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. Oxygen A conventional D-sized cylinder will provide 15L of oxygen per minute for no more th an 20 minutes. A spare should always be carried. Refills can usually be arranged through th e local ambulance service. Oxygen should always be administered via a Hudson re-breathing m ask with reservoir bag. Modern lightweight cylinders are also available. Ambulance services now regularly use CD cylinders with a capacity of 460L. Chest drain kits A number of complete intercostal drain kits are available which contain ev erything needed for drain insertion but NOT skin prep, needles, syringes, and local anesthe tic. Circulation Intravenous cannulae A wide range of sizes of cannula should be carried in adeq uate numbers. Fluids are best given via a blood administration set. Appropriate means of se curing the line after insertion should be co-located with the cannulae, and should include a two-inch crepe bandage. Fluids At least 4L of crystalloid should be available. CHAPTER 1 An approach to pre-hospital care 18 Intraosseous needles Screw-in needles are preferable and should be stored with a three-way tap and 50ml syringe for fluid administration. Adult intraosseous needles are now available , although their use is not fully established. A number of automatic intraosseous devices a re now available, of which the most commonly used are the FAST (sternal) and the Bone Inj ection Gun (BIG ). Check the use-by date of disposables on a regular basis. MEDICAL EQUIPMENT1 19 Puncture site Cricoid cartilage Thyroid cartilage Cricothyroid membrane Fig. 1.1 Possible arrangements for needle cricothyrotomy. Reprinted with permission from Gr eaves I, Porter K, Hodgetts T, et al., (2006). Emergency care \200\224a textbook for parame dics, 2nd edn W.B. Saunders Ltd. CHAPTER 1 An approach to pre-hospital care 20 Personal protective equipment Appropriate personal protective equipment is absolutely vital for the safe practice of pre-hospital care. Essential items are shown in Table 1.2. Helmets Industrial \200\230bump hats \200\231 are not acceptable. An appropriate helmet wi ll meet British Standard BS prEN 443. The shell should be made from a strengthened material such as Kevlar and a visor should be fitted. A mounting for a head torch and clear labelin g with \200\230doctor \200\231 or \200\230paramedic \200\231 are essential. Eye protection Conventional glasses do not provide adequate eye protection in high-risk sit uations. Appropriate eye protection which will accommodate specta- cles (if worn) is recomm ended. This should meet BS EN 166. High-visibility jackets and waistcoats Medical personnel should wear a yellow jacket with g reen shoulder yolks. There should be two reflective strips around the chest, two round the arms, one around the bottom of the jacket, and a strip on each shoulder. Jackets should be appropriately labeled with the status of the wearer and should conform to BS EN 471 class 2 or preferably class 3. Many modern jackets have a detachable quilted \200\230inner \200 \231 which can be removed in warm weather. High-visibility waistcoats are not a substitute for an appropriate jacket and should only be used in hot weather and limited situations, si nce they offer little if any protection. They should comply with BS EN 471 class 1 standard s. Overalls Many immediate care schemes have their own \200\230uniform \200\231 overalls. The y should include padded elbows and knees and have labels indicating the professional group of the wearer. Overalls should be flameproof or flame-retardant and have two reflective str ips on each limb. Waterproofs High-visibility waterproof trousers should be carried. Gloves Leather debris gloves are essential. Good quality gardener \200\231s gloves are a su itable alternative. Non-sterile latex gloves and sterile surgeon \200\231s gloves should al so be carried. Boots Robust footwear with a rubber sole which offers a good grip should be worn. Metal rei nforced toecaps are useful. \200\230Wellington boots \200\231 offer very little protection and are not usually appropriate. PERSONAL PROTECTIVE EQUIPMENT1 21 Identity cards All pre-hospital care practitioners must be able to produce proof of identit y. BASICS produces a membership card for all its accredited practitioners, as do some of th e larger schemes. An identity badge with a photograph from an NHS trust is a less satisfact ory alternative. Table 1.2 Essential items of personal protective equipment