Pre-hospital emergency medicine matters
A London Air Ambulance doctor
David Lockey grew up in London and went to medical school in Newcastle upon Tyne. After qualifying he embarked on a career in obstetrics and gynaecology. He then moved to anaesthesia and intensive care medicine and completed training in Nottingham, Australia, and Bristol. Medicine has also taken him to the Seychelles, Jersey, Kosovo, Iraq, and Afghanistan. He spent two full time periods working at London’s Air Ambulance and has remained there part time as a consultant since 2000. He was appointed consultant in anaesthesia and intensive care medicine at Frenchay Hospital in Bristol in 2001 and holds honorary academic appointments at Bristol University and Queen Mary College London. He is also acting trauma network director for the Severn region in the run up to the launch of the regional trauma network next year.
Congratulations on your appointment as honorary professor of trauma and pre-hospital emergency medicine at the University of Bristol—what will this new role involve?
The role formalises a link with Bristol University and provides me with the infrastructure of a very successful university to help develop research projects in the areas of trauma and pre-hospital emergency medicine. It also helpfully comes at a time when we are developing regional trauma networks in the south west of England to improve the care of trauma patients. Research is a component of regional trauma networks, and this will hopefully generate a number of new trauma projects.
What were the challenges in getting pre-hospital emergency medicine formally recognised as a subspecialty of anaesthesia and emergency medicine?
The members of the intercollegiate board for pre-hospital emergency medicine have had to put in an enormous amount of work to get the subspecialty recognised by the General Medical Council. Pre-hospital emergency medicine is quite unique, because by definition it is carried out outside hospitals and by doctors from different specialty backgrounds. Direct supervision can be difficult, and working conditions can make the provision of high level care challenging. Pre-hospital emergency medicine will initially be a subspecialty of emergency medicine and anaesthesia, but in time this is expected to include other specialities.
What qualities are needed to be successful in trauma and pre-hospital emergency medicine?
Solid skills in the assessment and treatment of seriously ill patients are essential. In addition an ability to make clear decisions and communicate well. Not only do successful practitioners have to be effective team players and team leaders, but they often meet the team members at the same time as they meet the patient. The ability to work quickly and a sense of humour also help.
You’re one of London’s Air Ambulance consultants—what major incidents have you been involved in?
I have been involved in a variety of very different major incidents. The 2005 London bombings are most memorable because I had to go over the events in great detail while giving evidence at the bombings inquest held recently in London. Doctors from London’s Air Ambulance have been involved in almost all of the major incidents in and around London in the last 20 years. They have mainly consisted of bombings and train crashes.
Since joining London’s Air Ambulance in 1997, what changes have you seen in the way pre-hospital care is delivered to patients?
Although the service has always been about delivering high quality trauma care to patients when they need it, there have been major changes in the way we deliver care. The concept that a lower standard of care is acceptable in the pre-hospital environment because conditions can be difficult is now completely obsolete.
Although treatments may be simplified they are carried out to a uniformly high standard and in a system that provides intense scrutiny and support. Cases are discussed twice weekly and also at monthly clinical governance meetings, which are not only multidisciplinary but also open to individuals from other organisations. Case audits include standardised contributions from paramedics, doctors, pilots, and fire crew. The training for new doctors lasts four to six weeks. This period is busy and all aspects of practice are developed and tested. Many people also attend a helicopter crew course that makes use of challenging low fidelity simulation.
What have been the most important findings from your research in the field of pre-hospital trauma care?
I think one of the key messages that I have got from looking at pre-hospital and trauma care is that although technology and high level research may create some exciting treatment opportunities in the very near future, saving increased numbers of lives now is about being successful at what we already know works. Checking and altering practice to achieve established goals is critical. We have demonstrated that aggressive treatment of traumatic cardiac arrest, thought to be futile by many, can be as effective as for any other causes of cardiac arrest. We have shown that thoracotomy performed by non-surgeons outside hospital can produce neurologically intact survivors where previously there was none. Pre-hospital airway management has been consistently shown to be substandard but also essential. Understanding how basic and advanced airway management can be delivered safely to the patients who really need it is a real challenge that we have started to tackle.
How did you balance your work as a consultant with your research?
Badly. I have always done clinical research in my spare time, and it has not always been efficient or comfortable. Clinical work has always come first. Although I am hoping to develop into a highly organised productive individual in the near future, that may be very optimistic. There is no doubt that the conduct of large effective studies requires a great deal of specifically allocated time. Since most of the research in trauma and pre-hospital care is retrospective database work, however, and of only moderate quality, there is plenty of opportunity for new work.
What advice would you give to anyone interested in specialising in pre-hospital emergency medicine?
Pre-hospital emergency medicine is finally emerging as an exciting subspecialty. The Faculty of Pre-hospital Care in Edinburgh has been the key organisation driving examinations and training. Structured training will enable trainee doctors to join proper training programmes and emerge ready to provide high quality pre-hospital care as consultants. You do not need to wait that long, however—the student pre-hospital care programme that started at the Royal London Hospital has been reproduced in a number of medical schools around the country. The challenges of pre-hospital emergency medicine and the pleasure of working with paramedics are unique and not to be missed.
- Prehospital Care Programme—prehospitalcareprogramme.org
- Faculty of Pre-hospital Care—www.fphc.info
1doc2doc and specialty portals, BMJ, London
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2011;19:d7472