funds and you don't think money should go to Air Ambulances so that they can "up their game". Fine, help vote in someone who'll sort out the Health Service and only donate to charities that don't have properly-trained, supervised doctors on board. However, let those who've done the research, tried the alternative and found it better get on with their work without the sniping, eh? Oh, and crack on with the excellent SAR stuff you folk do so well - much appreciated.

ps - were you a student of mine at Shawbury? I seem to remember chatting to someone with your debating methods between 1984-6

[[email protected]]

Thud, the NHS provide the paramedics for AA because there is a clear need for them - if there was such a clear need for all AA to have doctors on board would they not provide them? They don't so the question is why?
Many of the posters on this thread seem to disagree that doctors are absolutely needed on AA.

Personally I think the paramedics do an excellent job - if you want them to have doctor skills then pay them more and give them extra training.

I accept that my idealist concept whereby money that comes from the public, via donation or taxes, should be used for the greater good, doesn't fit within current political or financial constraints. However, if charities are sitting on large surpluses of cash (that info came from other posters, not me) then maybe they should be looking at ways of providing better AA cover (numbers of aircraft, 24/7 ops) or even procuring larger helos for the increase in numbers of inter-hospital transfers that everyone is expecting.

PS I left Strawberry in early 84 to go to 72 so it's probably not me you are wistfully remembering:)

[Vie sans frontieres]

Correct me if I'm wrong (no doubt someone will), but doesn't the fact that on most Air Ambulances there is a lack of space to work on the casualty enter the equation? What's the point of having a clever doctor if he can't do his stuff in the air? Said clever doctor has to do it all on the ground, draining the aircraft of fuel (assuming it's not shut down) and negating the efforts to achieve the golden hour. With the exception of his/her ability to provide rapid sequence intubation (which helps but isn't essential - there are other ways to manage airways), having a doctor on board an Air Ambulance is over-egging the pudding somewhat, don't you think?

[whoateallthepies]

TTT
You have hit the nail on the head, I believe. Train the Paramedics to anaesthetise and deliver RSI, they are well up to that job. Also increase the meds they can give to include Morphine. Doctors not then needed on the Air Ambulance freeing them up, cost savings all round, increased paramedic skills and still a good level of pre-hospital care for patients.

My two-penny worth after reading this interesting thread.

[MINself]

Also increase the meds they can give to include Morphine

Not sure about all the air ambulance units in the UK but certainly all those I have worked at the paramedics are able to administer morphine, up to 20mg per patient. I Agree with allowing air ambulance paramedics licence to RSI, especially those combative patients that could present a danger to themselves and the flight.

[Heliport]

if you want them to have doctor skills then pay them more and give them extra training.
Assuming the training is free, why would you pay them more? :confused:

[Vie sans frontieres]

Some people call it Rapid Sequence Intubation - call it what you like, it does the same thing and if it is the main reason for carrying a doc then he's going to feel mightily redundant and over-qualified a lot of the time.

[Bertie Thruster]

..interesting thread.

.....no extra skills actually required for a UK Paramedic to RSI........

They can already intubate (any cas with a GCS of less than 8) and cannulation (for drug introduction) is a routine skill.

So no extra skills training required ......just the ("god-like" doctor) authority to paralyse somebody by using the additional drugs.

ps....there is no actual limit on amount of morphine a UK Paramedic can administer.

pps... just read the previous post.......spot on!

[MINself]

According to JRCALC, Clinical Practice Guidelines on the Dosage and Administration of Morphine Sulphate for adults the maximum dosage is 20mg?? It might be that different regions have different protocols but certainly where I work the maximum dosage is 20mg, as for the rest of the skills to RSI I take the point that the close confines of the back of the helicopter is not the best place to do this but then again what is easy to do in the back of a helicopter? At least if the option exists and this does not delay the immediate and rapid transportation of the patient to definitive care then in some cases to RSI a patient on scene will be the best option.

[Bertie Thruster]

..no different protocols for different regions; JRCALC is the UK national document and 20mg is the stated maximum for morphine.....

But the answer is in its title; Clinical Practice Guidelines

All maximums stated in JRCALC are not definitive; they are 'guidelines'. They can be overridden if required.

[Flaxton Flyer]

Very interesting thread. which has shot off at so many tangents it would be nigh on impossible to comment on them all.

As for the initial thread re doctors on the AAs I'm intrigued by Mr. Philpott's call for more Government funding to "reflect this shift in practice".

Is there really a shift in practise going on? How many air ambulances are we talking about here, 5 out of 23? (Likely more, I'm sure that the soon-to-be-introduced second aircraft at YAA wasn't counted here) Hardly a ground swell of support. AND if you consider that London HEMS and Great North have had doctors on for a long time anyway (so no shift there) , and Mr. Philpott, Grand Wizard of this plan runs two of the other aircraft then I don't see this being a runaway train of support.

Crab asked whether CHAS was still in existence..interesting question. The short answer to that is "YES" . Interestingly, the main proponents of this "shift" are, shall we say, not CHAS' greatest supporters. Perhaps a little bit of rival empire building going on?

