Do ambulance crews triage patients.

Abstract

Sir I have read with interest the article on paramedic care (Rouse, 1991) and the conclusion that ambulance crews do not triage patients properly and that prehospital care by paramedics may be jeopardizing patient care. Twenty-four per cent of the patients were 'very seriously injured: they had multiple other injuries, vascular compromise, shock and amputations'. It is clear that most of the patients required an intravenous infusion as early as possible, particularly as the mean transit time to hospital was 20min. Intravenous infusion, of course, follows the primary assessment where priority must be given to airway care the maintenance of breathing and arrest of external haemorrhage. Airway care and spinal immobilization are all important time consuming factors and even if a scoop and run policy is adopted the neck must be protected and a clear airway established and maintained. It has been shown in this unit that delayed resuscitation in patients with compound fractures in isolation increases the incidence of complications particularly fat embolism, and I would advocate early oxygen therapy and intravenous infusion. Clearly there must be accepted protocols for the time it takes to set up an intravenous infusion and an analysis in the West Midlands recently of 100 trauma cases (excluding entrapment) in which intravenous infusion was part of stabilizing care revealed a mean on-scene time of 17min. Doctors with experience of pre-hospital care will appreciate the time it takes to satisfactorily stabilize a patient and I would include this time as being part of effective treatment within the 'golden hour'. For instance, a patient with a compound fractured femur needs a full assessment and treatment based on the usual priorities of care and for his fractured femur appropriate dressings, splintage and pain relief, all of which takes time and if the accident is some distance from the hospital and intravenous infusion is necessary. I have never seen a paramedic undertake these measures to the detriment of attending to the greater priorities in care, in particular, airway care, neck care, breathing and circulation and on many occasions I have received patients where minimal treatment, if any, has been given for there limb fractures because of life threatening priorities elsewhere. Based on the clinical information in this paper it would not be unreasonable to come to the conclusions that pre-hospital management by paramedics is enhancing the care as there are no data in this paper to suggest that paramedic intervention is jeopardizing patient survival. Prospective patient audit using more acceptable techniques such as TRISS (Boyd et al., 1987) need to be undertaken before prehospital management by paramedics can be fully evaluated and, in particular, before suggesting that they are jeopardizing patient care.