forms returned by the participating doctors over the past five years. INTRODUCTION .... quickly and can protect the site once he has arrived. The doctors wear ...
Injury, 15, 13-l 8
Printed in Greet Britain
13
A decade at the roadside Paul P. Silverston
there was little that they could offer to the living. The Mid Anglia General Practitioner Accident Service (MAGPAS) was established to fill this ‘therapeutic vacuum’ by equipping and training the doctors and set by Dr Ken Easton OBE and his Road Accident After Care Scheme in the North Riding of Yorkshire. The followensuring that they are called early enough to be of ing paper outlines the operational details of MAGPAS and some assistance to the injured. analyses the statistics compiled from the accident report Although MAGPAS was inaugurated in 1972, the forms returned by the participating doctors over the past five period from 1972-1976 should be considered as the years. formative years of the Service, during which time the doctors established their operational policies and INTRODUCTION learned to adapt their medical skills to a new, CAMBRIDGESHIRE is a predominantly rural county of and often hostile, environment. From the outset, some 1500 square miles, with many small townships MAGPAS doctors were asked to complete and return and villages and two larger urban centres, namely an accident report form after every accident that they Cambridge and Peterborough. A number of recently- attended; although over 1000 of these forms were opened motorways, and several main trunk roads tran- returned during this early period, a large number of sect the county, carrying a considerable volume of accidents attended were not reported upon and, thereheavy goods vehicles from the East Coast ports to fore, the forms for 1972-76 have been excluded from London and the Midlands, and holiday traffic in the this study. In 1976, MAGPAS, in conjunction with the opposite direction. On average, 2500 persons are Cambridge Medical Answering Services Limited, built injured annually on the county’s roads. There are two hospitals in the county capable a complex radio communications system consisting of of handling seriously injured casualties (New a control room at Old Addenbrooke’s Hospital, Addenbrooke’s Hospital, Cambridge and Peterborough Cambridge and three strategically sited transmitters, District Hospital) and an RAF hospital (RAF Hospi- enabling the doctors to be contacted by radio and longtal, Ely) which an accept seriously injured casualties range pocket bleeper over an area of 2000 square for resuscitation, but which has a limited number of miles. At the same time, a new accident form was beds available. designed, (see Appendix 1), and a system for actively A considerable amount of time may elapse between retrieving the forms was put into operation. Over the past ten years MAGPAS has spent the accident occurring and the patient reaching hospital because of distances involved and the dual function &I22 000 on radio communications and medical of the Ambulance Service. In a rural area, an ambu- equipment and it costs around f 12 000 a year to lance cannot always be kept in reserve for emergencies, operate and maintain the service, the main expense being the upkeep of the communications equipment. but may well be loaded with patients for outpatient clinics or urgent GP admissions to hospital when the MAGPAS is a registered charity and it is the good emergency call is received. At present, the ambulance people of Cambridgeshire who have paid for what they crews are not trained to perform such tasks as intuba- consider to be a vital service to the community. tion and infusion, although it is hoped that they may DETAILS be permitted to do so soon. It was evident that a ‘thera- OPERATIONAL peutic vacuum’ existed between the time that the There are 82 doctors in MAGPAS and although the patient was injured and the time that the first majority of participants are GPs, a number of off-duty Consultants, (including the Directors of the two main medically-trained person was available. Furthermore, since the patient had to be transported to a hospital Accident & Emergency Departments in the county), before resuscitation treatment was initiated, there was and RAF Medical Officers also actively participate in a considerable delay before even fluid replacement and the scheme. Each doctor covers a seven-mile radius adequately relief of pain was afforded, even more so from his or her base, although MAGPAS does operate a two-tier service whereby a number of the doctors if the patient was trapped for any length of time. In the past, it was not unusual for country GPs to with particular experience and expertise in the field of be called to serious accidents by the local police, pre-hospital care cover larger areas, and can be called usually only to confirm that the victim was dead, but upon if the nearest doctor is unavailable or requires occasionally finding a seriously-injured victim still assistance. All the doctors have volunteered their alive. With neither medical equipment nor experience, services and receive no remuneration for their efforts. Summary
The Mid-Anglia General Practitioner Accident Service (MAGPAS) was formed ten years ago, following the example
Injury: the British Journal of Accident Surgery Vol. 1~/NO. 1
KEY = MOTORWAY = DUALCARRIAGEWAY PETERBOROUGH
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Each doctor.__ is provided with a special accident kit containing all the necessary medical and non-medical emergency equipment (see Appendix 2) and the majority of the doctors are also equipped with a ‘bleep’ and car radiotelephone. The radiotelephone is crystalled on to the MAGPAS radio frequency, thus allowing practice messages to be relayed, and to Cambridgeshire and most of the surrounding counties’ ambulance frequencies, enabling the doctor to be in direct contact with the ambulance crew. Magneticbased flashing green lights and audible warning devices are provided so that the doctor can reach the scene quickly and can protect the site once he has arrived. The doctors wear reflective jackets bearing the legend ‘DOCTOR’ so that they can be identified as a member of the ‘accident team’. CALL-OUT
POLICY
The fundamental policy of MAGPAS is that each time an ambulance is despatched to attend an accident, a MAGPAS doctor is also sent. There is no on-the-scene assessment by the emergency services before calling for a doctor. The exceptions to this procedure are accidents occurring in the cities when doctors are sent only if the accident is reported as being serious, when there are trapped casualties, or when there is no available
Table I. MAGPAS in 1981
incidents dealt with by
CMAS
Type of incident
No.
