i OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Pre-Hospital Care ii Published and upcoming Oxford Handbooks Oxford Handbook of Clinical Medicine 7/e Oxford Handbook of Clinical Specialties 7/e Oxford Handbook of Acute Medicine 2/e Oxford Handbook of Anesthesia 2/e Oxford Handbook of Applie d Dental Sciences Oxford Handbook of Cardiology Oxford Handbook of Clinical Dentistry 4/e O xford Handbook of Clinical and Laboratory Investigation 2/e Oxford Handbook of Clinical Dia gnosis Oxford Handbook of Clinical Hematology 2/e Oxford Handbook of Clinical Immunology an d Allergy 2/e Oxford Handbook of Clinical Drugstore Oxford Handbook of Clinical Surgery 2/e Oxford Handbook of Critical Care 2/e Oxford Handbook of Dental Patient Care 2/e Oxford Han dbook of Dialysis 2/e Oxford Handbook of Emergency Medicine 3/e Oxford Handbook of Endocrin ology and Diabetes Oxford Handbook of ENT and Head and Neck Surgery Oxford Handbook for the Foundation Program Oxford Handbook of Gastroenterology and Hepatology Oxford Handbook of G eneral Practice 2/e Oxford Handbook of Genitourinary Medicine, HIV and AIDS Oxford Handbook of Geriatric Medicine Oxford Handbook of Medical Sciences Oxford Handbook of Nutrition and Dietetics Oxford Handbook of Neurology Oxford Handbook of Obstetrics and Gynecology Oxford Handbook of Oncology 2/e Oxford Handbook of Ophthalmology Oxford Handbook of Palliative Ca re Oxford Handbook of Practical Drug Therapy Oxford Handbook of Psychiatry Oxford Handbook of Public Health Practice 2/e Oxford Handbook of Rehabilitation Medicine Oxford Handbook of Respiratory Medicine Oxford Handbook of Rheumatology 2/e Oxford Handbook of Tropical Medic ine 2/e Oxford Handbook of Urology 1 iii Oxford Handbook of Pre-Hospital Care Ian Greaves Visiting Professor of Emergency Medicine University of Teesside, UK; Consultant in Emergency Medicine British Army and Keith Porter Professor of Clinical Traumatology University Hospital Birmingham, UK iv Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the Unive rsity of Oxford. 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ISBN 0 \200\22319 \200\223851584 \200\2237 (flexicover: alk. paper) 978 \200\2230 \200\2231 9 \200\223851584 \200\2235 (flexicover: alk. paper) 10 9 8 7 6 5 4 3 2 1 1 v Foreword By Rudy Crawford There have been many changes in clinical medicine and in the UK National H ealth Service since the publication of Pre-Hospital Medicine: The Principles and Practice o f Immediate Care, in 1999.1 Advances in the treatment of cardiac emergencies have moved tim e critical interventions such as thrombolysis for acute myocardial infarction to the prehos pital arena, while in-hospital primary percutaneous coronary intervention is increasingly t he treatment of choice in hospitals for patients with acute coronary syndromes. The introdu ction of thrombolysis for acute ischae- mic stroke (brain attack) is a time critical treatm ent that places further pressure on pre-hospital practitioners involved in the care of pati ents with acute cerebrovascular emergencies. These developments have increasing implication s for those involved in pre-hospital care, which is the first step in the process of care f or the acutely ill and injured. In addition, changes in primary care have resulted in many general practitio- ners no longer providing 24-hour care. This has left a gap in health-car e provision, which is driving the development of the role of existing pre- hospital care pr oviders to include activities previously undertaken by medical practitioners only, and is i ntroducing new roles, such as the emergency care practitioner, to fill the unmet need for o ut-of-hours care. The rapidity of National Health Service reform means that most of these c hanges are being introduced without any clinical evidence base to support their effectivene ss or appropriateness. There has been very little research done to demonstrate the value of advanced pre-hospital care, although there is some evidence in the area of basic life supp ort and defibrillation. Consequently, defibrillation has moved from being an advanced life support technique to a basic one and volunteer first aiders and other lay people have been trained in its use with additional lives being saved. In the past ten years, the Faculty of Pre-hospital Care has become firmly established as the authoritative body in the field of pre- hospital care, both setting and raising standards and supporting research to provide a firm evidence base for what we do. Pre-hospital care is becoming increasingly specialized and may eventually be recognized as a separate subspecialty within Emergency Medicine. Nowadays, practitioners who are committe d to pre-hospital care not only have to be competent in dealing with individual casualties in an environ- ment that brings unique challenges, but also increasingly have to be able to respond effectively to civil emergencies involving mass casualties or terrorist threats wh ich include bomb, chemical, biological, radiological, or nuclear threats. The Faculty has d eveloped a structured training and exami- nation syllabus which is open to medical and non- medical practitioners. 