Prehospital care in the EMJ.

T here is increasing recognition and acceptance of the view that the emergency medical system should provide seamless and appropriate care from the moment the patient is injured, taken ill, or seeks help. Coupled with this is a developing understanding that the many different demands for emergency or ‘‘unscheduled’’ health care can only be met by new and innovative working patterns and practices within emergency departments, ambulance services, and primary healthcare teams. The work on ambulance service roles and curriculums and the evolving emergency care practitioner concept published in this edition are just two examples of work being undertaken to meet prehospital care demands and improve access. This work is important and necessary. Among all this activity however, there is a small but real risk of neglecting the educational needs of those who currently provide urgent immediate care needs in the prehospital environment. So how can the EMJ help? Firstly, our ABC of Community Emergency Care is aimed at both existing prehospital practitioners and those who are part of evolving systems of care. We hope that it provides a starting point for further educational and curriculum development and we would welcome your input and feedback. Secondly, the EMJ is also the official journal of the British Association for Immediate Care (BASICS) and the Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh. Both organisations have a great deal of expertise and experience within their memberships and this should be shared. Consider the use of ketamine for example. Most experienced immediate care doctors consider that there is no real alternative drug when faced with a trapped, conscious patient who requires pharmacological sedation and analgesia to facilitate extrication and rescue. 2 Yet there are few trials to support its safety or effectiveness in prehospital care and a lively debate continues regarding its use in the emergency department. The summary of product characteristics for ketamine states that it should be used ‘‘only in hospitals by or under the supervision of experienced medically qualified anaesthetists except under emergency conditions’’. Serious injury with entrapment is clearly such an emergency condition. The real question is one of patient safety. Keith Porter’s personal audit of prehospital ketamine use is a good example of how safe practice can be shared. Although we encourage submission of similar audit and review, the sharp contrast in the data and level of evidence available for emergency department use compared with prehospital use is striking and further coordinated primary research is essential. Submitting such research to the EMJ is one of the best ways to ensure that it is disseminated widely to those who need to know. Thirdly, many of the prehospital readership have commented that there is little guidance on equipment selection for prehospital and emergency department use despite the fact that equipment considerations can have a major impact on our ability to provide care. Take for example the apparently simple intervention of intraosseous access. What devices are available and what evidence is there of any advantage or disadvantage in the prehospital or emergency department setting? Although most Best Evidence Topic reports (BETs) and clinical topic reviews focus on the evidence underpinning diagnostic strategies or therapeutic interventions, there is a need to disseminate answers to equipment questions such as these. The well established structure of the BET (asking the right question, searching for the evidence, appraising the evidence, and providing a summary relevant to your practice) is just as relevant to medical devices and novel equipments as it is to pharmaceuticals and diagnostic tests. The evidence may however be harder to find given that published clinical trials are not necessarily the place to find the rationale for an equipment development. We welcome proposals for these Best Evidence Equipment Reviews and hope to publish some examples in the near future. Finally, case reports may not be evidence based but they certainly have a place in education, training, and informing practice. Much adult learning is experiential and we should not dismiss the opportunity to learn from others. Although we encourage the submission of case reports relevant to prehospital care and the prehospital/ emergency department interface, our experience is that they are of little educational value if they are not accompanied by a brief but comprehensive review of the relevant literature and, where possible, commentary from experienced practitioners and experts in the field. We therefore invite authors to contact us and discuss their case reports before submission so that we may provide editorial guidance and commission suitable commentary. These additional developments in the prehospital care content of the EMJ represent a strong editorial commitment to providing evidence, education, commentary, experience, and debate throughout the entire patient journey. We hope that they will complement the existing content and help provide for the educational needs of the prehospital and emergency department readership.