[Another Old Git]

In the interests of healthy debate:
Add a couple of weeks to the Paramedic course for a PPL(H)
What skills can a CPL bring to the stick that a Paramedic PPL cannot?:E
Add an hour on the end for winching, what do you think Crab? :D
Sometimes I think I stick my neck out just too far.
Just off to count the savings.

[Helinut]

AOG,

If I may say so, nicely put :)

[[email protected]]

Heliport - I would pay them more because they don't get an awful lot for what they do anyway so taking on extra responsibilities should be rewarded with extra dosh (or is that an old fashioned concept).

AoG - don't forget to fit floats so they can do over water stuff as well and give them powers of arrest like a copper - then you have the ultimate multiskilled airborne asset. I hope you have phoned the Home Office to let thme know you have sorted their problems out. Now, about world peace...........:)


It doesn't seem as though anyone except Mr Philpott, Thud and his A&E consultant is actually in favour of this 'shift in practice'.

Empire building amongst ambitious doctors and pilots.....surely not. Anyway if they get too big the MCA will want to take them over:)

[206 jock]

UnconflictedInterest

I gave up on this thread a while back: clearly 'mules' and 'helicopter pilots/winchmen' have something in common. There's only point in having debate if there is at least a willingness to listen.

Paramedics who think they are doctors...there's a scary thought.

If you are who I think you are, see you later ;-)

[Thud_and_Blunder]

It doesn't seem as though anyone except Mr Philpott, Thud and his A&E consultant is actually in favour of this 'shift in practice'.

Interestingly, they're also 3 of the contributors who've seen the difference the properly-constituted system makes. Still, why let that get in the way of pre-formed opinions, eh?! It'll be interesting to revisit this thread in a year or 4 when the system under discussion has become the norm.

BTW just in case anyone thinks I reckon this is the be-all-and-end-all solution, I still think that units like Wilts and Sussex have a thing or 3 to show the Air Amb world. An aircraft that can react to calls after dark AND bring the expertise of a pre-hospital-medicine specialist; that's an Air Ambulance system I'd pay to see working! Plus an aircraft with a ground (and noise) footprint the size of an Explorer but the cabin-space of a 412... There's always room for improvement.

ps Crab, I finished my CtoI on 2 Sqn at 2FTS in Mar 84 - prob know you but have been told you're not the fella I orig thought, one "TS"...

[Bertie Thruster]

unconflictedinterest said; Let's not forget that paramedics were not funded until 2002,

Not true. I know of at least one unit where the paramedics have been NHS funded since the unit was formed in 1994.


Within the next year to 18 months all air ambulances will have doctors


...only if an individual charity wants the extra funding for it......

.....and some of those charities trustees are very much in agreement with Crabs sentiments.

[[email protected]]

Ah well, glad to see everyone is pulling in the same direction on the air ambulance front - no wonder CHAS nearly went into meltdown earlier in the year.

Thud - a be-all-and-end-all solution would be 24/7 air ambulance cover across the whole country with standardised crew composition and medical protocols and big enough helicopters to do inter-hospital transfers whilst allowing the medical teams to work on the casualties. By declaring UDI you run the risk of further fragmenting what should be a national service into the haves and have nots.

I hear what you say unconflicted - you seem very sure that ALL AA will have doctors on board - that means that unless all the charities agree to fund them then the NHS trusts will have to do so - back to my argument about how the money would be best spent I think.

PS Thud, who is TS? I am JE

[Bearintheair]

Whilst there are undoubtedly times when the additional skills of a doctor are needed on scene, the aim should still be to use those skills to get the patient away to hospital as quickly as possible. Unfortunately it seems that this is not always the case, with patients being worked on for a considerable length of time when they are less than ten minutes away from a hospital.
It seems from their publicity that the Kent/Surrey/Sussex charity consider that the Golden Hour is the time to get the doctor to the patient, not the patient to the hospital!

[helmet fire]

The very word "paramedic" translates into so many variations of protocols and definitions, even across state lines let alone international ones, that it is hard to come up with one model that suits all resource bases or discussions on protocols.

I say "resource base" because that is what should be driving this argument. It stands to reason that having a trauma hospital ED on each traffic intersection would (in a resource unlimited world) be the ideal solution. From that ideal to having just one ED in a city of 20 million for a resource poor situation is simply a matter of the individual cost benefit analysis. And as armed with all the facts and figures as we like to think we are, we rarely get to decide on the resource allocations that settle arguments like this.

Resource base expansion enabled the ground ambulance in the first place. What a great idea to get initial medical help to the patient, then retrieve that patient back to the hospital. By doing that we don't have to build multiple r trauma centres - cost effective for the gummint and patient outcome positive.

Same argument for the advent of the helicopter air ambulance. Only now it is possible to cover a much larger area too. It has three sudden advantages:
1. The rapid transport - aka golden hour advantages as pointed out numerous times in this thread already.
2. The ability to concentrate higher medical resources quickly.
3. The ability to access (by speed or environment) patients that previously could not be accessed either at all, or in time to prevent a poor outcome.