1 Greaves I and KM Porter (eds) (1999). Pre-Hospital Medicine: The Principles and Practice of Immediate Care. Arnold, London. vi FOREWORD Membership of the Faculty is open to nurses, ambulance service staff, and voluntary aid soc iety members as well as medical practitioners, reflecting the Faculty \200\231s commitment to improving pre-hospital care across the whole spectrum of practice and encouraging a mult idisciplinary app-roach. The authors are prominent members of the Faculty and serve on its Board of Management. This comprehensive book deals with all aspects of pre- hospital care i n a pragmatic down to earth style, which encompasses best practice and is also underpinned by the currently available research evidence. The discerning reader will find numerous pear ls which will be relevant to them as doctors, nurses, paramedics, and voluntary aid society members alike. Rudy Crawford MBE BSc (Hons) MB ChB FRCS (Glasg) FCEM Consultant in Accident and Emergency Medicine and Surgery Glasgow Royal Infirmary and Chairman St Andrew \200\231s Ambulance Ass ociation September 2006 Foreword 1 vii Foreword By Fionna Moore The publication of an Oxford Handbook has to be a defining moment in the re cognition of the specialty of Pre-hospital Care, which has existed, often unsung and practi ced by a relatively small number of enthusiasts, for many years. This handbook joins a comp rehensive list of publications covering almost forty very diverse specialities. It is perha ps unique in that it covers an area which is increasingly recognized as a vital part in the continuum of patient care, even by doctors who still treat patients as if they had collaps ed or received injuries just outside the doors of the Emergency Department. It is an area o f care often practiced in difficult circumstances when compared to hospital medicine, with a sometimes inadequate history, poor lighting, inclement weather, hostile conditions, and l imited assistance, both in terms of personnel and equipment. Pre-hospital care is an environment well known to ambulance services, historically regarded as the health arm of the emergency services but increasingly regarded as the emergency arm of the health service. With increasing integration between primary and secondary care ambu lance staff and other pre-hospital care practitioners have opportunities to assume even gre ater responsibility for delivering care outside hospital, as highlighted within the recent Ambulance Service Review Taking Health- care to the Patient.1 The emphasis of the specialty has changed from having a purely trauma focus to include all the conditions which might present to the pre-hospital practitioner. The concept of such a practitioner is an inclusive one cover- ing individuals from a medical, nursing or paramedi c background, whether working for an Immediate Care scheme, for the Armed Services or an am bulance service, whether from the statutory, private, or voluntary sector. The settings inc lude primary care emergencies, sporting and mass gathering events but also cover the less c ommon but very challenging areas of CBRN and major incident management The conditions cover ed include not only those commonly dealed with in the emergency hospital setting, such as a cute medical, surgical, and trauma emergencies, paediat- rics, obstetrics, and gynecology b ut also the less common and unique pre-hospital areas of mass gatherings and sporting event s. Given the variety of clinical settings that may arise, many of the existing sources of writ ten advice are too large and unwieldy to be of much help in the emergency setting. Hospital doctors are very familiar with the assistance afforded by the small, easily referenced and robust handbook which is small enough to fit in the pocket of a white coat, the Emergency Department scrubs, or to keep nearby the phone. This Handbook will fill an important role b oth as an educational tool well as an aide-memoire when the practitioner might most need it . This is due to the authors 1 Department of Health (2005). Taking healthcare to the patient: Transforming NHS ambulance services. DH, London. viii FOREWORD being