Fluorescent Saturn yellow waterproof, wind-resistant jacket with reflective flashes and identification panel Overtrousers (as appropriate) - Protective (Kevlar) helmet with polycarbonate visor - Splas h protection goggles - Gloves Waterproof, thermal - Debris - Neoprene chemical-resistant (as appropriate) - Disposable pr ocedure Boots with non-slip, spark-free soles - ID badge with photograph - Whistle - One-piece disp osable CBRN protection suit (as appropriate) CHAPTER 1 An approach to pre-hospital care 22 Packaging A wide range of types of packaging is available. The two main types are rigid box es and soft-skinned grip bags. The authors \200\231 preference is for the latter. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 24 A pre-hospital formulary The choice of drugs is a personal one and only familiar drugs shou ld be carried. A suggested drug list for a pre-hospital care doctor is given in Table 1.3. Anesthetic drugs should neither be used nor carried by those who are not competent and trai ned in their use. The legal aspects of pre- hospital care drugs are considered on p.26. Because of the limited amount of available space in bags designed to be carried by one pers on, each class of drugs should ideally only be repre- sented by one carefully chosen exampl e. Multiple drugs whose effects are equivalent or nearly equivalent should not be carried. Individual drugs are discussed in detail in Chapters 4 and 5. A PRE-HOSPITAL FORMULARY1 25 Table 1.3 Suggested drugs for pre-hospital care Cardiac arrest drugs Adrenaline 1 in 10,000 100mcg/ml 10ml pre-filled syringe Adrenaline 1 in 1000 1mg/ml 1ml pre-filled syringe Amiodarone 300mg in 10ml pre-filled syringe Atropine 3mg in 10ml pre-filled syringe Cardiac drugs Buccal nitrate 2mg tabs Frusemide 10mg/ml 5ml ampoule Glyceryl trinitrate spr ay 400mcg/metered dose Lignocaine 20mg/ml 5ml pre-filled syringe Aspirin soluble 300mg tabs Thrombolytic (depending on local protocol) drugs Tenecteplase Respiratory drugs Salbutamol nebulizer solution 1mg/ml 2.5ml ampoule* Hydrocortisone 100mg vial with 2mg water Other drugs Chlorpheniramine 10mg ampoule Dextrose 50% 50ml pre-filled disposable syringe D extrose 10% 500ml bag** Diazemuls 5mg/ml 2ml ampoule Diazepam (rectal) 2mg/ml 5mg tube Gluc agon 1ml vial with water Hypostop Analgesics Diamorphine 10mg ampoule Ketamine 10mg/ml 20ml vial Morphine 10mg/ml 1 or 2ml am poules Antiemetics Cyclizine 50mg/ml 1ml ampoule Metoclopramide 5mg/ml 2ml ampoule Antidote s Flumazenil 100mcg/ml 5ml ampoule Naloxone 400mcg/ml 1ml ampoule Gasses Nitrous oxide/oxyg en 50:50 (Entonox) Oxygen Obstetric drugs Syntocinon 10 units/ml 1ml ampoule Anesthetic dru gs Ketamine (see above) Midazolam 2mg/ml 5ml ampoule Fluids Normal saline 4x1L bag Water fo r injections 5ml ampoules * If a nebulizer is not carried, salbutamol may be given by meter ed dose inhaler via a spacer device. ** For pediatric use. CHAPTER 1 An approach to pre-hospital care 26 Drug security Prescription-only drugs must be kept in a locked container in a locked compar tment of the vehicle in which they are carried. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 28 Things to take to a call or keep in your vehicle Inevitably, the departure for an incident tends to be somewhat rushed. It is helpful, therefore, to have a checklist of items which m ay be helpful or necessary at an incident scene. The following lists may be useful. Items to be prepared in advance - Maps \200\224ideally, a customized \200\230map book \200 \231 should be prepared using a book of see-through polythene pockets into which appropriat e sections of Ordnance Survey and local street maps have been inserted. Use of an A3 folder (opening to A2) allows extensive areas to be covered and avoids difficulties with large ma p sheets in the car. Satellite navigation is increasingly utilized. Satellite navigational equipment (GPS) if available. - Foul weather clothing \200\224robust waterproofs and boots. Wellington boots can also be carried but may be punctured and shoul d only be used when conditions are appropriate. Warm clothing/change of clothing. - Helmet, gloves, and goggles. - Warm fluids in electric warmer in boot. - Medical equipment (see pp.15 \200\22321). - Drugs \200\224in a separate l ocked container in the boot. - Extrication equipment (if carried) \200\224this will depend on the nature of likely calls, the operating environment, and the availability of equipment from the ambulance service. Blankets. - Spade \200\224only necessary when snow is lying or expected. - De-icer (cold co nditions only). - Note pad and paper. - Torch and batteries. - Adequate fuel supplies \200 \224in icy weather, it is essential to begin defrosting the windshield and rear window as s oon as a call is received. It may be necessary to wait until it is safe to drive. It is nev er permissible to drive looking through a letter-box-size clear patch in the ice on the win dshield. This book! Items to be prepared before departure - Overalls/jacket and trousers \200\224where possible , put them on in a warm, light environment. Identity card \200\224provided by BASICS or the local ambulance service. - Mobile phone. - Spare car keys. THINGS TO TAKE TO A CALL OR KEEP IN YOUR VEHICLE1 29 Cash \200\224small amount for snacks or unforeseen events such as return fares after helicopter evacuations. Credit cards. - Snacks \200\224chocolate bars, Kendal Mint Cake, boiled sweets (take a bag \200\224handing them round is always a popular move!) or other items of choice will always be welcome. Flask of tea/coffee \200\224if there is time and the call is expected to be prolonged. CHAPTER 1 An approach to pre-hospital care 30 Transportation The majority of pre-hospital care providers will respond in their own vehicl es; a few may use vehicles provided by the ambulance service (or other agencies). In any ev ent, the driver is responsible for the mainte- nance and safety of the vehicle. The followi ng checks must therefore be carried out at regular intervals: - Tires (pressure and treads ). - Oil. - Windshield washers and wipers (blades and washer fluid \200\224do not forget regular antifreeze in cold weather). Road tax. The law offers no exemption or leniency to emergency vehicles regard- ing legal s afety requirements. Lights and sirens The law allows medical practitioners responding to emergencies to carry g reen lights. These may be either bar-mounted or magnetic. The Road Vehicle Licensing Regula tions 1984 state: - Any vehicle being used by a registered medical practitioner for the purposes of an emergency may display one or more green lights. The doctor must be fully reg istered. Each green light or warning beacon must be capable of emitting a flashing or rotating beam throughout 360 \227 in the horizontal plain. Only those entitled to use a green beacon may have one fitted to their vehicle. Each beacon must be visible a reasonable distance from the vehicle, must be mounted not less than 1200mm from the ground, and flash at a rate between 60 and 24 0 times per minute. Bulbs must not exceed 55watts. In some circumstances, following successful completion of appropriate driving courses, resp onders have been granted permission by the police to use blue lights and sirens. This is su bject to local agreement. The practitioner must drive within the confines of the relevant r oad traffic legislation. The use of high-visibility reflective markings on any vehicle which will be regularly used for pre-hospital care is strongly recommended. The Road Traffic Act 1984 allows the use of red reflective markings on the rear of a vehicle and markings of any other color on the sid es. Driving law Drivers of emergency vehicles are not exempt from any of the normal rules of th e road, although they are given more discretion than other road users under certain circums tances. These include permission to: - Exceed the statutory speed limit by 20mph. - Treat r ed traffic lights as a \200\230give way \200\231. - Pass on the offside of a keep left sig n. - Turn right where this is not normally permitted. transportation1 31 Use a bus lane. - Stop and park on clear ways. - Stop and park on a pedestrian crossing or its controlled area. - Park on double yellow lines. Drivers of emergency vehicles are specifically not allowed to: - Park dangerously. - Drive without reasonable consideration for other road users. - Ignore one way signs. - Ignore sto p signs. - Drive against the flow of traffic at a roundabout (i.e. go the wrong way round). Cross double white lines. - Fail to stop after being involved in an accident. - Fail to pro vide information after being involved in an accident. - Ignore police directions. CHAPTER 1 An approach to pre-hospital care 32 The law and pre-hospital care Consent Informed consent should always be sought from a patie nt before any procedure is undertaken. However, in pre-hospital practice where con- sent ca n be obtained, it is likely that this consent will be verbal. If