Road Traffic Accidents Medical Emergencies Industrial Accidents Fires Agricultural Accidents Riding Accidents Explosions Suicides Building Collapses Shootings Aircrashes Boating Accidents Parachuting Accidents Stabbings
1225 50 14 13 9 8 4 4 3 3 2 1 1 1
Total
1338
ambulance. Apart from road accidents, doctors are also called to attend victims of agricultural, industrial, and domestic accidents if it is reported initially that there may be serious injuries. MAGPAS doctors will also attend medical emergencies and ‘collapses’, but
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A completely new portable aspirator. Operation by compressed oxygen or a=r. Manual alternative allows pump to be used at accident site. Functions in wall mounted position or horizontally. Hanging bracket, vacuum gauge, vacuum reducing valve, available as optional extras.
Ambu
Ambu International (UK) Limited Charlton Road Midsomer Norton Bath BA3 4DR telephone (0761) 416868
iv
Injury, Vol. 15 July 1983
Silverston: A decade at the roadside
15
Table il. The number of occasions on which the doctors arrived in time to render medical assistance 1977
1978
7979
1980
1981
Arrived in Time Recalled en route Arrived too late
549 (56%) 254 (26%) 172 (18%)
522 (57%) 277 (30%) 116(13%)
388 (63%) 139 (23%) 85 (14%)
680 (62%) 323 (29%) 98 (9%)
818 (62%) 373 (28%) 139 (10%)
Total No of Report Forms
975
915
612
1101
1330
Table Ill. Details of the number of patients seen by the doctors per annum and the relative degree of injury 7977
7978
1979
7980
1981
Fatal Serious Minor
70 (9%) 212 (26%) 526 (65%)
50 (7%) 191 (27%) 458 (66%)
61 (11%) 151 (26%) 369 (64%)
82 (9%) 230 (25%) 595 (66%)
90 (7%) 280 (22%) 882 (71%)
Total number of casualties
808
699
581
907
only if the patient’s own doctor cannot be contacted; if the ambulance is a considerable distance from the incident, or is not available to attend immediately; or if a specific request is made from the scene of the incident by the ambulance crew for a doctor to be called. The reasons for the ‘blanket’ callout to road accidents are as follows:1. In the more rural parts of the county, the doctor may arrive as much as 15-20 minutes before the ambulance, which has proved to be lifesaving on several occasions when patients have been found to have had an obstructed airway. 2. It is very important for doctors to develop a routine for dealing with road accidents and to gain experience in working at the roadside, before he or she has to cope with a seriously injured patient in an otherwise strange and unfamiliar environment. 3. Experience has shown that it is frequently difficult for the doctor to ‘join in’ with the other rescue services if he arrives late in the extrication process. 4. By regularly attending accidents, the doctors learn how the other services operate and what equipment they carry, and soon establish an informal relationship with the ambulance and fire crews, a vital factor in such highly-charged and tense situations. The creation of a ‘team’ approach is fundamental to good care of patients at the roadside. 5. Finally, in a rural area, an excessive delay would result from waiting for an assessment on the scene and it would place unnecessary pressure on the ambulance crews who would have to assess the need for a doctor, particularly as ambulancemen are not yet trained in advanced life support and are encouraged to transport the casualty to hospital without delay. The Control Room statistics for _ 1981_ demonstrate _ . the diversity of the calls, but also show that the majority of calls (96 per cent) are to the victims of injury. CALL-OUT
PROCEDURE
The MAGPAS Control Room is operational
between
1252
08.00 and 23.00 hours, seven days a week and can be
