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The Scene In The Sixties
A Case Study
A young woman, three months pregnant, died after her car hit a tree in dense fog. The District Nurse living nearby heard the crash and called me to the scene.
The patient was trapped with severe facial and possible neck injuries, lapsing in and out of consciousness, choking on the vomit of her recent meal.
Having freed her (and the unconscious dog also found trapped under her seat) she had a twelve mile journey to the nearest accident unit.
She died as the ambulance neared the doors, and could not be resuscitated. She succumbed to respiratory obstruction, due to food inhalation. Her husband and the dog survived.
An Uncommon Situation
The uncommon thing about this accident was that a doctor was called.
The first we usually knew about most accidents was when the patient was discharged from hospital, or perhaps from the report in the local paper.
Ambulance staff said they often had wanted a doctor to attend, but had no means of identifying the nearest one, or of contacting him.
Radio-communications were rare on ambulances.
The Problem
There were no suckers or endotracheal tubes in the ambulance, nor did General Practitioners carry them.
Most doctors had sticky plasters, lint, a bandage or two, injections, and metal/glass syringes, but no intravenous fluids or transfusion equipment, oropharyngeal airways, or splints.
Nor had they worked in Casualty departments that prepared them for difficult diagnostic and management decision-making at the roadside.
Ambulances were as ill-designed as they were ill-equipped, in some areas manned by only a driver, with minimal training in first aid and none in CPR.
There were no statistics on the numbers dying in transit, for death could only be certified by a doctor at the site or on arrival at the hospital.
What Could Be Done?
Medical Advances
Many doctors recently trained in hospital techniques were now working in general practice. Properly equipped, those doctors could prevent shock from blood loss by setting up a drip with the new plastic giving-sets before veins had become collapsed; new IV fluids were also becoming available.
Doctors could prevent or treat airway obstruction or lung collapse which could be fatal within a very few minutes; they could monitor head injury and relieve pain – if only they could be got to the scene in time.
It seemed logical to suggest that the police or ambulance control centres could alert the nearest doctor as well as the ambulance when an emergency call came in.
Nor were road accidents the only occasion when specialised skills and equipment might be used. Accidents at work (especially farming injuries, which often occurred a long and difficult journey from hospital facilities), at sport and leisure, and at home, were equally common.
Newborn babies may need resuscitation, so infant-sized airways and larygoscopes were necessary; haemorrhagic shock from bleeding ulcers, ante- and post-partum haemorrhage, etc., could be treated by intravenous fluids with live-saving results.
The Difficulties That Lead To NARS
Greater expertise and better equipment would undoubtedly contribute to raising general practice standards and thus benefit the community as a whole.
The main difficulties could be summarised:
- Communications: how can the doctor be alerted?
- Availability: how can medical care best be organised?
- Training: what extra training is necessary for roadside work, for new techniques and materials?
- Equipment: what is there, and how can it be provided?
- Payment: for services, equipment, organisation, time.
The Norfolk Accident Rescue Service went operational on 1st October 1970, after only five months of planning and organisation, with 71 General Practitioners participating, covering well over 80% of the County.
Its Constitution read “that the Service is for the provision in the geographical county of Norfolk and areas contiguous thereto of immediate medical treatment and care to persons in need by reason of accident or other emergency”.
