The title of this brief comment was the final part of my inaugural Larrey Lecture given in London on 13 July 2016. It represents only an opinion; hence, some disagreement is naturally expected, and indeed, welcomed. Honest debate can stimulate progress.
Whilst physical maps and individual knowledge of local areas allow paramedics to find their way to critical locations, the use of satellite navigation is still used in the vast majority of tactical operations through the on-board vehicle mounted communications systems. What's more, the use of GNSS is likely to become even more integral to everyday missions. Oulu in Finland recently linked a monitoring system between the town's CCTV and central traffic light system with GNSS tracking. This enables emergency vehicles to be ‘green lighted’ through the main urban intersections to an incident anywhere in the municipal area, vastly improving the efficiency and effectiveness of the emergency response call-outs.
I have had a major interest in resuscitation since 1966, when Jude, Knickerbocker and Kouwenhoven reminded us of the value of external chest compression (Jude et al, 1966). Their paper triggered a chain of ideas that led to modern cardiopulmonary resuscitation (CPR). A dramatic but sad event in 1970 led me to teach an ambulance attendant on-scene how to perform CPR. His rapidly acquired skill prompted me to introduce the ‘extended training’ for ambulance crews into Europe in 1970–71, which included defibrillation and drug administration. Dr Peter Baskett had already taught ambulance personnel the use of entonox. Progress thereafter was a joint effort that led to the creation of a group we now call paramedics.
Although I am at an age where one should leave progress to others, I cannot resist interfering by putting forward my own views.
The ambulance service in the United Kingdom has common governance. But this is complex and permits multiple interpretations. A single ambulance service within the UK with officers elected from within professional organisations including the College of Paramedics is something, I believe, may be more conducive to efficient function. This body would be responsible for bulk purchases of equipment and material, for direction of major national policies, and could also grant a degree of regional autonomy for areas of 1 to 2 million population that would take account of demographic differences. Medical advisers would be appointed who would not automatically have administrative roles.
Private ambulances are contracted to undertake much of the non-urgent work such as conveyance of patients who are not seriously ill. But inevitably, dispatchers are not able to discern the full implications of all cases. In general, the private services perform well in their management of highest risk patients, partly because many of their staff are paramedics, but the training of all staff in private ambulances is usually impressive. Nevertheless, private ambulances should not be deliberately tasked with Red 1 calls.
We also need a comment on training levels within the statutory service. Paramedics are no longer a single entity but a profession in the full legal sense, and within the profession are grades with higher levels of training that may carry the title of Critical Care Paramedic (or for domestic/home emergencies paramedic practitioners). But ambulance services at present vary in their interpretation, nomenclature, and use of these higher grades. They should be regulated by the College of Paramedics, to which all practitioners at every level should belong.
Emergency medicine is a complex discipline, and frontline staff at all levels will sometimes feel the need for advice or reassurance. Reliable communication must be in place with backup systems if necessary. The workload at the receiving end will be variable. A tiered response is therefore useful, with the most complex problems passed to the most experienced adviser. Medically qualified practitioners should be needed only in exceptional cases. They will not be part of the general system but at least three individuals should be available on a rota system.
Frontline standards must be maintained, but open to improvement. This can be achieved adequately only by non-intrusive monitoring. I recommend very strongly an analysis of electronic downloads from the most critical cases. Management of cardiac arrest is the best choice as the most demanding of emergencies (and one that the basic paramedic may encounter only three or four times a year). With download analysis, however, a strict ‘no-blame culture’ is essential. Apart from simple defibrillation, a perfect resuscitation is never achieved – a fact that should be well understood by all.
Liaison with other services is a paramount need, and with it the acceptance of the adage, ‘compare and improve’. It is not enough to wish for a strongly cohesive service in the UK: we must hope for the same in all European countries with high level representative meetings that would enable us to learn from each other. Liaison with interdisciplinary groups such as ILCOR remains essential.
Even a near-perfect ambulance service must recognise one inevitable limitation. It will never be adequate for the most challenging emergency: cardiac arrest. Out-of-hospital cardiac arrest (OOHCA) is not an ambulance problem, but a community problem and an ambulance service problem. We should stress the need for co-responders for Red 1 calls. A very close link with the fire-service is advisable, probably moving towards full integration as a single emergency service. But this is not enough: the wider community must be involved. At its most basic, this includes effective ‘telephone CPR’ designed to achieve first compressions within 2 minutes of a cardiac arrest – a far cry from most present systems that waste much time with needless questions. But we must go further with effective use of community first responders who will be deployed no later than 30 seconds after the ambulance, and in most cases should then arrive appreciably sooner, particularly in more remote areas.
Involvement of the community must extend to a general understanding of critical first aid, that can be achieved only by making instruction mandatory in all schools. Courses can be progressive on a year-by-year basis, starting with the recognition of a ‘need to call’ from the age of 4/5 years. This should progress to wide knowledge of first aid including skill in CPR and confident use of AEDs.
A paper from Denmark (Wissenberg Jørgensen, 2015) proves what can be achieved. Data are available from a wide area of that country over the period from 2001 to 2010. Information was collected on 19 418 cases of OOHCA that were not EMS-witnessed. During this period, the rate of bystander CPR increased from 21.1% to 44.9%, and 30-day survival from 3.5% to 10.8%. Many strategies were used, including training in schools, and a requirement for those applying for driving licences to have the required knowledge. This illustrates well how community activities are needed to support the ambulance services.
With so many lives depending on it, we need to reassess the present situation and move as quickly as possible to ‘what it ought to be’.