contacted by the Emergency Services via a direct radio link with the Ambulance Control Room and via a restricted GPO telephone number by the Police Control Room. Once the call has been received the MAGPAS operators refer to a specially designed data retrieval system for details of whom to call for the given time of day or night. Between 23.00 and 08.00 hours the Police Control Room contacts the doctor by GPO telephone. However, from January 1983, MAGPAS will be extending its Control Room hours to provide a full 24-hour cover. In 1981, 36 per cent of the doctors were contacted within one minute of the call being received and 62 per cent of the calls had been passed to the doctors within two minutes. MAGPAS ACCIDENT STATISTICS
REPORT
FORM
The form issued to all MAGPAS doctors in 1976 was designed essentially to provide the Scheme’s coordinators with information on how the system as a whole was functioning. Many of the questions relied upon the subjective judgement of the individual doctor and little emphasis was placed upon finding out clinical details of the casualties injuries or the medical treatment rendered. However, the form fulfilled its function and enabled the co-ordinators to detect within the call-out system and the need for further training and equipment. The form itself can be folded so as to make a pre-paid, addressed, business reply packet. At the end of each week the MAGPAS and Police Controllers return their call-out sheets listing details of the accidents to which doctors have been sent during that week. As the doctors reports are received they are ‘ticked-oh on the call-out sheet. If a report for a particular accident has not been received within one week of the accident occurring, a form is sent to the doctor to complete and return. This ensures an almost 100 per cent return rate. The following Tables illustrate the information gathered from the 4933 report forms returned by MAGPAS doctors between 1977 and 198 1.
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 1
16 Table IV. Information of the medical treatment
Assessment of Injuries Reassurance Dressings Splints Analgesia I.V. Infusion Clearing/Maintaining Airway Certification of Death Sent for Renal Transplant
rendered to the 4247
1977
1978
1979
1980
1981
611 375 67 47 26 46 28 70 1
603 514 101 57 33 51 24 50 9
459 339 63 41 27 39 21 61 5
760 573 104 79 47
1096 807 158 139 60 90 66 90 5
Tab/e V Analysis of the medical treatment
rendered to 1064 1977
Splinting Analgesia I.V. Infusion Clearing/Maintaining
Airway
Seriously injured patients
casualties
47 26 46 28 212
patients classified as having sustained ‘serious’ injuries
7978
(22%) (12%) (22%) (13%)
57 33 51 24
7979 41 27 39 21
(30%) (17%) (27%) (13%)
191
1981
1980
(27%) (18%) (26%) (14%)
79 47 73 43
151
Table VI. Cases where the doctor felt that the service he/she personnel
Not within the capacity Excluding Certification/Confirmation of Death Expressed as a % of Seriously Injured Casualties
:: 82 3
139 60 90 66
(34%) (20%) (32%) (19%)
230
(49%) (21%) (32%) (24%)
280
rendered was within the capacity of the Ambulance
1977
1978
1979
1980
1981
145 75 35%
167 117 61%
145 84 56%
200 118 51%
240 150 54%
Table VII. The degree of inconvenience caused to the doctor by the call
None at all Slightly Moderately Greatly Unacceptably
1977
1978
7979
1980
1987
260 (27%) 333 (34%) 189 (19%) 66 (7%) 9 (1%)
332 (36%) 294 (32%) 165 (18%) 52 (6%) 4 (1%)
290 (47%) 148 (24%) 122 (20%) 45 (7%) 2 (1%)
645 (59%) 275 (23%) 138 (13%) 57 (5%) 2 (1%)
788 (59%) 289 (22%) 192 (14%) 52 (4%) 9 (1%)
DISCUSSION
The number of Immediate Care Schemes has increased steadily over the past few years which has led to the formation of a national organization known as the British Association for Immediate Care (BASICS). The BASICS Research and Data Collection Committee is currently encouraging all the Immediate Care Schemes in the country to compile and present their statistics annually in a manner similar to that of MAGPAS, so that the effectiveness of these Schemes can be assessed. In the meantime, the statistics provided by MAGPAS are worthy of consideration in that they show some of the shortcomings of such schemes, but also some of its benefits to the community.
