PHEM Experiences

We all have a hand to play in patient care.

Over the years we’ve all witnessed tremendous change in prehospital care. When I think about what’s happened in some areas, it’s mind-blowing; new formal sub-specialty of PHEM, new trauma systems, new treatment pathways, new equipment, trauma dolls that scream and bleed, new information, new research, new leadership…and of course, thanks to SARS-COV-2, a new disease to battle with! 

The pace of change does not appear to be slowing down.

There are so many stakeholders now involved in the delivery of prehospital care that it is sometimes difficult to understand how it all comes together and works … but it does!

Most of the public still think that all prehospital care is being delivered by paramedics, and the concept others working or contributing in this environment, is not really understood. This is entirely understandable, as generally speaking, the first people to turn up when you call 999 will be those highly trained paramedics, arriving in an ambulance with blue lights and sirens …and if they are lucky, they may be the same paramedics they have seen on telly! 

Hidden behind this important 999 response, is a small army of highly skilled group of clinicians who work in partnership with the ambulance service. Their role is to provide enhanced care to the sickest of patients. Alongside these PHEM specialists is another group of dedicated responders who voluntarily respond to 999 calls and provide vital first aid to the ill and injured before the ambulance service arrive. These first responders maybe from the general public as first aiders or from existing blue light services such as the police or the Fire Service, who in many cases, may be the first to arrive on scene of an incident. 

Because of the way all these people link hands in the chain of care, our patients probably do well.

Or do they…?

As the system is so highly tuned, technically and target driven, the evolutionary changes that we are now seeing are effectively small tweaks by comparison to what has happened historically. Improving clinical performance and patient outcome now relies upon aggressively hunting out the smallest of challenges and pressing hard for marginal gains. As the system is so good, these gains are getting smaller and smaller. In pursuance of excellence, many are now reaching across to equipment as an answer …but is this clever technology and equipment really the answer? The medical industry has seen this evolution and seized the many opportunities that have present from an emerging speciality. As a result, there has been what can be best described as an equipment explosion. Much of the equipment that I’ve seen produced has been ‘old stuff’ just made shinier and more ‘gadget like’ for the modern eye. 

Does it always help?

Not always! I attended a case where a crew were struggling to work out how to use one of the new ‘gadget like’ splints. We worked together as a team and thankfully achieved the outcome. But afterwards I thought, was it a failure of training, or a failure of the equipment if the crew couldn’t work out how to use it? I’d argue that it was a combination of both, which highlights my view about the danger of industry over complicating things to make a sellable product. Personally speaking, I’ve never really been bothered if a splint has got pulley systems, Velcro straps, or has bits of string that glow in the dark, a splint is a splint, the clinical principles are the same. Likewise, a dressing is a dressing, is it really that important that a field dressing can do 4 things? And I’ve lost count of the number of tourniquets that I have seen come forward in recent times.   

What is being lost in all this equipment fog is the understanding that to improvise can be effective… and acceptable! Simple things really do work.

Improvisation is a skill which I feel is being sadly lost over time. When someone is bleeding to death or has a broken limb, the first responder may not have access to equipment, so they will need to improvise. My paramedic colleagues who were stumped by the modern splint problem earlier could have easily improvised with simple kit that they had in the ambulance, but sadly, no one had ever shown them how to do that. What I also noted was the crews focus was on the equipment complexity and not on the patient, this did upset me.

The promotion of improvisation does not generate income for industry. This makes me ponder, what is the true motivation for all this equipment flooding into PHC, is it part of a system’s evolution, is it profit … is it really patient need driven? Of course, we do recognise that some parts of the medical industry have also been drivers for some amazing innovation and have created some really important ‘tools’ to be used in the prehospital setting, and their philanthropic endeavours are commendable. Sadly, these are companies are few and far between.

A hidden asset

What has been overlooked in the chain of care is the capability of the public. What can the general public do before anybody arrives? Working on the basis that a member the public is the ultimate first responder, perhaps the time is right to redirect some of our focus towards this group.  The small charity that I work with called citizenAID empowers the member of the public to exactly this, to provide timely life-saving interventions before anybody else arrives. The context of this information is against the background of a deliberate/terrorist attack, and they are empowered to do all this with no medical training at all. What we’ve created in terms of our free support material, is eminently translatable to everyday incidents. If citizenAID can tell a member of the public how to deal with somebody with a catastrophic external compressible haemorrhage following a frenzied knife attack, the very same information can tell them what to do if they come across someone who has cut their arm in a factory incident.

As a specialty, I think we do need to do more and empower the public, lobby HMG and educational bodies for change. By doing so we can then work to unlock this capability throughout UK and ultimately save lives.

Some things don’t change

When I reflect upon all this, it’s reassuring to see that patients haven’t changed, admittedly some are bigger, and many are older! But in this equipment drive, we should not forget the importance of talking to the patient, connecting with them. I do now worry that the propensity of equipment/processes/systems is possibly squeezing us all too much, leaving little room for this very important aspect of care to happen. Are we becoming just too busy and too technical in our delivery of prehospital care?

Paying attention to how our patients feel is what makes a real difference to them. When we do this well, the personal satisfaction it generates adds charge to our own internal batteries, it certainly keeps me going.

If technology/equipment has turned into your comfort blanket in PHC, then there is a real danger that it will it smother your patient! Filling in a PRF, pressing a button for a data upload, passing a message over the radio all should be seen as a short and rude interruptions to our human contact with our patients’ and certainly should not be the main focus of the care that we deliver.

A high performing prehospital system is all well and good, but in many cases, the lasting memory from every patient will be the eye contact of the responder, the hand that is held, those words of comfort offered. Whoever it is, they really don’t care who does it. We all have a hand to play in patient care… let’s not forget to use it.

Mr. Andrew Thurgood, MSc, FIMC RCSEd, DipUMC RCSEd, DipHS, RN, MCPara,. 

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