Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept.

Abstract

Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients.
Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions.
Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.

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Paramedic versus emergency physician emergency medical
service: role of the anaesthesiologist and the European versus
the Anglo-American concept
Arnd Timmermanna, Sebastian G. Russoaand Markus W. Hollmanna,b
Introduction
Outlining the role of physicians or even more specifically
of anaesthesiologists in the emergency medical service
(EMS) based on solid evidence is challenging, since
organizational differences make direct comparisons
between the paramedic and physician-based EMS diffi-
cult [1??,2].
Beforelooking at some studiesaddressing this topic,two
crucial questions should be asked. Is the decision of
whether paramedics or specially trained physicians
should be present in the field just a matter of different
approaches or is it mainly a financial question? Do
we really have to study whether a high density of
less qualified EMS personnel leads to similar or even
better outcome than a system in which highly qualified
physicians, providing better transportation stability,
take care of the critically ill patient? Or does the main
question relate to how much we are willing to pay for the
improved care and the feeling of safety?
The crux with solid clinical studies
Supporting improved outcome by physician-based EMS
with level I evidence would require a prospective
randomized double-blinded trial including thousands
of patients. Taking into account that for only approxi-
mately 5% of emergency calls the presence of a specially
trained physician was shown to be of critical importance
(96–100% of life years were gained in only 2.5–7% of
patients studied [3,4]) and excluding those patients with
a fatal prognosis, a substantial number of patients have to
be screened to show a significant improvement in a hard
outcome variable (e.g. mortality) using physician-based
treatment. We hazard a guess that such a study will never
be done. Within a working physician-operated EMS,
withholding care provided by a physician would be
unethical and comparisons between systems are difficult
because of the great structural differences between EMS
systems [1??,2]. Strikingly, assigning long-term beneficial
effects to prehospital treatment alone would not be
possible, since prehospital and hospital treatment are
aDepartment of Anaesthesiology, Emergency and
Intensive Care Medicine, Georg-August University,
Goettingen, Germany andbDepartment of
Experimental and Clinical Experimental
Anaesthesiology (LEICA), University of Amsterdam
(AMC), Amsterdam, The Netherlands
Correspondence to Professor Dr med. Dr rer. nat.
Markus W. Hollmann, DEAA, Department of
Experimental and Clinical Experimental Anesthesiology
(LEICA), University of Amsterdam (AMC),
Meibergdreef 9, Postbus 22660 H1Z-112,
1100 DD Amsterdam, The Netherlands
Tel: +31 20 5663630; fax: +31 20 6979441;
e-mail: m.w.hollmann@amc.uva.nl
Current Opinion in Anesthesiology 2008,
21:222–227
Purpose of review
Much controversy exists about who can provide the best medical care for critically ill
patients in the prehospital setting. The Anglo-American concept is on the whole to
provide well trained paramedics to fulfil this task, whereas in some European countries
emergency medical service physicians, particularly anaesthesiologists, are responsible
for the safety of these patients.
Recent findings
Currently there are no convincing level I studies showing that an emergency physician-
based emergency medical service leads toa decrease in overall mortality or morbidity of
prehospital treated patients, but many methodical, legal and ethical issues make such
studies difficult. Looking at specific aspects of prehospital care, differences in short-
term survival and outcome have been reported when patients require cardiopulmonary
resuscitation, advanced airway management or other invasive procedures, well directed
fluid management and pharmacotherapy as well as fast diagnostic-based decisions.
Summary
Evidence suggests that some critically ill patients benefit from the care provided by an
emergency physician-based emergency medical service, but further studies are needed
to identify the characteristics and early recognition of these patients.
Keywords
anaesthesiologist, emergency medical service, emergency physician, outcome,
paramedic
Curr Opin Anesthesiol 21:222–227
? 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907
0952-7907 ? 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

