Pre-Hospital Emergency Medicine (PHEM)

What is Pre-hospital Emergency Medicine?
Pre-Hospital Emergency Medicine (PHEM) is a General Medical Council approved sub-specialty for anaesthesia and emergency medicine. As an approved sub-specialty, anaesthesia trainees who complete the sub-specialty training will have their Certificate of Completion of Training (CCT) in Anaesthetics annotated with sub-specialty of Pre-Hospital Emergency Medicine.

The term ‘pre-hospital care’ covers a wide range of medical conditions, medical interventions, clinical providers and physical locations. Medical conditions range from minor illness and injury to life threatening emergencies. Pre-hospital interventions therefore also range from simple first aid to advanced emergency care and pre-hospital emergency anaesthesia. Care providers may be lay first responders, ambulance professionals, nurses or physicians of varying backgrounds.

All of this activity can take place in urban, rural or remote settings and is generally mixed with wider out-of-hospital and unscheduled care. The complexity of unscheduled and urgent care provision is illustrated below:

What is the role of a specialist in Pre-Hospital Emergency Medicine?
PHEM encompasses the knowledge, technical skills and non-technical (behavioural) skills required to provide safe pre-hospital critical care and safe transfer.

‘Pre-hospital’ refers to all environments outside an emergency department resuscitation room or a place specifically designed for resuscitation and/or critical care in a healthcare setting. It usually relates to an incident scene but it includes the ambulance environment. Implicit in this term is the universal need, by this specific group of patients, for transfer to hospital. Although a component of urgent and unscheduled care, PHEM practice relates to a level of illness or injury that is usually not amenable to management in the community setting and is focused on critical care in the out-of-hospital environment.

‘Critical care’ refers to the provision of organ and/or system support in the management of severely ill or injured patients. It is a clinical process rather than a physical place and it requires the application of significant knowledge and technical skills to a level that is not ordinarily available outside hospital. Hospital-based critical care is typically divided into three levels: Level three (intensive care areas providing multiple organ and system support), level two (high dependency medical or surgical care areas providing single organ or system support) and level one (acute care areas such as coronary care and medical admission units). In the context of PHEM, all three levels of critical care may be required depending on the needs of the patient. In practical terms, the critical care interventions undertaken outside hospital more closely resemble those provided by hospital emergency departments, intensive care outreach services and inter-hospital transport teams.

‘Transfer’ refers to the process of transporting a patient whilst maintaining in-transit clinical care. A distinction between retrieval and transport (or transfer) is sometimes made on the basis of the location of the patient (e.g. scene or hospital) and the composition or origins of the retrieval or transfer team. Successful pre-hospital critical care services in Europe, Australasia and North America have recognised that many of the competences required to primarily transport critically ill or injured patients from the incident scene to hospital are the same as those required for secondary intra-hospital or inter-hospital transport. In the PHEM curriculum, the term ‘transfer’ means the process of physically transporting a patient whilst maintaining in-transit clinical care.

A sub-specialist in PHEM should be capable of fulfilling a number of career or employment roles which include, for illustrative purposes, provision of on-scene, intransit and/or on-line (telephone or radio) medical care in support of PHEM service providers such as:

  1. NHS Acute Hospitals (particularly regional specialist hospitals with an outreach capability);
  2. NHS Ambulance Trusts (e.g. as part of regional Medical Emergency Response Incident Teams (MERIT) or their equivalent);
  3. The Defence Medical Services;
  4. Non-NHS independent sector organisations such as immediate care schemes, air ambulance charities, event medicine providers and commercial ambulance and retrieval services.

The PHEM sub-specialist practitioner role is uniquely challenging. The tempo of decision making, the threats posed at incident scenes, the relatively unsupported and isolated working conditions, the environmental challenges, the resource limitations and the case mix all make this a very different activity compared with in-hospital emergency medicine and anaesthetic practice.

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