Prehospital Care in the Outer Hebrides
BASICS Scotland Responders — who, what, why and how
The Islands of the Outer Hebrides
The Outer Hebrides is an archipelago of islands off the West coast of North Scotland. The main islands are Lewis and Harris, North Uist, Benbecula, South Uist and Barra, some of which are interconnected by a network of causeways and others by ferries. The population of the Outer Hebrides is around 27 000 with a visiting population of over 200 000 tourists a year. The Outer Hebrides is also the gateway to reach the more remote islands that make up the even more remote St Kilda archipelago sitting 64 km (40miles) from the Outer Hebrides.
Emergency Medical Services in Scotland
The Outer Hebrides are served by the Scottish Ambulance Service, which is the organisation responsible for providing prehospital care in Scotland, including the more remote areas of the Highlands and Islands.
The Scottish Ambulance Service serves a population of around 5 million people across over 13 000 km2 (5000 square miles), including the island group of the Outer Hebrides, Orkney and the Shetlands (150 km north of the Scottish mainland). They employ over 5000 staff members and respond to in excess of 740 000 calls each year. They provide land ambulance resources, as well as a fleet of fixed and rotary wing aircraft in addition to specialist units to manage specialist rescue, hazardous chemical incidents, rescues at height requiring rope access and to support Police Scotland when firearms are deployed.
The ambulance service works alongside a number of rescue organisations, including the Scottish Fire and Rescue Service, the Royal National Lifeboat Institute (RNLI) and Her Majesty’s Coastguard. They are also supported by the Scottish Charity Air Ambulance and BASICS Scotland (the charity for whom I respond).
I responded for over a year in the Outer Hebrides on the island of Lewis and Harris to support and assist the local Scottish Ambulance Service crews. While working alongside the ambulance service, I operate as an unpaid volunteer doctor for the British Association of Immediate Care Scotland (BASICS Scotland), a pan-Scotland prehospital care organisation.
BASICS Scotland provides clinical governance support for over 190 responders across Scotland. It also runs education courses in resuscitation and prehospital care and liaises at an organisational level with the Scottish Ambulance Service to facilitate effective co-working and development of clinical guidelines to be used across the two organisations.
BASICS Scotland is supported by The Sandpiper Trust, which was established in 2001 after the tragic death of 14 year old Sandy Dickson to support lifesaving initiatives across remote and rural Scotland. The Sandpiper Trust supplies custom-designed emergency response bags, personal protective equipment and medical equipment to prehospital responders across Scotland, with responders such as myself often referred to as BASICS Scotland doctors/nurses/paramedics or Sandpiper Responders.
The cornerstone of their support lies in the provision of the Sandpiper Bag! This bag contains a multitude of lifesaving equipment, and has been adopted as the official bag for Royal College examinations as well as similar responder initiatives in Australia! BASICS Scotland is essential to the ongoing success of these rural responders through this provision of ongoing training both in person and online and in terms of clinical governance and pastoral support for responders.
Responding to Emergencies
BASICS Scotland responders are usually requested to attend emergency calls by the ambulance service Alternative Response Desk (ARD) located on the Scottish mainland. A triage algorithm used by the control room staff will identify 999 emergency calls near a responders location (many carry a global positioning system tracker) and these will be flagged to the ARD. Responders may also be requested to attend calls as a result of a request from an ambulance crew, any other emergency service or at the discretion of staff in the ambulance control room.
Locally, I also worked closely with the Scottish Fire and Rescue Service and Her Majesty’s Coastguard rescue teams, and the Coastguard Search and Rescue Helicopter team based in Stornoway. Such interagency working and training is essential in a remote environment where single-agency resources will be limited in number and scope.
Enhanced Clinical Skills
During 12 months of responding in the Outer Hebrides I provided a wide range of clinical interventions to the pre-hospital setting. Each responder will bring a set of core skills, and will often augment these with others from their previous education, training or clinical experience. In my case, I have a background in anaesthesia and prehospital care, as well as family medicine, allowing me to bring a wide range of clinical skills to patients during the prehospital phase of their journey. During these twelve months I used the following technical skills:
Oral endotracheal intubation — Placing a breathing tube into someone’s windpipe
Sedation to undertake a painful procedure — Such as relocating a dislocation or DC Cardioversion (see below)
Sedation after return of spontaneous circulation — When the heart has started beating again after a cardiac arrest
Fascia iliaca compartment block — A form of regional anaesthesia
Intraosseous access — Drilling into someone’s bone to give fluids and medications
DC cardioversion — Using an electric shock to restore the heart’s normal rhythm
Thoracostomy and drain insertion — Cutting a hole into someones chest to reinflate a collapsed lung
In addition to the clinical skills, the availability of a doctor to the prehospital teams (paramedics and emergency medical technicians) provides them with access to a senior decision maker and facilitates stepping outside clinical guidelines where this is appropriate and necessary. Such deviation from set guidelines is often referred to as Clinical Courage, and you can read more about that HERE.
Call frequency for responders varies enormously, and as I aim to be available and on-call at all times (except when I am off-island or engaged in other pressing clinical work) these calls can be at any time, day or night. The average is about two or three calls per month, but can be three calls in a single day.
The case mix I experienced over these 12 months included:
Paediatric seizures
Near-drowning
Traumatic and medical cardiac arrests
Falls
Palliative emergencies
Road traffic collisions
Sepsis / Severe Infection
Acute coronary syndromes / Heart Attacks
Challenges — Personal and Professional
A pressing challenge is maintaining competence in a system where there is a low volume of high-acuity calls. Ongoing clinical governance and support is provided from both BASICS Scotland and the Scottish Ambulance Service, and I supplement this with attendance at conferences off-island and undertaking online learning in areas of self-perceived weakness.
On a more personal note, an important challenge is practising prehospital medicine in a small, tight-knit community. The community will often know if I have attended a patient overnight, and furthermore will know the person, the nature of the call and the subsequent outcome. As a primary care physician, I also frequently become involved in the wider ripples of tragic events within the community. It is often difficult to separate my responding, my day job in primary care and personal life. All of these factors contribute to a potentially stress-inducing environment, requiring significant emotional resilience.
In Summary
Responding in the Scottish Outer Hebrides presents a number of challenges above and beyond standard prehospital work, due to its remoteness in terms of reaching definitive care, and the limited resources available on the island.
As a prehospital physician it is important to have an excellent working relationship with all local emergency services, and with the wider community. The use of tele-education as well as face-to-face training mitigate against de-skilling and loss of competence and confidence.
Emotional resilience is tested when responding and living in a rural setting, when you are far less removed from the tragedies you encounter when providing prehospital care, and the impact of this should not be underplayed.
BASICS Scotland responders wouldn’t be able to do their excellent work without donations from the public and partner agencies. They give their time freely, and usually foot the bill for expenses themselves! You can support them by donating to The Sandpiper Trust.
A previous version of this article was published in Remote and Rural Health.
Please consider donating to The Sandpiper Trust HERE,learning more about their fundraising work HERE, or checking out their online shop HERE.