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linked to each other. Paradoxically, outstanding prehos-
pital performance may even increase hospital mortality,
whereas iniquitous or no prehospital treatment at all
could lead to improvement in hospital mortality, because
patients may die before admission or while in transit
[1??,5,6].
The logical approach to the question
It is obvious that specially trained emergency physicians,
and in particular anaesthesiologists, are skilled in airway
management, cardiopulmonary
treatment of critically ill/injured patients and monitoring
patients’vitalsigns,sincethisispartoftheirdailyroutine.
They have profound knowledge which enables them to
make individual decisions that are at times different from
standard operating procedures (SOPs). Overall they are
trained, on a daily basis, to increase survival. Therefore,
the stay and play approach providing advanced life
support (ALS) to increase transportation stability is
adequate for the majority of clinical scenarios [2,7]. In
situations when performance of prehospital procedures
may have a negative impact on survival (e.g. critically
injured penetrating trauma patients [8??]), however,
physicianscan decide totake thescoop and run approach.
resuscitation(CPR),
Paramedics,incontrast,performinvasiveprocedures[e.g.
endotracheal intubations (ETIs), intravenous line and
chest tube placement], or diagnostic procedures (e.g.
with mobile ultrasound devices) rather infrequently.
Additionally, their therapeutic concepts rely much more
on guidelines and SOPs. These may be very effective
for standardized procedures, such as CPR, but for many
out-of-hospitalsituations,
neither exists nor is applicable [9?].
SOP-orientatedmedicine
We would like to focus on three different topics to point
out possible differences between the paramedic and the
emergency physician based EMS: airway and trauma
management and severe cardiac events.
Airway management
Securing the airway is the most important task in emer-
gency medicine. In the absence of an open airway and
adequate oxygenation all other measures of care will fail.
In 2005 the International Consensus on Cardiopulmon-
ary Resuscitation and Emergency Cardiovascular Care
Science with Treatment Recommendations and the
European Resuscitation Council Guidelines for Adult
Advanced Life Support [10,11] stated that the tracheal
tube remains the gold standard for securing the airway
during CPR when placed by experienced personnel.
The advantages of tracheal intubation over bag–mask or
extraglotticairwaydeviceventilationincludemaintenance
oftheairway,protectionfromaspirationofgastriccontents
or blood from the oropharynx, the ability to provide an
adequate tidal volume during chest compressions, the
ability to suction tracheal secretions, providing a route
for administering drugs, and the ability to deliver higher
positive pressure ventilation [11,12??].
Other studies, however, have shown no difference or
reducedsurvivalrateswith ETIinpatientswithtraumatic
braininjuryorinchildren[13–16].Davisetal.[17]assigned
the increase in mortality to transient hypoxia, inadvertent
hyperventilation, and longer scene times associated with
the rapid sequence induction (RSI) procedure. These
factors may be attributed to an inadequate level of profi-
ciencyandknowledge,sinceETIlaryngoscopyisadifficult
skill to acquire and deteriorates over time if it is not
regularly practised [18,19]. Whereas scores of reports and
vastexperienceinmanysystemshavedocumentedtypical
intubation success rates well in excess of 90% [20–23], it
must be pointed outthat the vast majority ofthese studies
have been retrospective in nature and relied entirely on
EMS personnel identifying and documenting complica-
tions. Therefore, those findings are subject to bias [24].
According to studies by Konrad et al. [25] and Mulcaster
et al. [26], laryngoscopic-guided tracheal intubation must
be performed approximately 50–60 times in patients who
appear to be normal on a routine airway examination
to achieve proficiency. Johnston et al. [27??] reported an
average of only 6–10 ETIs performed by paramedics
during their airway management training in the operation
room. Therefore, success rates as low as 50% have been
noted for emergency medical technicians, who do not
frequently perform tracheal intubation, even under the
controlled environment of the operating room (OR)
[28,29]. A recent survey among German EMS physicians
(nonanaesthesiatrained)[30],however,alsodemonstrated
that20%ofthephysicianshadperformedlessthan20ETIs
under supervision prior to their assignment to the rescue
ambulances.
These quantities are insufficient to the challenging needs
and demands of securing the airway in an emergency
situation. In contrast to the controlled environment of
theOR,out-of-hospitalairwaymanagementofteninvolves
coping with the presence of debris, secretions, blood,
vomitus, emphysema, anatomic derangement, dental
damage,ortheapplicationofcervicalspineimmobilization
devices and in-line axial stabilization, which reduces the
ability to use direct or indirect laryngeal visualization
techniques and face mask ventilation. Additionally,
difficult out-of-hospital airway management is mostly
unanticipated, airway equipment is limited, respiratory
dysfunction and hypoxia are often present, and the
position of the patient sometimes makes access to the
head difficult. Other issues complicating the airway
management of the emergency patient include CPR
Paramedic versus emergency physician Timmermann et al.
223

