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Medical teams, Flying Squads — the arguments revisited
204
Injury (1990)2l, 204 PrintedinGreat Brituin
Editorial Medical Teams, Flying Squads - the arguments revisited
Debate about Flying Squads to attend injured patients at the scene has been reopened by the Irving report on preventable deaths, and a succession of major disasters in the UK. The emotive scenes of the first few hours occupying attention from the public whilst the suffering and work goes on for months and years later with little attention. Steedman sets out to rationalize some of the arguments. That there are deficiencies in the management of injured patients is not in doubt - in spite of the fact that we are told our emergency services are the best in the world. It is not easy to criticize patient care without undermining the very system we work in and wish to improve and without appearing to denigrate what caring people are doing under difficult circumstances. The deficiencies start with resuscitation at the roadside; continue through accident departments; in the various surgical specialties; and to rehabilitation facilities which, unlike the aforementioned treatment areas, do not even exist in large areas of the country. Any improvement in immediafecare must therefore be seen in context, especially since the number of road traffic accident victims is falling in the UK. Keeping patients alive only to have a poor quality of survival is counterproductive. If doing so creates improvement in other areas it is praiseworthy. The fear is that resources redirected to, say, a flying squad, will be taken from one of the other areas of trauma care. As in other current health care debates, someone else will suffer unless the total size of the cake/budget is increased. At its most simplistic, if senior medical and nursing staff leave a hospital to attend an accident, who will care for the next victim from a different source. This situation is not unknown and results from poor staffing levels as well as poor priority assessment. Can we afford to have teams of doctors and nurses waiting to be called when, even in the article published by Steedman, the vast majority of call-outs are not essential when viewed retrospectively? We must also beware of the emotive reaction that flying squads only do good or at best no harm. As Steedman points out, it is crucial to have properly trained and experienced staff (again where from?). There may occasionally be delays in getting the team to the patient, thus delaying his/her arrival in hospital. If that patient happens to need a life-saving operation (as opposed to resuscitation) the existence of the team will unwittingly have contributed to the death. Individual cases (successful or not) must be studied as well as the statistical approach. Thus, there are some essential points to attend to: 0 1990Butter-worth-Heinemann Ltd OOZO-1383/90/040203~1
A. The most important issue to be resolved in the use of such a team is What are the criteria for calling out expertise?’ This has not been tackled in Steedman’s article. B. The prime needs of the injured patient are: 1. dbtain and maintain an airway, 2. Prevent further danger and injury, 3. Monitor and supply intravenous fluids, 4. Provide pain relief, 5. Release trapped victims efficiently and safely, 6. Get them to the best equippedand sfafid hospital at the earliest opportunity. Why is it considered necessary to have a doctor or a nurse to perform any of these in most cases? It may be that the most cost-effective solution is the proper training and rewarding of the ambulance service and expansion of the paramedics. Both issues rely upon feedback and relationships between accident surgeons and the emergency services. The most useful information which could come out of such pilot studies is - precisely whaf expertiseis requiredand when - when call-outs were justified, and when a call-out should have occurred but did not. Did the expert contribute to saving life, limb, speed, comfort or simply an immeasurable air of authority and confidence? Could this contribution have been made by a paramedic, or did it need an anaesthetist, surgeon or perhaps a nurse. Do we need to discharge both barrels of a shotgun every time, when a more finely tuned pistol would suffice? C. Finally, in any rational argument (not emotive or empirical) the financial consequences must be faced. How are these improvements to be funded? Not at the expense of later treatment. Are insurance companies interested in reducing mortality or morbidity after injury? Even when the objective and scientific analysis is better, the decisions will still be political, emotive and financial. Sadly, the desire for improvement does not yet come from the correct quarter. Current pressure for improvement comes from the surgical accident lobby; not patients, politicians or other bodies who could readily express an interest. If complaints about the wait for elective surgery, waiting in accident departments, the shortage of transplant organs, were matched by complaints about preventable death and morbidity from injury, we would be nearly there. Paul Staniforth
