Pre-hospital Emergency Medicine has been something I've been interested in for a while. There is a bit of info online from The Faculty of Pre-Hospital Care and the catchily titled Intercollegiate Board for Pre-Hospital Emergency Medicine. However, an article in Anaesthesia gives a nice summary of the development of the speciality, and is worth a look if you're that way inclined. (And it's free)

Article: Anaesthesia and pre-hospital emergency medicine DOI: 10.1111/anae.12064

The journal calls it a review and I suppose it's sort of a non-systemic review but it does much more than that, as it covers the justification of the speciality, how it's developed and what training is involved. 

Trauma is relatively infrequent in the UK and tends to affect younger age groups. Even with the dense population, patients may still be relatively far from a suitably equipped hospital. There have been calls for some time for dedicated pre-hospital teams, but these have taken a long time to develop. Although paramedics + BASICS Dr make a good combination, coverage, availability and training may be variable. The idea is to start care at the highest level on-scene and continue throughout the patient's stay and rehabilitation. The current system commonly involves Enhanced Care Teams (ECTs, doctor + paramedic) which are generally funded by charities (with the exception of the EMRS in Scotland). This system has been formalised over the past few years. [The paper doesn't comment that there is still a lot of work & training done by groups such as BASICS]

PHEM was formally recognised in 2011 by the GMC and the first formal trainees started in 2012. It adds 12 months to a normal training programme, but in ideal circumstances the PHEM is 'blended' with the parent speciality over a longer period of time. 

It is estimated that about 250 whole-time equivalent (WTE) Consultants are required. Now, people aren't expect to work full time in PHEM so that translates to about 600-700 in total. The rest of the time would be spent in the parent speciality. This is quite a lot of jobs!

They predict there will be about 25 training places per year. I'm not quite sure how this tallies with how many Consultants they think will be required.
Applicants must be >=ST4 in either Anaesthetics or Emergency Medicine [since this was published they can now come from Intensive Care too]. 

A mix of hard and soft skills, taught in a variety of ways, from on-line to full high-fidelity simulations in the outdoors. No one speciality contains everything which needs to be known to practice PHEM. Just like in other parts of training, everyone's favourite Workplace Based Assessments (WBAs) make an appearance. There is no mention of the Dip IMC.

This being an Anaesthetics journal, there is a specific section on Pre-Hospital Emergency Anaesthesia (PHEA). There has been some controversy about PHEA and if it is associated with poorer outcomes. Here they argue that in the right pair of hands (well trained, checklist, governance etc), it can be delivered safely. Ketamine is noted as the preferred induction agent over etomidate and there are some more references (42 - 45 in their text) for those who are concerned about increasing the intra-cranial pressure. They state:
"recent evidence suggests that secondary brain injury is lessened, not only by the avoidance of systemic hypotension commonly seen with other induction agents, but also because ketamine attenuates the haemodynamic response to intubation and appears to also have neuroprotective properties"
Interestingly suxamethonium is commonly used and even those using rocuronium don't routinely carry sugammadex (reversal is not really an option). Sedation is maintained with bolus midazolam & morphine or propafol infusions. 
The airway algorithm followed bears a lot of similarity to those used in hospital, following the order of DL/VL/LMA/FM/Surg. (Direct laryngoscopy, video laryngoscopy, laryngeal mask airway, face mask, surgical airway). They point out that the best results in PHEA are likely to occur in the context of a bundle of good care (lung protective ventilation, damage control resus etc etc) which seems sensible (although isn't referenced). 

There's some stuff on trauma networks and funding of PHEM, but that's probably of less relevance for budding trainees.

PHEM in one form or another has been developing for a long time in the UK but only relatively recently become a GMC-recognised speciality with its own training programme. Training jobs are open to post-fellowship SpRs and add about a year. Training itself is varied and PHEA (including pre-hospital rapid sequence, one of the really trendy bits) is one part of good clinical care.


Thanks for reading.

By Tom Heaton

First described by Sellick in 1961, cricoid pressure was originally designed to make life difficult for smart-arsed junior anaesthetic trainees that were feeling rather pleased with themselves just because they had intubated half a dozen patients. It achieved this with a potent combination of impairing laryngeal view, resisting passage of an endotracheal tube and, crucially, also making manually ventilating the patient more challenging. ‘Sellick’s Triad’, born from this simple application of cricoid pressure, was able to successfully increase the number of trainee 'brown trouser' moments and a new trend in anaesthetic practice was born.

Okay so I may have completely made this bit of history up, but this collection of complaints seems to be widely cited as being behind cricoid pressures descent from favour in recent times, especially with it’s partnering question of ‘Does it actually do anything?’ If you have been following some of the stuff at SMACC Gold through Twitter (or been lucky enough to actually attend) you might have heard some of the arguments around this increasingly controversial technique.   

By Tom Heaton

“Just when you thought it was safe to return to your anaesthetic room, the makers of ‘Etomideath: An Anaesthetic Horror Story’, bring you the terrifying sequel - Etomideath 2: The Heartbreaker!! No RSI is exempt, no adrenals are safe, and this time it’s after your heart!”

After our recent look at etomidate and its fall from favour as an induction agent, my eye was caught by this recent study on etomidate in the March 2014 publication of Anesthesiology. It primarily caught my attention as it appeared to be trying to look at some of the questions that we had discussed around the last post; namely where do we stand with etomidate in non-septic patients. The evidence of adrenal suppression seems to be there even if the clinical consequences aren’t clear, but most of this examination of clinical effects seem to be focused on the septic patient needing intubation where perhaps this adrenal suppression could be seen as being more problematic. There seem to be (to me at least) a good selection of other clinical scenarios where having a cardiovascularly gentle induction agent might prove advantageous e.g. a multitrauma patient with head injury where ketamine would definitely raise the ICP (little something for you there John), but even brief peri-induction hypotension is bad. In this paper the authors look at the use of etomidate in another group of patient where it might be advantageous; those undergoing cardiac surgery who probably have knackered hearts to start with. Hopefully this preamble is enough to get your interest stoked too whilst we go in for a closer look at the paper. If you haven’t been able to have a look at it for yourself yet then the link is below.