well known within the pre-hospital care community, being at the leading edge of pre-h ospital training and education, and having immense credibility through their practical day- to-day involvement in the specialty. With its succinct style, comprehensive contents, and p ractical advice, this book will find its way into the Hi Viz jacket pockets, Thomas packs, and the vehicles of pre-hospital practitioners. It will be an invaluable quick reference gu ide both in the emergency setting, for those in training within the specialty and those wor king towards the Diploma and Fellow- ship examinations set by the Faulty of Pre-hospital Ca re. Fionna Moore Medical Director London Ambulance Service September 2006 foreword 1 ix Contents Foreword by Rudy Crawford v Foreword by Fionna Moore vii Abbreviations xi Note: the content of individual chapters is detailed on each chapter \200\231s first page 1 An approach to pre-hospital care 2 Acute medical and surgical problems 3 Trauma 4 Formula ry 5 Analgesia and anesthesia 6 Poisoning and substance abuse 7 Acute psychiatric emergenci es 8 Pediatrics 9 The hostile environment 10 Major incident management and triage 11 Chemic al, biological, radiological, and nuclear (CBRN) incidents 12 Emergency obstetrics and gyne cology 13 Patient rescue and transportation 14 Sporting events and mass gatherings 1 69 169 307 359 396 481 495 553 575 619 641 681 703 Index 707 x Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and the publishers do not accept responsibility or legal liability for any error s in the text or for the misuse or misapplica- tion of material in this work. 1 xi Abbreviations AAA ac ACCOLC access overload control ACE ADI A&E AED AF AIS ALS ALSO AOC AP APLS ARDS ATLS AV AVLS AVNRT BA BASICS BLS BP BTLS CAA CAD CBRN CCS cm COPD CPP CPR CSF CVA DAI abdominal aortic aneurysm alternating current angiotensin converting enzyme acute decompression illness accident and emergency automated external defibrillator atrial fibrillation abbreviated injury scale advance life support ad vanced life support obstetrics air operations center anteroposterior advanced pediatric lif e support acute respiratory distress syndrome advance trauma life support atrioventricular automatic vehicle location system AV nodal re-entrant tachycardia biological agent British Association for Immediate Care basic life support blood pressure basic trauma life support Civil Aviation Authority computer aided dispatch chemical, biological, radiological, and nu clear casualty clearing station centimeter chronic obstructive pulmonary disease cerebral p erfusion pressure cardiopulmonary resuscitation cerebrospinal fluid cerebrovascular acciden t diffuse axonal injury xii ABBREVIATIONS dc DipIMC DKA DNR DVT ECG EMD EMJ EPO ERL ET FIMC FPOS GCS GTN HAZCHEM hazardous chemical h azardous material HAZMAT helicopter emergency medical service HEMS hour hr intercranial pre ssure ICP Institute for Health Care Development IHCD ischaemic heart disease IHD intubating laryngeal mask airway ILMA intramuscular im intravenous iv Joint Royal Colleges Ambulance Liaison Committee JRCALC jugular venous pressure JVP kilogram kg liter l laryngeal mask air way LMA lysergic acid diethylamide LSD meter m military aid to the civil powers MAC monoam ine oxidase inhibitor MAOI mean arterial pressure MAP Maritime and Coastguard Agency MCA mi crogram mcg metered dose inhaler MDI milligram mg myocardial infarction MI mean intracrania l pressure MICP direct current Diploma in Immediate Medical Care diabetic ketoacidosis do not resuscitate d eep vein thrombosis electrocardiogram electromechanical association Emergency Medicine Jour nal emergency planning officer emergency reference level endotracheal Fellowship in Immedia te Medical Care first person on scene Glasgow Coma Scale Glycerol trinitrate ABBREVIATIONS1 xiii MIMMS major incident medical management and support min minutes ml milliliters mm millimete rs MRCC Maritime Rescue Co-ordination Centers MRSC Maritime Rescue Sub-centers NAIR Nationa l Arrangements for Incidents involving Radioactivity NPIS National Poisons Information Serv ice NRPB National Radiological Protection Board non-steroidal anti-inflammatory drug NSAID ORCON operational research consultantancy PASG PCI PE PEA PEFR PEPP PHEC PHPLS PHTC PHTLS P PE PR PTS RCSEd RED RICE RNLI RSI RTC RTS RVP SAH sc sec/s SIDS SSRI stat SVT TCA tds pneumatic antishock garment percutaneous coronary intervention pulmonary embolism pulseless electrical activity peak expiratory flow rate pediatrics for pre-hospital professionals pr e-hospital emergency care pre-hospital pediatric life support pre-hospital trauma course pr