Florian Breitenbach

Rettungsdienst und mehr


Yes, Ormskirk. A little town in the North West of England, 14 miles north of Liverpool. Bus driver, pub owner, town locals…all asking me the same question: “What are you doing here?!” It seems visitors, be it from London or from Mars, are a rarity. Ormskirk is not a place that prides itself on tourism.

Doesn’t matter to me, I didn’t get to see much of the place anyway. I was here for the Continuing Professional Paramedic Development – a one day conference put on by the UK College of Paramedics.

The day started off with Dr John Freese, Chief Medical Director of New York City Emergency Medical Services. A rather good speaker with an interesting background (John started as a basic EMT in the rural US, worked his way up to Paramedic, then turned to medicine). His talk was based around trauma care in the US, its history and direction of the future. Some interesting points I picked up:

  • Skill decay is a big problem amongst NYC paramedics. Intubation success rate is approximately 30%, many paramedics don’t even get a chance of intubating, and their average training is far less than that of an average UK paramedic.
  • For severe trauma patients, definitive care is needed. Where this care is provided best (i.e. what is the most suitable hospital), NYC EMS has developed a simple reductive flow chart based on patient presentations, events and mechanism in order to determine if a patient should be taken to a trauma centre, and if so, what level. An important note was emphasised: the clinicians decision. The chart could not indicate any need for higher care, but the paramedic must still be allowed to take a patient to the highest care facility if judged so by their clinical experience.
  • Then the big one: “Spineboards: they need to go”. NYC EMS has realised that far too many patients are immobilised for no good reason. Research is proving that immobilisation is possibly doing more harm than good. Currently, new guidelines are being written in order to drastically lower numbers of spineboard usage in NYC. Personally, I applaud this. A big step in the right direction.
This talk was particularly interesting for me, as I had just visited New York last year (if you’ve been reading this blog recently, I am just putting up the stories now). Very nice having seen NYC EMS, then hearing all about it from the Chief MD.
Up next was Professor Kevin Mackway-Jones, Medical Director of the North West Ambulance Trust (NWAS). The presentation was similar to the previous, but this time from the NWAS perspective – a much more diverse landscape with urban, regional and rural settings (something you wouldn’t find in NYC!).
  • To provide a similar level of care that urban area enjoy everywhere in the NWAS catchment area, another 14 full time helicopters and anaesthetist would need to be employed. Far too expensive and ridiculous, he explored the alternatives: Full time HEMS, vs on call residential doctors, vs volunteer doctors (e.g. BASICS), vs full time specialised (critical care) paramedics. The last option won – cost effective, good exposure means good quality, experienced, available and a good skill set.
  • Kevin agreed with John about spineboards, and repeated the overuse of the device, stating that many UK services are re-evaluating their use. Additionally, he stated he is not convinced by pelvic splints; there is not enough evidence to support them.
Next speaker was Professor Andy Newton, Chair of the College of Paramedics and Clinical Director of South East Coast Ambulance Service. After some information update from the College itself, Andy got us in the right mood with a clip from the Simpsons: Homer as an Ambulance Driver (could unfortunately only find it online in Italian). Some points Andy talked about:
  • The history of Paramedicine, especially with regards to the “founder” of out of hospital care, Dominique Jean Larrey.
  • The specialisation of the workforce. The police have a very specialised workforce: General duties, traffic, homicide, fraud…certain cops target certain crime. Paramedicine should (and is) heading int he same direction: Paramedic Practitioners for minor issues that can bypass the A&E department, Critical Care Paramedics for very serious cases.
  • Apparently providing Ambulance Services in the United Kingdom costs 2 billion Pounds annually (surprising actually, since London’s Metropolitan Police alone have an annual budget of 3.5 billion Pounds. Compared to the 282 million Pound London Ambulance annual budget).
  • Then a great point: “Paramedics as a disruptive technology“. Adapted from the business world, the point was made how Paramedicine is influencing healthcare, changing the way care is delivered (e.g. via Paramedic Practitioners), together with potential ways Paramedicine may influence the provision of healthcare in the future.
  • Another video, this time from a cardiac arrest in London from the early 1980’s. Horrible grey uniforms, ghastly hairstyle, but the intubation was spot on (unfortunately nobody cared about chest compressions…). Nothing how an arrest is run in 2012, thirty years later.
After lunch, there were two more presentations; Sudden Arrhythmic Death, and Obstetric emergencies.

In other words: Quite a good event. Interesting speakers, decent venue, and a good attendance. Can’t ask for much more! For those who would like an online summary, I did tweet most of the event under the #ParaUKCPD hashtag on twitter (should be visible on my timeline, dated 19th October).

Couldn’t make it? I will be visiting the Emergency Services Show in Coventry on the 21st and 22nd of November, tweeting and blogging again. Hope to see you there!


Medic Wicket says:

As a NYC medic, I was quite taken aback by what Dr. Friese had to say. I have a hard time believing we only have an intubation success rate of 30% percent. I have worked for 3 different agencies here, had a QA capacity in one, and while I don’t have the exact numbers, all are far better than 30%. Perhaps He is speaking of Just FDNY, and his numbers don’t include the stats of the numerous voluntary hospitals and private services in the city.
Moving on to trauma. Trauma of all kind is primarily BLS, including pedestrians struck, shootings, and stabbings . ALS is only called If the patient is unresponsive or in arrest on initial dispatch, or BLS requests after evaluating. There is no complex guide. Traumas go to trauma centers. We aren’t even told If the hospital is a level 1 or 2. From what I’ve seen, NYC needs to start sending all BLS providers to PHTLS or an equivalent, which are almost impossible to find courses in the city. They spend too much time on scene bandaging and splinting distracting injuries while often missing the bigger picture.
Finally, there is selective spinal immobilization. For starters, many traumas also get a fire engine to respond. For some reason they are usually dispatched before EMS to medical and trauma calls. The firefighters are only required to be trained to first responder level, which to me is very disappointing for one of the largest fire departments in the country. At this level, they cannot clear c-spine, and often board and collar everyone before or as EMS is arriving. Our protocols do not allow us to remove the collar once it has been applied. Also, many providers who do get there before the ffs apply the collar are also Leary about this, and also board and collar unnecessarily. Please do not fall for the hype Dr.Friese is selling. .NYC is still far behind compared to more progressive areas in both this country and the world.

flobach says:

Thanks for your comments, always good to hear both sides of the story.
Not sure about the exact stats.
The trauma decision guidelines are currently being written (if I remember correctly), and should be distributed to frontline staff next year. He did state that Trauma is currently BLS only, but with the evidence behind tranexamic acid given IV in trauma helping mortality, it may be become an ALS thing in the future.

Will be interesting to see the developments of the future, NYC and elsewhere.

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