Anaesthesiologists in emergency medicine

Are out-of-hospital emergency medical services involving anaesthesiologists a luxury? If you were suffering from an acute severe illness, would you like to be treated by an experienced doctor? Do we need physicians in ambulances? These questions – and other similar ones – are still vital questions in 2011. Professor Martin Kirschner (1879–1942), a surgeon, introduced the first physician-staffed emergency medical service at the University Hospital of Heidelberg in Germany in 1938. He made it clear that ‘the doctor should come to the patient, and not the patient to the doctor!’1,2 Why do we need experienced physicians at the scene? Experienced physicians can successfully perform life-saving invasive procedures (intubation of the trachea), can treat acute conditions, can make differential diagnoses and are capable of making decisions concerning outcome and, indeed, are trained to improve outcome. This is critically important for the successful acute management of prehospital emergencies [severe trauma, traumatic brain injury, sepsis, acute myocardial infarction and out-of-hospital cardiac arrest (OOHCA)].3,4 We know from Gries et al.5 that physicians involved in German air rescue encounter a situation requiring an intubation manoeuvre every 2 weeks compared with around 6 weeks in the ambulance emergency medical services, and for an intubation manoeuvre without cardiopulmonary resuscitation (CPR), the figures are approximately every 3 weeks compared with almost 4 months, respectively. This is too infrequent to support adequate routine training in and maintenance of airway skills and other invasive life-saving procedures through the OOH emergency medical service alone.5,6,7 Konrad et al.8 showed a cumulative intubation success of about 60% after 25, 90% after 57 and 98% after 159 intubation procedures. Even after 80 intubations, 18% of the physicians in this investigation still required assistance from experienced colleagues. A finding confirmed in reports is that completing the first 25 tracheal intubations can actually induce a false sense of security, with the result that field airway management disasters occurred more often than expected, resulting in brain damage and fatalities. Often those responsible did not have enough clinical training in tracheal intubation.9 Timmermann et al.10 found an incidence of out-of-hospital oesophageal intubation of 6.7% and for endobronchial intubation the figure was 10.7%. These intubations had been performed by ground-based emergency physicians and the problems were detected by anaesthesiologists on a corresponding helicopter-based air rescue system. The misplaced tube is also a particularly important problem for small children and newborns. Extrapolation of these data indicates that field airway management disasters are responsible for 3000 deaths per year in Germany and more than 12 000 deaths per year in Europe. This is an area in which experienced physicians and anaesthesiologists can make a difference. Physician-staffed emergency medical services clearly generate improvements in survival rates and benefit patient care. In 1999, Garner et al.11 in a retrospective analysis of helicopter emergency medical services found that there were eight to 19 extra survivors per 100 patients who received treatment from physicians as opposed to paramedics. In 2002, Lossius et al.12 estimated that 1 life-year was gained with every 14th patient who was assisted by a physician, and they concluded that the role of anaesthesiologists was crucial for health benefits. In 2003, Osterwalder13 from Switzerland claimed that physicians might prevent up to 23% of all deaths from blunt trauma. In 2004, Frankema et al.14 in a 2-year prospective observational study found a two-fold better chance of survival for multiple trauma victims with an Injury Severity Score of at least 16 (odds ratio 2.8, 95% confidence interval 1.07–7.52, P = 0.04) when treated by helicopter emergency medical service physicians. In 2005, Ohshige et al.15 concluded that a nationwide doctor-manned ambulance system was the best form of service to adopt. In 2006, Klemen et al.16 presented data from traumatic brain injury victims treated by physicians as opposed to paramedics and found a significant reduction in mortality at 1 and 24 h and, in general, in those with a Glasgow coma scale of 6–8 who had received care from the former. In a study supported by the European Union, Fischer et al.17 reported a remarkable difference in outcome between a paramedic-staffed emergency medical service in Birmingham (n = 3502), UK and an anaesthesiologist-staffed emergency medical service in Bonn (n = 3422), Germany. Their results showed that a higher rate of advanced life support (ALS) manoeuvres that included intubation of the trachea, drugs and fluid provided by emergency medical service physicians improved vital signs more often than treatment by paramedics. Moreover, the figures for return of spontaneous circulation (ROSC 45 vs. 16%), during CPR, admission to hospital (40 vs. 11%), 24-h survival (30 vs. 6%) and survival to hospital discharge (15 vs. 4%) were significantly better in those treated by anaesthesiologists (P < 0.01). Despite a comparable CPR incidence, reliability of response time and similar infrastructure with double response emergency medical service in both cities, the survival rate for the physician-staffed service was still four-fold higher than that of the paramedic-staffed service. A recently published meta-analysis showed that survival from OOHCA was improved almost five-fold with physician-staffed emergency medical services.18 Last but not least, Fischer et al.19 published very recently another comparison between two physician-staffed emergency medical services in Bonn, Germany (n = 149) and Cantabria, Spain (n = 103) and two paramedic-staffed emergency medical services in Coventry, UK (n = 67) and Richmond, Virginia, USA (n = 480). Survival following OOHCA was significantly better in the physician-staffed emergency medical services than it was in the two that were paramedic-staffed. The authors concluded that higher qualifications and the greater training and experience of ALS unit personnel increased the rates of survival after OOHCA and the successful treatment of cardiac chest pain and respiratory failure. Outside Europe, the Japanese Circulation Society Resuscitation Science Study (JCS-ReSS), a prospective, population-based, observational study with 431 968 patients, which was presented at the American Heart Association/ReSS Scientific Meeting 2010, demonstrated a significantly better survival from witnessed OOHCA in the physician-treated group than those treated by paramedics.20 After propensity score matching for clinical characteristics, the physician-treated group (n = 2072) when compared with the paramedic-treated group (n = 2072) showed a higher ROSC (27 vs. 12%, P < 0.0001), a higher survival rate at 1 month (16 vs. 11%, P < 0.001) and a higher survival rate at 1 month with minimal neurological impairment (9 vs. 7%, P = 0.009). The authors concluded that a physician on board has incremental benefit to those suffering from OOHCA.20 How much money is needed to gain benefit from physician-staffed emergency medical services? The costs for the anaesthesiologist-staffed emergency medical services in Bonn, Germany as compared with paramedic-staffed emergency medical services in Birmingham, UK were €14.92 vs. €10.43 The additional cost of an experienced doctor on board is equal to €4.49 per inhabitant per year.17 Worldwide, many deaths occur that could be prevented. Anaesthesiologists as experienced prehospital emergency medical service physicians can make a difference and achieve a win for our patients and a win for our specialty. Acknowledgement The study received no assistance of financial support/sponsorship and there are no conflicts of interest. This article was checked and accepted by the Editors, but was not sent for external peer-review.