Forgetting the rescue elements of the third point which are not really being debated here, it is this second one that could be included in our considerations. Do we spend millions of dollars on providing a rapid transport vehicle to bring more paramedics to a scene that already has paramedics, OR do we try and multiply the benefits of the expenditure by throwing on a higher level of medical capability?

I note that even where non-doctor models are the norm, it seems most operations would ascribe to this point because they already put the highest trained or "level" of ambulance officer on board - ie paramedic. And most of this thread calls for increased training and a higher level of protocol for the paramedics.

SO what is the difference between the doctor and the high level of paramedic? Dollars?

NOT ONLY. The typical paramedic has an enormous amount of scene experience and pre hospital medical experience that just cannot be learned from a hospital ED, and the doctor brings an enormous amount of medical experience that cannot be learned pre-hospital. Surely the most appropriate model is a combination?????

It seems this thread has not discussed the fact that a paramedic/doctor can operate as an effective team bringing all the attributes that each side of this argument has so forcefully put forward.

In NSW, that is how the Sydney basin runs. The helicopters are manned by the highest level of paramedic who runs scene management, rescue situations, and enables the doctor to be protected, safe, and able to perform the medical intervention. He is also able to maintain the situational awareness re curing on roadside V getting back to the ED. He can also effectively manage medical interventions on patients in multiple casualty situations, provide a higher level of care using the scene doctor's protocols and liaise effectively with ground ambulance assets (he understands the system) to produce the most effective outcome.

The doctor is a senior trauma or anesthetic registrar or consultant who can manage the medical intervention, and rapidly provide triage. Given enough equipment, he can bring the golden hour care to the patient in a majority of cases. AND they get trained to listen to the scene experience of the paramedic and to take that advice - something that is not always part of their hospital backgrounds.

Great model if you have the resources. But it only takes one or two casualties experiencing a poor outcome per year for this resource expenditure to become viable - let alone the human value aspects!

[AlphaJulietHotel]

At the risk of setting myself up for some large calibre incoming…

One common misconception that the air ambulance charities like to throw around is that they, with doctors on board can get patients to the appropriate care where land ambulances have to go to the nearest hospital. I don’t know any trusts (certainly not the one I work for) that still insist on this. If we (and I’m a lowly technician) think a patient need to go direct to a burns, trauma, neuro or cardio (PCI) centre then that’s where we take them. Granted it would sometimes be a lot quicker with the aircraft but that’s not the issue. The time docs are really useful is actually with the patient that don’t really need to be in A&E at all, such as those whose optimum pathway would be to go direct to a general medical ward, or a re-hab ward, but you don’t often get an aircraft for a generally unwell 80 year old!

Does that mean doctors are not required? Not at all, but I think they are often needed for simpler reasons than people think. If we assume that the doctor/paramedic model air ambulance is targeted at the most serious jobs then we have to think what we need at those jobs. The main feature of such jobs is that they often need more than one ambulance crew to manage the very ill patient. That’s where the problems starts, since we always work in pair or at most as a three. Where I work I average about 30 calls a week, 50 weeks a year. In the last year I have been to six jobs with London HEMS, and those have been all my serious jobs. In other words, i have seen 6 very ill people this year. All of these have involved at least 3 HEMS staff (doctor/paramedic combo), an ambulance and two response cars, and five had had a duty manager on scene. Several had additional resources such as hazardous area team, more vehicles and crews, etc.

That’s at least eight clinical staff working on the patient. Who exactly is supposed to manage that team? One of us? What training do we have to do that? In fact, what training do we have at all? My training on scene management lasted precisely three hours, and was in a section of my training course that some ambulance trusts don’t actually run at all, since it’s not required. Helmet Fire made the often quoted point above that paramedics are supposedly good at managing the situation at the roadside and doctors are good at treating patients. Well, sometimes it’s true, but it isn’t because the paramedic has had any training, it’s dependent on experience. If a HEMS doctor goes to six serious jobs a day then he will equal a paramedic of ten years experience in less than three months in this specific regard. Plus he will have a background of working in large teams from his in hospital experience. In addition, because he is a doctor, and the NHS is required to continue training him, he will have attended multiple other courses such as vehicle rescue that very few paramedics ever go on.

Yes, occasionally a doctor is required at a scene to treat a patient with an intervention that can not currently, nor is ever likely to be done by paramedics, such as thoracotamy (opening the chest to repair direct damage to the heart). However usually they are just required to turn up and get the on scene ambulance crews to work effectively together and carry out the interventions they should have been doing before the doctor got there or realistically could be trained to do, while making the general decisions about patient management (stay/scoop, awake/sedated, land/air, etc)

I’m not trying to have a go at ambulance staff, especially since I am one, but we just don’t see enough ill patients to actually know what to do when one comes along. Equally we have no effective form of clinical governance, so we never know if what we are doing is good, bad or out of date. We need doctors on these jobs to bring their management and leadership skills out to play, not because we need to be doing loads of thing to patients before they get to hospital.