e-hospital trauma life support personal protective equipment per rectum pediatric trauma sc ore Royal College of Surgeons of Edinburgh Russell extrication device rest, ice, compressio n, and elevation Royal National Lifeboat Institution rapid sequence induction road traffic collision revised trauma score rendezvous point subarachnoid hemorrhage subcutaneous second /s sudden infant death syndrome selective serotonin reuptake inhibitors immediately supra v entricular tachycardia tricyclic antidepressant three times daily xiv ABBREVIATIONS Telford extrication device TED transient ischaemic attack TIA transportation emergency TREM trauma score \200\223 injury severity score TRISS volts v ventricular fibrillation VF VT ventricular tachycardia WRVS Women \200\231s Royal Voluntary Service Chapter 1 1 An approach to pre-hospital care Why bother? 2 Getting started 4 Training and education 6 Qualifications in pre-hospital car e 10 Accreditation and re-accreditation 12 Medical equipment 14 Personal protective equipme nt 20 Packaging 22 A pre-hospital formulary 24 Drug security 26 Things to take to a call or keep in your vehicle 28 Transportation 30 The law and pre-hospital care 32 Insurance 40 Ge tting there: safe driving to the scene 42 Record keeping 46 The emergency services: the pol ice 48 The emergency services: the fire service 52 The emergency services: the ambulance se rvice 56 The emergency services: other agencies 58 The Faculty of Pre-hospital Care 60 BASI CS and BASICS Scotland 62 Suggested reading 64 Useful addresses 66 CHAPTER 1 An approach to pre-hospital care 2 Why bother? There are very few prospective randomized clinical studies proving the value of immediate medical care and its impact on morbidity and mortal- ity. Whilst there are repor ted series on the value of pre-hospital basic life support and defibrillation, there are ve ry few reports relating to trauma. Yet many people continue to sacrifice their free time to provide medical care everywhere from racecourses to oil rigs, from country cottages to tow er blocks. Every active immediate care doctor can recount an incident where a life was save d or a tragic future avoided by early acute medical intervention at scene. Whether the life -saving intervention is the establishment of a patent airway, the splintage of a shattered pelvis, the rapid extrication of an entrapped patient, or defibrillation of a VF arrest, we can all recollect an incident where being there did make a difference. In addition, althou gh in many cases intervention alters neither long-term morbidity nor mortality, there can b e no doubt that it greatly improves the patient \200\231s comfort and confidence, thereby m aking a potentially dread- ful experience slightly less so. For all these reasons, pre-hospital care is supremely worth doing. It is also a hugely chal lenging (and sometimes frustrating) specialty which demands a great deal of its practitione rs. Despite the difficult situations in which it is practiced, there can be no excuse for a nything but the highest professionalism. \200\230Better than nothing \200\231 is no justif ication for getting involved: the keys to effective pre-hospital care are education, practi ce, experience, and revalidation \200\224and enthusiasm. These are the keys to one of the m ost challenging branches of modern medicine. IG KP North Yorkshire, 2006 This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 4 Getting started Like any other subject, the secret of success in pre-hospital care is prepa ration. This chapter will help anyone beginning to work in the pre- hospital care environme nt. Having acquired the interest and enthusiasm, attention must be given to the following: - Training - Reading - Equipment - Personal - Medical - Transportation - Insurance - Joinin g a scheme - Validation (and revalidation). Each of these subjects is discussed in this cha pter. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 6 Training and education As in any other branch of medicine, appropriate training is essentia l. Experience is important, but knowing how to \200\230do it right \200\231 is crucial. Th e Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh, BASICS (the B ritish Association for Immediate Care), and BASICS Scotland organize or accredit a range of courses (for contact details see p.66). These courses are designed to be relevant to a wid e range of different professional backgrounds and skill levels. Pre-hospital Emergency Care (PHEC) The three-day Pre-hospital Emergency Care course and cer tificate is organ- ized jointly by BASICS, BASICS Scotland, and the Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh. Advice