possi- ble, witnesses shou ld be sought from amongst other professionals on scene. The patient \200\231s decision shou ld be respected and recorded. Refusal of consent must be respected unless the patient is no t competent to refuse. In this situation, it is essential that written refusal is obtained, signed by the patient and witnesses. Treatment without consent There are circumstances in which treatment without consent may be considered: - Unconscious patients - Critically injured patients - Children (with no legal guardian present) - \200\230Incompetent \200\231 adults. The unconscious patient may be t reated without their consent if the treatment is necessary to preserve their health or save their life. Similar decisions may have to be taken in cases of critical injury or illness where any delay might adversely effect the patient \200\231s outcome. As long as sensi- ble decisions are taken bearing in mind current best practice, it is extremely unlikely that a court would be critical. Nevertheless, it should be borne in mind that, in such circumstan ces, treatment must be restricted to that needed to save life or prevent serious deteriorat ion. Treatment of physical disorders is not permitted under the Mental Health Act. \200\230Gillick competence \200\231 is defined as the possession of sufficient under- stan ding and intelligence to understand fully any suggested treatment. Under \200\230Gillick r ules \200\231 children who are considered to be competent may consent to treatment without the presence of a guardian; they cannot refuse treatment on their own behalf. Such a refusa l may be overridden by those with parental responsibility. In an emergency, health care pro - fessionals may override the refusal of a Gillick-competent child if no more appropriate p erson is available. Parents or others with parental responsibility cannot refuse consent to treatment if a competent child has consented. Consent by one person with parental responsi bility can not be overruled by refusal by another. Some adults may be unable to give informed consent, for example due to a mental health cond ition. Such adults should be treated without consent in their own best interests. In all situations, appropriate explanation, both to the patient and their relatives, can on ly have the effect of decreasing distress and increasing co-operation. THE LAW AND PRE-HOSPITAL CARE1 33 Parental responsibility Parental responsibility is given to the following (Children \200 \231s Act 1989): - Both parents, if married at any time since the child \200\231s conceptio n. - The mother alone, if the child is illegitimate, unless the father has obtained agreement from the mother or a court order. The local authority, if the child is in care or under a care order. - An appointed guardian . - Those with a residence order. - Adoptive parents. - Those with an emergency protection order (usually a local authority). Confidentiality It is all too easy to break confidentiality in the pre-hospital setting. Th ere is often little, if any, privacy, and a curious crowd all to frequently gathers. In add ition, radio and other communications are often overheard and information is passed to othe r members of the emergency services when this is not appropriate. It is important, therefor e, that all responders attempt to maintain confidentiality at all times. CHAPTER 1 An approach to pre-hospital care 34 Dealing with the police Clinicians commit an offense by obstructing a police officer if the y dispose of evidence, warn a suspect, or assist a suspect to escape. Good relations should be maintained with the police at all times, bearing in mind the restrictions the law place s on doctors and other medical professions. Negligence Claims of medical negligence (valid or otherwise) are all too common today. In o rder to prove negligence, however, it is necessary to establish the following four componen ts of a claim: - A duty to act. - A breach of that duty. - The presence of harm. - That the harm arose from the breach of duty. Duty to act means that a professional has a responsibi lity to act (and act competently) in a clinical situation. Those who put themselves forward to attend emergency situations in a medical capacity accept a duty to act. Breach of duty to act occurs when a professional fails to perform to an appropriate standard. Breaches of duty may be acts of omission or commission. In order to establish a claim for negligence, i t is essential not only to establish that a breach