The consequence of operating a ‘blanket’ call-out can be seen by the number of times that GPs are recalled en route (in nearly one-third of calls) and the large number of casualties with ‘minor’ injuries (over two-thirds) treated by the doctors. The effectiveness of the call-out system can be judged by the fact that the doctor arrives before or with the ambulance in nearly two-thirds of the calls. However, these figures are somewhat misleading, for doctors in the more rural parts of the county always arrive at the scene well before the ambulance for geographical reasons, whilst those operating from towns in which there is an ambulance station are frequently recalled.
Silverston:
A decade at the roadside
17
Approximately a quarter of the patients seen by the doctors are subjectively assessed as having suffered ‘serious’ injuries. Since few doctors provided clinical details of the injuries, it is not possible to provide information concerning the types of injuries involved nor the clinical condition of the patient. However, by comparing the treatment rendered in 1977 to those patients classified as having ‘serious’ injuries with that recorded in 198 1, one can see a trend towards more active intervention at the roadside by the doctors. The dramatic increase in the number of patients splinted is due to the introduction of new equipment, such as the Hines Cervical splint and the Hare traction splint. Training sessions and local symposia have encouraged the doctors to apply and adapt the medical skills that they bring with them to the roadside, and to initiate resuscitation and relief of pain (as necessary) at the scene. However, many patients are still arriving at the Casualty Department without adequate intravenous replenishment and it must be appreciated that a proportion of the doctors still do little more than ‘assess and reassure’, despite the fact that the doctors felt that in over 50 per cent of the cases of serious injury, the services they rendered at the roadside were not within the capacity of the ambulance crews. What then are the benefits to the community of such a service? If one takes the figures for 198 1, although the doctors were called out on nearly 1400 occasions, in only 18 per cent of the total call-outs did they consider that the medical services that they rendered were not within the capacity of the ambulance crews. Excluding confirmation or certification of death, the figure is 11 per cent. Nevertheless, because the doctors operate in a rural area, they are frequently at the scene well before the ambulance, which is an important factor in cases where the airway is at risk. In addition, the doctors have been accredited with saving the lives of a significant number of casualties by rapid intravenous infusion in cases where the patients was trapped or was some distance from the hospital. In humanitarian terms, relief of pain and reassurance is often appreciated not only by the casualties, but also by relatives, onlookers and the other emergency services personnel. In practical terms, another pair of hands at the roadside and someone who will take the ultimate medical responsibility for the patient is generally welcomed by the emergency services. Even in cases of minor injury, if the doctor arrives first, he can save both the patient and the ambulance crew an unnecessary trip to a distant hospital by recalling the ambulance. A considerable amount of time, effort and public money has been spent on setting up and maintaining MAGPAS but the questions fundamental to all medical services still apply: Is the service cost-effective, care-effective, and efficient? Since MAGPAS is a
charity, it costs the NHS nothing to run and indeed because the doctors are involved in fundraising and provide their own time and petrol-money, they may actually be more involved, altruistically, than if it were a NHS funded service. The fact that in 80 per cent of the cases they were negligibly inconvenienced, perhaps confirms this. In effect, since the community is actively involved in raising money for the Service, it is a case of a community looking after its own interests. In terms of care-effectiveness, the doctor is carrying equipment which he would not otherwise have done and is gaining experience which will benefit not only his own practice’s patients, but also the community should a major incident occur. (Dr Hines, who attended the recent fire-bombing in the Chinese quarter of London is an Immediate Care practitioner). However, the question of ‘Efficiency’ does pose a dilemma, for properly trained and equipped ambulance crews (or ‘Paramedics’ as they are called in America), regularly turning out to all emergency calls, would probably provide a higher overall level of care. In fact, in Cambridgeshire, several members of MAGPAS are actively involved in passing on the knowledge and experience that they have gained at the roadside over the past decade to the Immediate Care Practitioners of the future, by organizing a training course in advanced life-support for selected ambulance crews. Most Immediate Care doctors would reason that their presence at the roadside is an honest attempt to improve the chances of survival of a critically-injured patient; to improve the condition of a severely injured patient; to alleviate the suffering of the patient in severe pain; to provide moral and medical support to the other emergency services, and through these actions to reduce the mortality and morbidity rate of the unfortunate victims of injury and acute illness. At present, the BASICS Research Committee is preparing an accident report form for the Immediate Care doctor to complete at the scene and which will accompany the patient to hospital and become a part of his medical records. It is hoped that this will not only provide the hospital staff with important details of the patient’s condition at the roadside and changes en route, but will also demonstrate the importance and effectiveness of Immediate Care. Acknowledgements I would like to thank the following for their assistance
in preparing this paper: The Members of MAGPAS and the Cambridge Medical Answering Services, especially Mrs A. Gooch SRN; Inspector V. F. Shepherd of Cambridgeshire Constabulary; Mrs Frances Pocock and Miss Nicky Harris, AMAEMT, for their secretarial help.
