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Prehospital care Stephen Hearns and Andrew Morris discuss what it is, what is involved, and what opportunities there are for medical students At some time in their professional careers most doctors will help at a prehospital incident, be it a heart attack in the city centre or a road accident on the way to work. For some, however, this forms a regular part of their practice. These doctors are mostly volunteers working over and above their NHS commitments. While the doctor at the scene of a motorway pile up is the most visible example, prehospital care covers a wide range of activities. These range from hospital flying squads to battlefield medicine, from medical cover at mass gatherings (such as T in the Park) to mountain and ski rescue and cover at motor sport and equestrian events. Prehospital doctors may also find their services needed overseas, as part of a disaster relief effort or as an expedition medic. Background Not surprisingly, for a subspecialty that deals mainly, although by no means exclusively, with trauma, it evolved from one of humanity's least attractive activities, warfare. The first organised civilian prehospital care group in Britain was established by Dr Kenneth Easton to deal with crashes on the stretch of the A1 near his RAF base at Catterick. As the idea spread, similar groups sprung up across Britain, in time coming to form the British Association of Immediate Care (BASICS), which is the representative body for this area of medicine. As the subspecialty has developed, the training has become increasingly standardised and is now overseen by its own faculty at the Royal College of Surgeons of Edinburgh. The philosophy of prehospital care can be summarised as "the appropriate intervention at the appropriate time." To this end it aims to bring the benefits of advanced medical care to the roadside or similar arena. However, it also requires careful judgment as to when it would be beneficial to perform an intervention, and when the delay involved would lead to a deterioration in the patient's condition. What is involved The practice of prehospital care is a far cry from treating a patient in a well lit, warm, and spacious resuscitation room. The situations may be uncomfortable--for instance, managing a patient in a upturned car--and frequently environmental conditions are less than ideal, as incidents often occur in bad weather or at night. Safety relies on working effectively with other emergency professionals, such as the police, ambulance, and fire services, who will often have far greater experience of the environment than the doctor. In some European countries the role of the doctor in prehospital care is more established than in Britain. In Germany, for instance, there is a nationwide network of helicopter and land based doctors who respond to all serious incidents (the Notarzt system). Although the value of such doctors functioning alongside a well trained and skilled paramedic workforce is increasingly being recognised in Britain, the work remains almost exclusively voluntary. Some emergency departments have flying squads--for example, Medic One based at the Royal Infirmary, Edinburgh--and research posts exist, such as the ambulance service secondment option on the Yorkshire emergency medicine specialist registrar rotation. In Scotland the Scottish Executive has given the subspecialty a significant boost by funding the training of rural GPs. However at present only one prehospital training post exists, that of the Helicopter Emergency Medical Service (HEMS) in London.
Training Doctors involved in this specialty come from a range of backgrounds including general practice, emergency medicine, surgery, and anaesthetics. However, some experience of emergency medicine and anaesthetics is vital for all those who work in this subject. Specific training is largely organised through local immediate care groups. Most people will take courses provided by BASICS, leading to the diploma in immediate care (DipIMC). In addition, many will hold qualifications such as advanced training in life support (ATLS) and major incident medical management and support (MIMMS). Membership of the Faculty of Prehospital Care is available not only to suitably qualified doctors but also to nurses and paramedics, so reflecting the range of professions involved in this area. Involvement as a medical student is possible but requires careful consideration. Incidents often occur out of hours and are not places for the unwary and unskilled. Opportunities do exist, however, such as going out with the flying squad when on a suitable placement in an emergency department or joining a voluntary aid society (such as the Red Cross) and getting trained in ambulance aid. The Territorial Army Field Ambulance Units take on medical students and will provide training in battlefield advanced trauma life support (BATLS). As explained, the work is often unpaid, uncomfortable, and at unsocial hours, so why do doctors do it? Certainly, practising in the prehospital arena is challenging and requires considerable reliance on clinical skills and diagnostic acumen. There are no x ray facilities or blood gas machines available at the roadside. Equipment is usually limited and an ability to improvise and think laterally is a definite advantage. The interactions with, and dependence on, members of other professions such as paramedics and fire fighters build teamwork and leadership skills which can often be transferred to the doctor's normal working environment. Prehospital care is now coming into its own as a recognised subspecialty with its own training and expanding research foundation. As with all new branches of medicine it was pioneered by a small group of highly enthusiastic volunteers, and will no doubt continue to grow into a fully established part of the medical panoply.
Stephen Hearns specialist registrar in emergency medicine, Western Infirmary, Glasgow Further information
Shirley P. Prehospital medicine [career focus]. BMJ 2000;321(classified section 22 July):2-3. Hearns S. Mountain rescue medicine [career focus]. BMJ 2000;321(classified section 9 December):2-3. www.bmj.com/cgi/content/full Hearns S. Expedition medicine [career focus]. BMJ 2000;320(classified section 6 May):2-3.
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