regarding the content of the co urse is also taken from ambulance service representatives and representatives of the Royal College of Nursing. This course is open to anyone who may be called upon to deal with emergency situations incl uding general practitioners, practice nurses, emergency services personnel, paramedics, vol untary aid society mem- bers, and those involved in sports medicine. Successful completion of the course and end-of-course assessment leads to the awarding of the PHEC certificate. The course covers all aspects of emergency care in a pre-hospital setting in relation to ad ults concentrating on medical and trauma emergencies with an introduction to pediatric emer gencies and trauma and major incident management. Course details can be obtained from BASIC S Education or BASICS Scotland (see p.66). First Person on Scene (FPOS) The First Person on Scene awards have been developed by the In stitute for Health Care Development (IHCD) and the Faculty of Pre-hospital Care. Two awards are currently available: - First Person on Scene (Basic) \200\22410 hours \200\231 trainin g (including assessments). First Person on Scene (Intermediate) \200\22430 hours \200\231 training (including assessments). The content of the two levels is designed to reflect how long responders are likely to have to deal with a patient before the arrival of an ambu- lance. For the Basic Award this is u p to 20 minutes; for the Intermediate Award, up to 40 minutes. Additional skills can be add ed to both levels of award to accommodate specific responder requirements. To achieve the FPOS award (at either level) both knowledge and practical assessments have t o be successfully completed. Questions are selected from central question banks and trainin g can only be delivered at IHCD accredited centers. Clinical endorsement of the FPOS awards , assessment, and training support materials are the responsibility of the Faculty of Pre-h ospital Care. Further information is available from Edexcel or the Faculty of Pre-hospital Care (see p.66). TRAINING AND EDUCATION1 7 Pre-hospital Trauma Course (PHTC) This is a two-day course with 19 hours of highly practica l educational activity. Topics include scene safety, triage, clinical assessment, and treat ment. There is an emphasis on entrapment and extrication. Candi- dates are individually ass essed on the practical aspects of pre-hospital trauma care. Further information is availabl e from the Faculty of Pre- hospital Care (see p.66) or from www.basics.org.uk Basic Trauma Life Support (BTLS) Basic Trauma Life Support courses were developed in the US A. BTLS aims to provide pre-hospital responders with a structured approach to the rapid ass essment, appropriate treatment, and evacuation of injured patients. The \200\230advanced \200\231 version of the course is aimed at paramedics and other advanced-level providers (s uch as trauma nurses) permitted to provide invasive treatment. There is also a \200\230bas ic \200\231 course, aimed at providers of pre-hospital care such as ambulance technicians a nd fire-fighters, which is limited to non-invasive skills. Both versions of the course are 16 hours in duration and are endorsed by the American College of Emergency Physicians and t he (USA) National Association of Emergency Medical Services Physicians. Contact details of BTLS chapters that run courses worldwide (including the UK) can be found at www.btls.org/or gan/chapters.htm Pre-hospital Trauma Life Support (PHTLS) Pre-hospital Trauma Life Support training was also developed in the USA and, like BTLS, offers basic and advanced courses, each of two days \200\231 duration and aimed at similar audiences. The USA National Association of Emergency Medical Technicians oversees PHTLS in conjunction with the Committee on Trauma of the Amer ican College of Surgeons. The courses have similar aims to BTLS, providing a structured app roach for the rapid identification, treatment, and extrication of time-critical trauma pati ents. The strategies taught are designed to integrate with the Advanced Trauma Life Support (ATLS) approach to trauma management, facilitating seamless care between the pre-hospital and emergency department settings. In the UK, PHTLS courses are accredited by the Royal Col lege of Surgeons of England. Details of courses run in the UK can be obtained from www.rcse ng.ac.uk Pre-hospital Pediatric Life Support (PHPLS) Pre-hospital Pediatric Life Support aims to pro vide paramedics, nurses, and doctors with the skills to identify and manage seriously ill a nd injured children in the pre-hospital setting. Although its content is strongly allied to the