Appendix
1
A. Accident Details Date _. . . . . . Time ._ . Location . . . _ _ . PoliceO Ambulance0 CMASO Other (please state) Call out by: _ 1. Did you turn out? YesO Non If not, why not? 2. Did you arrive in time to render medical assistance? YesO Non Recall0
. . _
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 1
18
3. If you arrived
late, to what
(a) Wrong location0 (c) Other (please state)
would you attribute the delay? (b) Delay in being called0
B. Clinical Details 4. (a) Number of casualties. (b) State the number of injured you attended in each of the following categories: MinorO Serious0 FatalU 5. What medical services did you render to EACH casualty? 1 2 3 4 (a) Assessment of injuries (b) Reassurance (c) Dressing (d) Splinting (e) Analgesia
(f) (g) (h) (i) (j)
1 i.v. infusion Clearing/maintaining airway Certification of death Sent for renal transplant EIZ Other (please state)
2
3
4
C. General 6. Did you feel that the medical services you rendered were within the capacity of ambulance Yes0 No0
personnel?
7. Did this call interfere with your daily work? Slightly0 ModeratelyiX Greatly0
Not at allU Unacceptably0
8. Did you feel that there was good co-operation
between the emergency services on the scene? (please comment)
9. If you are equipped with a bleeper/radio Doctor
telephone,
did you find these facilities an advantage? (please comment)
...................
Address.__
....................................
P.T.O. For General Comments Appendix
2
DOCTORS' EQUIPMENT COMMUNICA TIONS Pocket Pagers Car & Portable Radiotelephones NON-MEDICAL Protection ‘Doctor’ Beacon ‘Doctor’ Jacket ‘Doctor’ Tabard ‘Doctor’ Helmets Two-tone Horns Fire Extinguisher ‘Doctor’ Windscreen signs Protective gloves and goggles Warning Triangle Ilhtmination Q-Beam Search Light Pocket Torch Access & Extrication S.0.S Rescue Kit Seatbelt Cutter Split Scoop Extrication
Chair
MEDICAL Airway & Breathing Ambu ‘BASICS’ Maxipump & Suction Booster Laerdal ‘BASICS’ Resuscitator Kit Oropharyngeal and Nasal Airways Endotracheal Tubes Laryngoscopes-Adult and Paediatric Oesophageal Gastric Tube Airway McSwain Pneumodart
LIST
Oxygen Cylinder Cricothyrotomy Cannula Jaw Spreader Tongue Grasper Magi11 Tongs Circulation Ambulance Dressings Haemostats Arterial Tourniquet Anti-shock Suit Haemaccel and Normal Saline IV fluids Giving Sets IV Cannulae IV Dressings Arm-Lok Splints Hot/Warm Paks Electronic Sphygmomanometers Splinting Hines Cervical Splint Loxley Collar Sherman Short Spinal Board Air Splints Loxley Box Splint Frac Straps Portable Traction Splints Miscellaneous Large Scissors Equipment ‘Holster’ Heat-retaining Blankets Stethoscopes Entonox Cylinder Stomach Tubes Fibreboard and Dressings Cases.
Requests for reprints should be addressed to: Paul P. Silverston, Beaulieu House, Bottisham, Cambs CB5 9DZ.
