Airborne medics save lives
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.
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.
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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??
"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??
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!
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!
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?
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?
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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??
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??
"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
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.
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
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.
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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?
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?
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.
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.
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).
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).
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.
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.
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.
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.
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.
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.
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:
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.
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?
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.
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)
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)
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 ....................................
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 ....................................
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.
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.
Last edited by Thud_and_Blunder; 29th Aug 2007 at 17:13.
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?
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?
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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
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.
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.
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...
I was concerned that the richer charities would outpace the poorer
Paramedics can intubate
The charities were set up to provide services that were not funded by the NHS
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...
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.
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.