Injury (1990)2l, 204 PrintedinGreat Brituin
Editorial Medical Teams, Flying Squads - the arguments revisited
Debate about Flying Squads to attend injured patients at the scene has been reopened by the Irving report on preventable deaths, and a succession of major disasters in the UK. The emotive scenes of the first few hours occupying attention from the public whilst the suffering and work goes on for months and years later with little attention. Steedman sets out to rationalize some of the arguments. That there are deficiencies in the management of injured patients is not in doubt - in spite of the fact that we are told our emergency services are the best in the world. It is not easy to criticize patient care without undermining the very system we work in and wish to improve and without appearing to denigrate what caring people are doing under difficult circumstances. The deficiencies start with resuscitation at the roadside; continue through accident departments; in the various surgical specialties; and to rehabilitation facilities which, unlike the aforementioned treatment areas, do not even exist in large areas of the country. Any improvement in immediafecare must therefore be seen in context, especially since the number of road traffic accident victims is falling in the UK. Keeping patients alive only to have a poor quality of survival is counterproductive. If doing so creates improvement in other areas it is praiseworthy. The fear is that resources redirected to, say, a flying squad, will be taken from one of the other areas of trauma care. As in other current health care debates, someone else will suffer unless the total size of the cake/budget is increased. At its most simplistic, if senior medical and nursing staff leave a hospital to attend an accident, who will care for the next victim from a different source. This situation is not unknown and results from poor staffing levels as well as poor priority assessment. Can we afford to have teams of doctors and nurses waiting to be called when, even in the article published by Steedman, the vast majority of call-outs are not essential when viewed retrospectively? We must also beware of the emotive reaction that flying squads only do good or at best no harm. As Steedman points out, it is crucial to have properly trained and experienced staff (again where from?). There may occasionally be delays in getting the team to the patient, thus delaying his/her arrival in hospital. If that patient happens to need a life-saving operation (as opposed to resuscitation) the existence of the team will unwittingly have contributed to the death. Individual cases (successful or not) must be studied as well as the statistical approach. Thus, there are some essential points to attend to: 0 1990Butter-worth-Heinemann Ltd OOZO-1383/90/040203~1
A. The most important issue to be resolved in the use of such a team is What are the criteria for calling out expertise?’ This has not been tackled in Steedman’s article. B. The prime needs of the injured patient are: 1. dbtain and maintain an airway, 2. Prevent further danger and injury, 3. Monitor and supply intravenous fluids, 4. Provide pain relief, 5. Release trapped victims efficiently and safely, 6. Get them to the best equippedand sfafid hospital at the earliest opportunity. Why is it considered necessary to have a doctor or a nurse to perform any of these in most cases? It may be that the most cost-effective solution is the proper training and rewarding of the ambulance service and expansion of the paramedics. Both issues rely upon feedback and relationships between accident surgeons and the emergency services. The most useful information which could come out of such pilot studies is - precisely whaf expertiseis requiredand when - when call-outs were justified, and when a call-out should have occurred but did not. Did the expert contribute to saving life, limb, speed, comfort or simply an immeasurable air of authority and confidence? Could this contribution have been made by a paramedic, or did it need an anaesthetist, surgeon or perhaps a nurse. Do we need to discharge both barrels of a shotgun every time, when a more finely tuned pistol would suffice? C. Finally, in any rational argument (not emotive or empirical) the financial consequences must be faced. How are these improvements to be funded? Not at the expense of later treatment. Are insurance companies interested in reducing mortality or morbidity after injury? Even when the objective and scientific analysis is better, the decisions will still be political, emotive and financial. Sadly, the desire for improvement does not yet come from the correct quarter. Current pressure for improvement comes from the surgical accident lobby; not patients, politicians or other bodies who could readily express an interest. If complaints about the wait for elective surgery, waiting in accident departments, the shortage of transplant organs, were matched by complaints about preventable death and morbidity from injury, we would be nearly there. Paul Staniforth