of duty occurred, but also to establish that harm to the patient resulted from that breach. If a mistake was made, but no harm accr ued, a claim of negligence will not succeed. Finally, it must be established that the harm sustained resulted from the breach of care. Living wills Whilst it is clear that a patient should never be treated against their clearl y stated will, the situation is often far from clear in pre-hospital care. If the patient r efuses treatment, the situation is clear. However, statements from a relative or friend to the effect that a patient does not wish to receive a certain treatment or to be resuscitate d have no legal validity. Similar caution should be applied to documents presented at such times. If there is doubt that a document is genuine, treatment should continue as if it did not exist. Withholding or terminating resuscitation Resuscitation may be withheld or terminated if the patient is known to be irreversibly close to death in the short term, if continuing resusc itation would confer no benefit, or if the risks of subsequent brain damage or death at a l ater stage are unacceptably high. Advance directives made by patients should be respected. Do not resuscitate orders should not influ- ence any other aspect of treatment. Pronouncing and certifying death Following a sudden death due to unnatural circumstances, t he attending doctor will not be able to issue a death certificate. Certification of death w ill be delayed until the completion of an autopsy and coroner \200\231s inquiry. In such ci rcumstances, the doctor must pronounce the patient dead and record this in the medical reco rds. If the patient is known to their general practitioner and has been treated recently by them, and there is no suspicion of unnatu- ral causes, subsequent certification may be car ried out. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 36 If the patient has died prior to the arrival of the doctor, it is the doctor \200\231s resp onsibility to pronounce death. In extreme circumstances, it can be very difficult to determ ine beyond reasonable doubt that death has actually occurred (for example, very cold condit ions) or clinical priorities with regard to the living may prevent an adequate assessment. In such circumstances, pronouncement may have to wait until after arrival in hospital. UK ambulance services now recognize circumstances in which attending paramedics may pronoun ce death. These are given in Table 1.4. This avoids unnecessary call out of doctors but doe s not, in any way, replace subsequent certification by an appropriate person. Table 1.4 Situations in which a paramedic may pronounce death Finding Caution Decomposition Rigor mortis Muscle rigidity as a result of parkinsonism or hypothermia Dependent lividity (post-mortem staining) Expected death from a terminal disease Presence of a written \200\230do not resuscitate \200\231 order preferred Decapitation Total incineration Temporary survival may occur in devastating burn injury Complete separation of the entire heart, lungs, or brain from the body Submersion confirmed as being greater than 24 hours The duration of the absence of both carotid pulses is confirmed as being greater than 30 mi nutes, in the absence of any CPR This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 38 Restraint Health care personnel have no right, beyond those of an ordinary citizen to restr ain an aggressive or violent individual, even if the patient is subject to the Mental Healt h Act. Any attempt to do so constitutes assault, unless a citizen \200\231s arrest is being made, in which case it must be clear beyond doubt that an illegal act has been committed. If restraint is neces- sary, therefore, the assistance of the police should be sought. If v iolence seems likely, police assistance should ideally be sought before patient contact occ urs. Police officers have the right to remove people to a place of safety on their own auth ority. Personnel who are assaulted are, how- ever, entitled to use \200\230reasonable forc e \200\231 to defend themselves. Breaking and entering Although doctors and paramedics do not have a legal right to force en try into a private address, even if a patient \200\231s life appears to be at stake, it is highly unlikely that legal action would ensue in such circumstances. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 40 Insurance All pre-hospital care practitioners must have adequate insurance protection for t hemselves and their equipment. BASICS and BASICS Scotland have negotiated reasonable insura nce rates for members. Providers of motor insurance should be informed that a vehicle is be ing used for emergency response purposes otherwise a claim resulting from such use may not be honored. Doctors and nurses should inform their professional indemnity body that they un dertake pre-hospital care, although no additional fee is usually raised. This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 42 Getting there: safe driving to the scene Rights and responsibilities Emergency vehicles hav e no special rights under the highway code. There is a tendency to get over-excited when dr iving to the scene of an inci- dent. Unfortunately, this significantly increases the risk o f causing an accident. The priority must therefore be SAFETY NOT SPEED. In order to lessen the driving time, whilst minimizing the risk to oneself and other road users, the technique of defensive driving is used. This is described in detail in Roadcraft: the police driver \200\231s handbook (see suggested reading). It should always be remembered that vehicles ar e not legally obliged to move out of the way of a responding emergency vehicle. It is a mat ter of courtesy that they do so. It is important to maintain a two-second gap behind the ve hicle in front whenever possible, in case it suddenly breaks (sometimes as a response to su ddenly seeing lights and sirens in the rear view mirror.) On country roads, appropriate use of the carriageway should be made to maximize visibility at all times (Fig. 1.2). Other road users may react to emergency vehicles in a number of ways. Hopefully, they will simply move out of the way in a safe manner. Sudden braking, rapid changes of lane, and ref usal to give way are also possible. When other motorists do co-operate, this should be ackn owl- edged. Escorted convoys pose particular hazards. Other vehicles may give way to one ve hicle before pulling out into the path of those follow- ing, confusion may occur when side roads are not blocked as expected, and the situation may degenerate into a race. Parking at scene The first vehicle on scene should park in the fend off position (Fig. 1.3) . If other vehicles are already present, the new arrival should use the system in Fig. 1.4, or follow the instructions of the police. If the police are in charge of the incident, a ( spare) set of keys should be left in the ignition. Otherwise, the vehicle should be locked. Accidents en route Green lights do not confer any privileges under the Highway Code. It is essential, therefore, that due care is paid to avoiding accidents. When an accident involvi ng a responding car does occur, the driver is obliged to stop and exchange details as in a \200\230conventional \200\231 collision. GETTING THERE: SAFE DRIVING TO THE SCENE1 43 Fig. 1.2 Using road position to maximize visibility on a rural road. Reprinted with permiss ion from Greaves I et al. (2006). Emergency care \200\224a textbook for paramedics, 2nd edn . W.B. Saunders. CHAPTER 1 An approach to pre-hospital care 44 Fig. 1.3 The \200\230fend off \200\231 position. Reprinted with permission from Greaves I et al. (2006). Emergency care \200\224a textbook for paramedics, 2nd edn. W.B. Saunders. GETTING THERE: SAFE DRIVING TO THE SCENE1 45 s e c i l e n o o P C , s c d e m a r a p i r o f 2 k o o b t x e t s e n o C e r i F a \200\224 e r a c y c n e g r e m E . ) 6 0 0 2 ( s e n o C 1 e r i F . l a t e n o i t a v r e s e r I r e d u o h s s e v a e r G m o r f l d r a H l a r t n e C h s a r C s e n o C n o i s s i m r e p h t i w d e t n i r p e R . e n e c s s e n o C e c n a l u b m A t a g n k r a p i . s r e d n u a S e c v r e s - i t l u M i . B W s e n o C r o t c o D . . n d e 4 1 . . g i F d n 2 CHAPTER 1 An approach to pre-hospital care 46 Record keeping Good record keeping is an essential component of pre-hospital care. How- eve r, the lone practitioner cannot be expected to complete records at the same time as assessi ng and managing a critically ill or injured patient. It is inevitable, therefore, that in s ome cases notes will be compiled retrospec- tively, usually after patient handover either t o ambulance personnel or in hospital. This is no reason for inadequate or incomplete record s. Missing clinical data should not be guessed or estimated! Good records should be kept for the following reasons: They may contain information which will otherwise be unavailable once pre-hospital personnel have