Advanced Pediatric Life Support (APLS) course, it differs in addressing the practical restrictions on treatment in the out-of-hospital setting and stresses the importance of ide ntifying patients requiring early and rapid transportation to hospital. The course is accre dited by the UK Advanced Life Support Group and details can be obtained from www.alsg.org/m ain_paed_resus.htm CHAPTER 1 An approach to pre-hospital care 8 Pediatrics for Pre-hospital Professionals (PEPP) Pediatrics for Pre-hospital Professionals was developed in the USA by the American Academy of Pediatrics and is offered in two-day \200\230advanced \200\231 and one-day \200\230basic \200\231 versions, the former being ai med at paramedics, doctors, and nurses. Training may also be delivered on a modular basis. The aims of PEPP are similar to those of PHPLS, although at the time of writing PEPP is yet to be Anglicized and is not directly accredited by a UK professional body. Courses are cur rently run by BASICS (see p.66). Details of the PEPP program can be found at www.peppsite.c om Advanced Life Support (ALS) Advanced Life Support is a UK-developed Europe-wide course whic h teaches the management of cardiac arrest and peri-arrest arrhythmias, including the skill s of manual defibrillation, drug administration, and endo- tracheal intubation. It is aimed at doctors, nurses, and paramedics and, whilst it emphasizes in-hospital care, the princip les taught may be easily adapted to an out-of-hospital setting. Details of courses can be o btained from www.resus.org.uk/pages/alsinfo.htm Advanced Life Support Obstetrics (ALSO) Advanced Life Support Obstetrics aims to teach adva nced providers who may be involved in emergency obstetric care. Although based on in-hospit al scenarios, the principles taught may be adapted for use in an out-of-hospital setting. D etails of courses can be found at www.also. org.uk/providercourses.asp Madingley Immediate Care Course Run by BASICS Education, this five-day course is primarily for those with experience in immediate care and has the aim of developing and enhancing the ir skills in dealing with medical and other emergencies encountered in all fields of pre-ho spital medicine. The course is an effective preparation for the Diploma in Immediate Care E xamination. Contact: BASICS Education (see p.66). Major Incident Medical Management and Support (MIMMS) Developed by the Advanced Life Suppor t Group, the MIMMS course is now internationally accepted as the standard training program for all those likely to be involved in the medical management of a major inci- dent. The th ree-day course consists of two days of lectures, tabletop exercises, and practical skill st ations such as radio voice procedure and triage. This is followed by a written and practica l assessment. The final day consists of two major incident exercises, each based at a locat ion near the course venue which might be considered at risk of a real major incident. These venues have included football grounds, industrial plants, and transportation facilities. A one-day \200\230introductory \200\231 MIMMS course and a specialist chemical incident cou rse are also now available. Contact: Advanced Life Support Group (see p.66). TRAINING AND EDUCATION1 9 Diploma in Immediate Care Preparation Course This intensive five-day course for the Diploma in Immediate Care is run by the Department of Academic Emergency Medicine of the Universit y of Teesside at the James Cook University Hospital Middlesbrough. It is designed to prepar e candidates for the diploma examination. Contact www.teessideEM.org.uk for details or see p.67. A similar course is offered by the West Midlands CARE Team based in Birmingham (details fro m www.wmcareteam.org.uk or from the Faculty of Pre-hospital Care). CHAPTER 1 An approach to pre-hospital care 10 Qualifications in pre-hospital care Diploma in Immediate Medical Care (DipIMC.RCSEd) In add ition to the courses listed above, those who intend a serious and long-term commitment to p re-hospital care should consider taking the Diploma in Immediate Medical Care run by the Ro yal College of Surgeons of Edinburgh. Indeed, in certain areas of professional pre-hospital practice, such as medical support at league football matches, possession of the diploma is mandatory. The diploma is open to doctors, nurses, and registered paramedics (including th ose holding the highest level of military paramedic qualification). Entry requirements Paramedics Any paramedic wishing to take the Diploma in Immediate Medica l Care must show evidence of state registration as a paramedic in the UK (or non-NHS equiva lent). Alternatives, such