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.