More public education and more intubationists will prevent prehospital deaths

Editor—In his letter in response to my editorial¹ Deakin² quotes Hussain and Redmond's study, which showed that at least 39% and up to 85% of preventable prehospital deaths may be due to airway obstruction.³ He did not, however, note the finding in that study that all the prehospital deaths occurred before medical or paramedical help arrived. Neither an anaesthetist nor a paramedic would have been of any use. There is no reason to suspect that the airway problems were complex: they might have been resolved by simple manoeuvres. The deaths might have been prevented if the public was able to undertake simple airway manoeuvres.

Deakin is correct in saying that present training allows paramedics to intubate only those people with a Glasgow coma scale of 3/15, a group who have a high mortality. Those who will benefit most from early intubation and assisted ventilation are those who will require neuromuscular blocking agents. Traditionally these have been given by anaesthetists. In prehospital care, like most areas of medicine, however, territorialism is a poor argument for continuing a tradition; measured outcome is far more effective an argument. Other groups such as accident and emergency staff and immediate care doctors are now being trained in advanced airway control with the use of drugs. The Royal College of Anaesthetists and Faculty of Accident and Emergency Medicine are working together on this educational initiative. In the United States graduate paramedics successfully use these techniques.

Operationally, the challenge is how to get these skilled staff to the patient quickly. Trauma needing advanced airway intervention is still relatively rare. How are we to get a qualified intubationist to the patient or vice versa within a few minutes of his or her accident?