as armed services training, may be recognized by the Royal Colleg e. Candidates must show documented evidence of clinical experience in the area of pre-hospi tal care for a period of 18 months post registration. Nurses Nurses must hold registration with the Nursing and Midwifery Council (or its equival ent) and must have been engaged in the practice of their profession for not less than two y ears thereafter. They must also show documented evidence of clinical experience in pre-hosp ital emergency care for a period of at least one year and of completion of training of not less than three months in hospital posts approved by the College, including emergency medic ine. Doctors Doctors must have been engaged in the practice of their profession for not less tha n two years after registration. Candidates must show docu- mented evidence of clinical expe rience in the field of pre-hospital emergency care for a period of one year. They must also show evidence of completion of training of not less than three months full time or equival ent part time in hospital posts approved by the College in the management of the seriously ill or injured patient. This may include participation in a vocational training scheme. Candidates who do not fulfill the normal requirements may apply for special consideration. Such candidates should submit details of their experience and a CV and will be considered b y the Education Committee of the Faculty of Pre-hospital Care. Examination format The examination consists of: - A theoretical paper with the following se ctions: - A projected material paper (30 minutes) - Multiple-choice question paper (20 ques tions, 20 minutes) - Short answer question paper (6 questions, 30 minutes) - Written incide nt scenario exercise (15 minutes). QUALIFICATIONS IN PRE-HOSPITAL CARE1 11 A practical examination consisting of: Core skills assessment (30 minutes) - Clinical incident scenario and viva examination (30 m inutes). Candidates who fail the core skills assessment cannot pass the examination. Further details about the Diploma are available from the Examinations Department of the Royal College of Surgeons of Edinburgh (see p.67). Fellowship in Immediate Medical Care (FIMC.RCSEd) The FIMC is open to medical practitioners who have successfully obtained the Diploma in Immediate Medical Care, have at least 4 year s \200\231 pre-hospital experience, and have completed a training program in pre-hospital c are which has been approved by the Faculty of Pre-hospital Care. It is first necessary to register an application in order to gain accep- tance onto the tra ining program and to allow the development of a structured program supervised by a mentor a ppointed by the Faculty. In the UK, the mentor may, for example, be the medical director of the local ambulance service NHS trust. During the training program, each candidate is required to show involvement in the following areas of pre-hospital care: - Operational experience - Analysi s and audit - Research activity - Clinical governance issues - Major incident management - Mass-gathering medicine - Teaching. These areas, along with three case studies, will form a portfolio of experience and training which must be kept up to date and will be inspected d uring the FIMC examination. Examination format The examination consists of the following components: - Written examinat ion: - Projected material - Multiple-choice questions - Short answer questions - Incident s cenario. - Clinical examination: Core skills - Medical skills - Trauma skills - Major incident scenario. In addition, there is a viva based on the candidate \200\231s personal portfolio of experie nce case reports and special interests. It is recognized that non-UK trainees may not follow a conventional UK career progression. This will be taken into consideration in respect of both the training period and the examin ation. Further details regarding the FIMC examination may be obtained from the Examinations Depart ment of the Royal College of Surgeons of Edinburgh (see p.67). CHAPTER 1 An approach to pre-hospital care 12 Accreditation and re-accreditation For doctors practicing in the UK, the basic accreditatio n standard is possession of the Pre-hospital Emergency Care (PHEC) Diploma and verification undertaken by BASICS. The PHEC certificate is valid for three years and an update one-day course secures re-accreditation. