Superacute response

[SpecialK]

Avo,

I've been reading a bit about various ambulance services' running specialised responses to "super-acute" patients. Most of these patients have major trauma, and most responses use a Doctor/Paramedic or higher level "critical care" type paramedics. Most respond by road and air to primary retrieval taskings and exclude interhospital transfers.

Examples I have seen are:
GSA-HEMS, part of NSW Ambulance, which responds by air and also by road within Sydney..
Auckland HEMS, run by ARHT, which has a road based response within central Auckland.
HART, part of Queensland Ambulance, road based response within Brisbane and the Gold Coast.
The car-based component of London HEMS
Medic One in Edinburgh

The idea behind these is to have a consistently exposed group of highly skilled personnel (often including a doctor) respond to deliver things like RSI and mechanical ventilation, chest drains, ultrasound, blood and various interventions or levels of clinical decision making outside the general scope of paramedics where frequent exposure is required to maintain competency.

These initiatives seem to be well developed internationally; so who else out there is doing them? are you using a doctor or not? what experience have you had?

Cheers.

 

[LanceCorpsman]

First of all, physicians can't really do much in the back of the ambulance due to equipment limitations. I think that having experienced medics/nurses is acceptable. Maybe give medics more training and increasing the scope of practice (ultra sounds, chest tubes). But having a dedicated MD on an ambulance seems financially impossible in the United States.

 

[dutemplar]

Where I am, it is running critical care paramedics as critical care paramedics and a slightly enhanced scope of practice than in a lot of the USA. Multinational providers working here, mostly split between USA, SA and some UK. RSI is a standard. Vents are.. depends on your system. Standard here and with a few back home (interfacility and arrest/ advanced CPAP/BiPAP). Blood here... just for IFT. No time for a cross and screen and the good stuff is a little too scarce in supply for the field for us (it's been discussed a time or two.) Tossing darts or dropping tubes in chests bilaterally isn't exactly super technical and fairly normal. With the new guidelines is standard on a trauma code (along with pelvic binder, based upon general mechanism). We're working on getting ultrasound, but the budget is the budget and it takes a good six months to order anything... minimum, not to mention shipping,handling,and customs. Currently, I have roughly 80 "EMT-I" ambulances in service and 6 ground CCPs, two air CCPs. Busier seasons, "weekends" may have twenty more ambulances and two or more additional CCPs on. CCPs are probably cancelled half the time, downgrade half the remaining time. Today so far it's been a busy day...

Generally speaking, they only recruit fairly experienced here with backgrounds from busy 911, plus critical care time and a definite solid capacity and experience at RSI in particular. A few new hires over the last two years didn't make it through orientation due to not as much experience and "I'm the man..." ability.

Most of the systems I'm more familiar with from home are a physician on-call or physician/ surgical support team (Maryland Shock-Trauma Go Team, etc...) to assist with specialized applications in the field (amputations, etc.) Lancaster EMS's medical directer was a bit of a whacker and did have his own response vehicle (plus SWAT) but wasn't formalized and didn't bring a lot of extra toys to the game. Montgomery County has a go-team for on-request advanced interventions. A few European services I've seen (Magdeburg Germany comes mine) runs a 911 doctor (which has been getting better accredited than whichever random doc from the hospital who was available is on call) but is also used to defray some transports from happening (no ER for you!) as much as to bring the advanced things to scene and mostly serves to detract from the paramedic scope of practice (judging from talking to several medics when visiting there) rather than truly enhance and expand the system.