So I had an interesting but short conversation with @on Twitter, following the EMS physicians vs paramedics blog. Well, as far as you can have interesting 150-character conversations. But Dan made a really good point: Prehospital care needs to focus on getting the basics right. And I couldn’t agree more.
For OHCA that is early recognition, bystander CPR, public access AED and short EMS response times. Hold on, that sounds suspiciously like the chain of survival…
So what’s the point then, of looking at things that Dan would refer to as prehospital ‘Gucci kit’: Intranasal cooling devices, prehospital ECMO, reintroduction of Lidocaine, ResQPODs, POCUS, critical care teams…It is a very valid question: Where is the benefit for our everyday patients?
I didn’t really have a good answer to this, until I happened to watch Kevin McCloud present an episode of Grand Designs. You know, towards the end of the show, when he gets all philosophical.
He said something along the lines of:
‘What’s the point of these exclusive and expensive buildings, full of unusual designs and technologies and filled with expensive furniture? How does this relate to everyday houses and everyday people?’
And he answered his own question:
‘These designs and buildings push the boundaries of what’s possible, they test and find new solutions that will, over time, filter into everyday buildings and benefit everyday people’s lives.’ (paraphrased from memory)
I think that research and critical care teams have a very similar role in prehospital care. Trying new interventions and diagnostics, often failing, but never giving up.
Consider the introduction of this novel device:
‘[The device] performs reliably in the field and can be invaluable as an adjunct to patient care. Further prehospital studies are needed to evaluate specific field treatments and techniques, to assess the [devices]’s effect on morbidity and mortality […].’
‘Though it would not be feasible for every immediate care doctor and front line ambulance to be equipped with [the device], it does seem reasonable that second response teams concerned in the management of trapped casualties and mas casualties should carry one.’
Sounds like the definition of prehospital Gucci kit: New and shiny, no clear evidence of benefit and only available to a select few… What we are talking about is, of course, the introduction of the humble pulse oximeter in 1988 and 1989.
Other examples of EMS diagnostics or therapeutics that made the step from prehospital Gucci to basics, over the last year: End-tidal capnometry, use of 1:100,000 Adrenaline as vasopressor, Tranexamic Acid and not forcing every single trauma patient into a cervical collar.
So I agree with Dan, we should focus on getting the basic rights. And we should continue to try and find the next thing, that might seem outlandish at first, but can be a basic for the next generation of EMS practitioners.
And of course, this concept doesn’t only apply to architecture and medicine. Whatever you are wearing right now will have been influenced by what was presented on a runway in Milan or Paris in the past (yes, really), your car will have elements tested in Formula 1 and rally cars, and so on.
And as we are on the subject of rally cars and the late 1980s, treat yourself to one minute shotgun driving the Audi Sport Quattro S1 with legendary Walter Röhrl. In German, of course.
Thanks to @__DanR__ for the discussion and the Gucci analogy!