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 14 Medical equipment The medical equipment carried by an immediate care practitioner is a matt er of personal choice and will depend on the skill level of the practitioner, the situation s that are likely to be encountered, and the equipment which is likely to be readily availa ble from other sources. There are, however, a number of key principles which must always be followed: - Only use equipment with which you are thoroughly familiar. - Only use equipmen t which is compatible with the emergency services equipment. Make sure you are familiar with specialist equipment carried by the emergency services. Ensure that equipment is regularly maintained and out-of-date disposables are replaced. Ensure that equipment is securely stored. - Ensure that the packaging is robust and appropr iate. Choice of equipment A suggested list of basic and advanced equipment is given in Table 1.1 Individual items are discussed using the ABC sequence. The notes that follow do not refer t o every individual piece of equipment but are designed to highlight particular points with regard to pre-hospital practice. MEDICAL EQUIPMENT1 15 Table 1.1 Suggested pre-hospital care equipment Airway Hand-operated suction unit Yankauer suction catheters Oropharyngeal airways 00 \200 \2234 Nasopharyngeal airways sizes 6, 7, 8 (with safety pins) Laryngeal mask airways (singl e use) 3, 4, 5 Laryngoscope handle, size 3 Mackintosh blade Spare batteries and bulb for la ryngoscope Magill \200\231s forceps Gum elastic bougie Lubricating jelly 50ml syringe for c uff inflation Set of cuffed (uncut) endotracheal tubes with connectors Tape and ties for se curing tubes Pulse oximeter End-tidal CO2 monitor Cervical spine control Set of semi-rigid collars* Breathing Oxygen cylinder and reservoir/flow control Oxygen tubing Oxygen mask with reservo ir (trauma/Hudson mask) Controlled flow oxygen masks Oxygen-powered nebulizer Pocket resusc itation mask with one-way valve and oxygen port Bag valve mask with oxygen reservoir Flexib le catheter mount connector Wide-bore IV cannula (for needle thoracocentesis) Asherman ch est seal Circulation Wound packs Pressure dressings Cling movie IV blood-giving sets IV fluids IV ca nnulae (range of sizes) Tourniquet (arterial) Tourniquet (vascular access) IV dressings and tape IV arm immobilizing splint Specimen and X-match tubes and labels Intraosseous needles Three-way tap and extension tube Syringes and needles Alcohol swabs CHAPTER 1 An approach to pre-hospital care 16 Table 1.1 (Contd.) Diagnostic pouch Stethoscope Pen torch Sphygmomanometer Blood glucose analyzer Peak flow me ter Reference charts Drug pouch See pp.307 \200\22358. Pediatric equipment Pediatric equipment is best packed separately but in the same sequence as adult equipment Child sizes of ABC kit Pediatric sizing and dosage guides Miscellaneous Plastic gloves Tough cut scissors Sharps bin Triage cards and triage count ch eck sheet Ancillary equipment Defibrillator/monitor with manual override and ECG data recorder Defibr illation pads, electrodes, razor 12-lead ECG machine Portable ventilator Additional oxygen cylinders Entonox apparatus Fluid warmer/IV insulation jacket Pressure infuser Immobilizati on equipment Rescue board (as appropriate) Straps Extrication device (as appropriate) Limb splintage Traction splintage Maternity/delivery pack (as appropriate) Plastic ground sheet Blankets Plastic waste bags Adjustable collars may be used, but provision must be made for all sizes from pediatric to adult. Large items (e.g. trolley cots, vacuum mattresses) will be carried by the ambulance service. MEDICAL EQUIPMENT1 17 Airway Endotracheal (ET) tubes ET tubes should not be pre-cut to length in case nasal intub ation is required. Laryngeal mask airway (LMA) The LMA does not offer the same degree of airway protection as a cuffed ET tube, but is easier to insert and skill retention appears to be longer for the occasional user. The LMA should not be used in the obtunded but not unconscious patient. Th ere is increasing evidence to support its use pre-hospital, and a fully equipped medical ba g should probably contain a set. Cricothyrotomy kit A number of surgical airway kits are available containing all the necess ary equipment for insertion. Whichever is chosen, it should have a minimum lumen of 6mm. The necessary equipment for needle cricothyrotomy should be pre- prepared and carried. A number of options are illustrated in Fig. 1.1. Breathing Face masks Both adult and pediatric face masks should be carried for use with a b ag valve ventilator. Such devices MUST have an oxygen reservoir. Ventilators A number of portable oxygen-driven ventilators are available. The majority of p ractitioners are likely to prefer to continue manual ventilation but automatic ventilators offer an alternative during long transfers or if there is more than one patient.