left the hospital. They will prevent drug errors such as repeat dosing or overdosing (this is particularly important if opiates have been given pre-hospital). They will facilitate audit, service development, and research. - They may offer some protec tion in the event of a subsequent complaint or inquiry. They are legal records in the event of an inquest or criminal case. All the necessary infor mation should be entered on a pre-printed sheet. Unless there is absolutely no alternative, scribbled notes on scraps of paper are inadequate, amateurish, and bring the specialty int o disrepute. Equally, there is little point in every pre-hospital practitioner inventing th eir own record chart. We suggest that practitioners either use the one provided by the loca l ambulance service (with their permission) or the BASICS report form, available from BASIC S (contact details on p.66). This page intentionally left blank CHAPTER 1 An approach to pre-hospital care 48 The emergency services: the police Roles Duties of the police include: - Keeping the peace. - Prevention and investigation of crime. - Protection of property. - Law enforcement (incl uding road traffic). - Major incident management. - Investigation of sudden death, as agent s of the coroner. Organization Each police force is under the operational command of a chief constable (commi ssioner in London). However, police services are required to consult the public they serve and, as a result, are heavily involved in community liaison. A number of authorities and bo dies have responsibil- ity for the strategy and efficiency of each individual force. The Ho me Office is responsible for promoting the general efficiency of the police and has ultimat e responsibility for levels of funding. In addition, it is responsible for the setting of n ational performance targets and approves the appointment of chief and assistant chief const ables. The local police authority consists of local councilors, magistrates, and independent membe rs. It is responsible for the provision of an efficient police service in its area and has ultimate responsibility for expenditure which is delegated to a greater or lesser extent to the chief constable. The police authority sets local policing objectives and targets and, in consultation with the chief constable, is responsible for the preparation and submission to the Home Office of a local policing plan. Civilian staff are employed by the police aut hority but, in general, are placed under the operational control of the chief constable. The chief constable directs and controls the police force. S/he is responsible for the fina ncial management of the force under the control of the police authority and directs police officers and civilian staff other than those managed directly by the police authority. The chief constable is responsible for drawing up the draft policing plan for approval or amend ment by the police authority. The chief constable is responsible for the operational deploy ment of his resources. Rank structure The rank structure of provincial police forces is shown in Fig. 1.5, and of the Metropolitan Police, in Fig. 1.6. The City of London police force uses the same rank st ructure as the Metropolitan Police. Other police forces The Royal Parks Police has responsibility for the London Royal Parks, t he British Transportation Police for railroad tracks and train stations, and the Ministry o f Defense Police for areas of Defense estates. The Special Con- stabulary is a part-time vo lunteer police force which assists the regular constabulary. THE EMERGENCY SERVICES: THE POLICE1 49 245 23 Constable Sergeant Inspector Chief inspector Superintendent Regional police services UK Chief superintendent Assistant chief constable Deputy chief constable Chief constable Fig. 1.5 Police service ranks and rank markings \200\224provincial (outside London). Reprin ted with permission from Greaves I et al. (2006). Emergency care \200\224a hand- book for p aramedics, 2nd edn. W.B. Saunders Ltd. 245 23 Constable Sergeant Inspector Chief inspector Superintendent Metropolitan and City of London police Commander Commissioner Chief superintendent Deputy assistant commissioner Assistant commissioner Deputy commissioner Fig. 1.6 Metropolitan (and City of London) police ranks and rank markings. Reprinted with p ermission from Greaves I et al. (2006). Emergency care \200\224a handbook for paramedics, 2 nd edn. W.B. Saunders Ltd. CHAPTER 1 An approach to pre-hospital care 50