THE PREHOSPITAL CONTROVERSY, IF THERE STILL IS ONE

I read an article in European Emergency medicine Journal. It compares prehospital skillsets of prehospital physicians with ambulance nurses. It is a descriptive study of the Dutch prehospital system but most of it should translate to most western environments. 

Instead of focusing on survival and outcomes it compares the number of prehospital competencies that you can expect the nurses and physicians to have respectively. For example a protocol for carbon monoxide poisoning would break into eight competencies

  • three diagnostic competencies (CO poisoning, GCS, pulse oximetri)
  • four therapeutic competencies (O2, IV lines, transport in semi sitting position and endotracheal intubation.)
  • Finally there is one clinical judgment competency. Whether to intubate or not.

The researchers went through all available prehospital protocols identifying and counting the competencies.

They found 438 mutual competencies and a further 62 competencies that were specific for the prehospital physicians.

What does this tell us? It demonstrates and quantifies the significantly wider range of the Dutch prehospital doctors skillsets. It gives us a better understanding of an important aspect of the long-standing controversy over whether there is any benefit of prehospital physiciansFurthermore the study does not take into account the qualitative differences. An ambulance nurse might be able to intubate but not nearly as good as an anesthetist.

For me it’s obvious physicians have an important and game changing role in prehospital care for the critically ill or traumatized. For exactly the same reasons that we have doctors at all in resus rooms and ICUs. It is a total no-brainer to me that we win by letting us physicians bring ‘upstairs care outside’ and combining our critical care skills with the exceptional prehospital expertise of the paramedics.

I am glad to see how this view is confirmed by the benchmark HEMS systems (London HEMS, Sydney HEMS, Norwegian Air Ambulance and some others). They are successfully employing a doctor-paramedic model. The double paramedic or nurse-paramedic HEMS model is gradually and thankfully being edged out by the guys who have decided to be the cutting edge of HEMS.

The abstract and links to the study can be found here.

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