In the spotlight… pre-hospital medicine
For Dr Matt O’Meara, an ST3 in anaesthetics and intensive care in Nottingham, pre-hospital medicine has given him the most exhilarating experiences of his career to date. Could it reward you in the same way?
Sitting on the edge of a motorway with the traffic speeding past, the rain drenching you and the only source of light the oncoming headlights, is not everyone’s idea of emergency medicine. Such was my introduction as a final-year medical student: attached to a pre-hospital doctor responding to 999 calls on behalf of the ambulance service.
The doctor I shadowed for the evening adeptly juggled the diagnosis and treatment of acute injury and illness, alongside the logistics of working without immediate backup – not to mention the weather!
My first lesson came when I was asked to hand him an oxygen mask. Reaching into the bag in the cold and the dark was difficult, but I proudly passed him the equipment only to discover it was a paediatric mask, no good for the adult patient in front of us. The lesson was clear – know your equipment.
The most important aspect of working in such environments is to keep safe and avoid becoming a casualty yourself. This was hammered home during that night as we attended a variety of potentially dangerous situations, including a motorway accident, a police firearms incident and a house fire. Perhaps the most unusual safety issue involved a woman who had collapsed in her kitchen and was being guarded by a vicious-looking pitbull terrier.
How to work in pre-hospital medicine
In attending one festival I was called to suture the head of an intoxicated rock star! His band mates sung to him whilst I infiltrated the local anaesthetic
There are many dimensions to the practice of pre-hospital emergency care in the UK. several schemes exist, consisting of local volunteer doctors organised under the umbrella organisation BASICS. They respond in their own time and are funded by charities. Others have organised rotas and deploy multi-professional teams to the scene of illness and accidents. Typically, these schemes consist of senior doctors (registrars or consultants) who are drawn from relevant specialties, such as anaesthetics, emergency medicine, ICU and general practice.
Another area of PHC is event medicine. In the wake of certain high-profile national disasters, many sports governing bodies have rules and regulations in place that dictate that there must be a medical presence at contests. The principle role of the doctor depends on the sport, but includes looking after the competitors (eg, boxing), or responding to significant trauma (eg, motorsport medicine). Any event attracting large numbers of spectators will have its fair share of crowd work.
Event medicine is not limited to sports. Large music festivals also require crowd cover. In attending one such festival I was called to suture the head of an intoxicated rock star! His band mates sung to him to calm him down whilst I infiltrated the local anaesthetic.
Getting in
Getting involved in pre-hospital care often begins at medical school. Several UK medical schools have specialist societies that focus on PHC, trauma, or wilderness medicine. This is a good place to start.
There are also courses dotted around, which medical students are welcome and encouraged to participate in. Some universities include this as part of their curriculum.1 It was at one of these courses where I was first introduced to this area of specialist emergency practice.
But the courses are no substitute for real-life experience. For those in junior medical positions, this is usually limited to observational shifts with experienced paramedic or medical crews. All the UK ambulance services have doctors in paid medical supervisory roles and these people can be a useful source of help and guidance.
The minimum entry criteria for most schemes are usually ST1/ST2 with experience of the acute care specialties. At the time of writing, a formal training structure for registrars wishing to cub-specialise is under development. It is likely that those having completed the acute care common stem (ACCS) will enter their parent specialties, principally emergency medicine, before going on to develop some of the specific skills required to practise pre-hospital emergency medicine.
This training will lead to accreditation and consultant appointment in a job with a pre-hospital component.
Necessary skills
Many of the skills required to practise PHC in the field are common to many areas of medical practice.
The ability to assess and treat common medical, surgical, psychiatric, paediatric and obstetric emergencies is important. As is an aptitude for being able to think on your feet, respond to fast-moving situations and communicate this to the teams around.
Patients, relatives and other members of the team look to doctors for guidance and leadership – a skill which comes with experience and practice. Other skills are more unique to the specialty, such as emergency driving, management of major incidents and pre-hospital anaesthesia. Getting involved in PHC also helps to hone many of the generic professional skills, which can then be taken back into hospital.
It can also help with application forms and always gives a good story to tell at ST interviews. It is an important component of good medical practice to ensure there are appropriate indemnity arrangements in place for all areas of medical practice, and PHC is no exception. So ensure that you contact your MDO to discuss what you are doing.
The NHS Litigation Authority usually provides cover for NHS-related activities, such as working on behalf of an ambulance service. However, for commercial activities such as sports events, it is important to make sure your defence organisation has been informed. Above all else, it is important to stay within the limits of your competency for any patient you treat.
I love my day job, but PHC has given me the most exhilarating and rewarding experiences of my career to date and I would thoroughly recommend it to anyone who is interested.
References
1. Porter, K. Training doctors in pre-hospital care: West Midlands (UK) approach. Emergency Medicine Journal (2004)