Injury (1993) 24, (11 69 Printed in Greuf Btifuin 69

Letters to the Editor

Dear Sir My thanks to Messrs Stevenson, Hodgkinson and Mackway-Jones for their comments. Excluding good airway management and cervical spine immobilization, much of what is done in the prehospital phase of trauma manage- ment is based on myth, dogma and prejudice. Examples of practices now being challenged include the use of Medical Antishock Trousers (MAST) and intravenous fluid replace- ment in the treatment of haemorrhagic shock. This paper examines procedures which result from complex clinical decisions made in a difficult environment and compares these with those allowed by paramedic protocol. It presents one aspect of a system still in the early stages of develop- ment. Of course, further studies concerning patient outcome and complication rates are essential and are being carried out. As in most endeavours, the search for truth is long and painstaking and cannot be accomplished immediately.

Prehospital care has largely been ignored as a target for medical audit and quality assurance in the UK. This is because lack of specific training in the prehospital arena results in doctors feeling uncomfortable and out of place in the uncontrolled and relatively hostile roadside environ- ment. Interest in, and understanding of, this important as- pect of medical care is therefore reduced. Resultant lack of medical direction leads to protocol-driven prehospital treat- ment, inadequate audit and subsequent lack of reliable data upon which to base changes in clinical practice. With lack of data comes a lack of appreciation of the need for improved prehospital care. A vicious cycle ensues.

I am in whole-hearted agreement that comparative studies must be performed, in ground-based as well as helicopter EMS operations. By placing suitably trained doctors in the field our understanding of prehospital trauma management is improved, essential data collected and useful research performed. Medical direction of paramedic EMS programmes in prehospital care (both medical and surgical) will then become meaningful and the chasm separating prehospital from hospital care bridged.

A. Mark Dalton FRCS(A&E)

Author’s reply

We read Dalton et al.‘s account of the work of the Royal London Hospital Helicopter Emergency Medical Service with interest. As the authors state, a large proportion of patients who eventually die following trauma do so before reaching hospital. They list some 73 doctor-only procedures carried out before evacuation to an appropriate hospital, and conclude that the presence of a doctor on scene is essential.

While we agree that it seems likely that the earlier that advanced procedures are carried out the better the chances of survival, we wish to point out that there is no evidence presented in this paper that confirms this. Errors of commis- sion can be just as detrimental as errors of omission. This paper does not address this possibility; in particular the authors do not state whether all procedures were considered appropriate at audit, how much time was taken for proce- dures to be completed, or what the complication rates were.

Some further analysis of this series would be of interest. Although we realize that the 23 patients who were

6’) 1993 Butterworth-Heinemann Ltd OOZO-1383/93/010069-01

ventilated before arrival at hospital are not easy to assess using current tools such as TRISS, a comparison of prehospi- tal and hospital survival probabilities for the 45 other patients would be informative. Similarly, data about out- come for all 68 patients would be useful.

In order to draw any conclusions about the usefulness of doctors at the scene, a further study is necessary. The outcomes of two matched groups of patients, only one of which had doctor-led resuscitation, must be compared. The present study has neither a measure of outcome nor a comparator group, and cannot therefore be used to argue either way about this important subject.

D. Hodgkinson MRCP FRCS

K. Mackway-Jones MRCP FRCS

Dear Sir I read with interest the article by Dalton et al. who conclude that doctors are an essential part of Helicopter Emergency Medical Service operations because they are able to carry out procedures at the roadside beyond the current training of paramedic personnel.

This conclusion appears to be reached solely on the basis that a number of invasive procedures normally carried out only by doctors were performed, rather than by showing any improvement in patient care or outcome resulting from the presence of a doctor. Throughout the paper there are no data showing a beneficial effect of these procedures on morbidity or mortality.

The administration of adequate analgesia by the intravenous route to someone in pain following severe injury is obviously essential and can be justified on humane grounds alone. Patients in class III shock do require more than the 2000ml of fluid currently permitted by the paramedic protocol and probably benefit from the increased volume of fluids administered by doctors.

The requirement for an out of hospital anaesthetic to facilitate endotracheal intubation in 70 per cent of patients intubated seems rather high. One wonders if the decision to perform this was influenced more by restricted airway access, lack of space and the potential for development of problems within the helicopter rather than the specific needs of the patient at the roadside.

The authors allude to the fact that one patient requiring pericardiocentesis died in hospital as a result of multiple injuries, but make no mention of the outcome of the other 99 patients included in the study.

It is stated that audit of prehospital care of patients transported by helicopter is assured by the presence of a doctor enabling recording and collection of essential data. It is a pity therefore, when such data are obtained, the conclusions presented are on the basis of assumption alone rather than resulting from a properly performed cycle of audit.

The presence of doctors on board helicopters adminis- tering prehospital care may well be of benefit in selected cases. It must be remembered, the actual ability to perform, at an early stage, the procedures described in the paper does not automatically result in improved final outcome for the patients.

James Stevenson FRCS