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or other medical procedures being performed simul-
taneously, altered and varying levels of patient conscious-
ness, and lack of professional help [12??,31,32].
Itisnotsurprising,therefore,thatseveralstudiesreportthe
incidenceofasurgicalairway(e.g.cricothyrotomy)tobeas
high as 10–15% when direct laryngoscopy was attempted
by paramedics [33–36]. For nonanaesthesia-trained emer-
gencyphysicians,Gerichetal.[37]reportedanincidenceof
emergency cricothyrotomyof 2.1%.Moreover,oneshould
be alarmed at the numbers of unrecognized misplaced
tubes by paramedics: when the position of out-of-hospital
placed tracheal tubes was reexamined by independent
observers on arrival in the emergency department, unrec-
ognized esophageal or hypopharyngeal intubation was
recorded in up to 25% [38,39]. One study also reported
an incidence of unrecognized esophageal intubations of
6.7% when ETI was performed by EMS physicians, even
though the level of airway management skills of the
physicians was not reported. While the 24h mortality rate
of patients whose tracheas were intubated correctly
was reported as 10%, this rate increased dramatically to
70–90% for those with misplaced tubes [39,40??,41?].
Successful airway management may not be a question of
whether the procedure is performed by a paramedic or an
emergency physician. It depends on the frequency of
traininginairwayskills,theusageofalternativetechniques
to ETI, and methods used to confirm tracheal tube
placement. Recent studies demonstrated a higher success
rate of extraglottic airway devices (e.g. the intubating
laryngeal mask) when compared with conventional
laryngoscopic intubation techniques [42??]. These find-
ings, however, support the important role of experienced
anaesthesiologists in the care of severely injured emer-
gency patients. The wide range of expertise in advanced
airway management would be hard to achieve by other
EMS personnel.
Trauma care
The prominent role of the highly qualified emergency
physician in the care of severely injured emergency
patients is not only restricted to airway management.
This section aims to highlight the impact of emergency
physicians in trauma care.
In a retrospective comparison of 207 patients with blunt
traumaandanInjurySeverityScoreofover10treatedbya
physician or paramedics, the following statistics were
reported: physicians intubated a greater proportion of
patients (51% versus 10%), including all patients with a
Glasgow Coma Score (GCS) of less than 9; physicians
gave significantly more fluids to hypotensive patients
(5035 versus 1475ml) and performed thoracic decompres-
sions on a larger proportion of patients (12% versus. 1%)
without increasing scene time. These data suggest that
there would have been between eight and 19 extra
survivors per 100 patients treated in the physician group
comparedwiththeparamedicgroup[43].Osterwalder[44]
concluded from a prospective, observational cohort study
inSwitzerlandthatphysiciansmaypreventupto23%ofall
deathsfrombluntpolytrauma.IntheNetherlands,a2-year
prospective observational study of consecutive adults
who suffered multiple trauma [45] revealed that use of a
physician-staffed helicopter emergency medical service
(HEMS)increasedchances ofsurvivaltwotothree-foldin
patients suffering from multiple trauma, especially
those with blunt trauma. Earlier studies had already
convincinglydemonstratedthatthebenefitsobtainedwith
the HEMS cannot be attributed to a faster mode of
transportation.
A multicentre study comparing trauma patients’ outcome
within and between five countries with a technician-
operated ALS system versus four countries using a phys-
ician-based EMS demonstrated a significantly lower early
trauma fatality rate in the physician-operated EMS [1??].
Although there are some limitations to the study design,
namely selection bias for recruited clusters and not a
completely random distribution of missing data, this is
the first multicentre study that used early trauma fatality
rate, and not in-hospital trauma fatality. This is because
in-hospital trauma fatality could be heavily influenced
by the quality of hospital care rather than prehospital
interventions.
In a recent noncontrolled cohort study, 64 patients with
severe traumatic brain injury receiving prehospital ALS
including RSI by emergency physicians were compared
with60patientswhodidnotreceiveprehospitalALSwith
RSI by emergency medical technicians. Patients treated
by a physician showed a significantly better first hour
survival rate (97% versus 79%), first day survival rate
(90% versus 72%), better functional outcome, less time
spentintheICUandshortenedoverallhospitalization.Ina
subgroup of patients with GCS of 6–8, significantly lower
total hospital mortality (24% versus 78%) was reported
[46].
In a prospective cohort study enrolling 150 patients, Chi
et al. [47?] determined the incidence and duration of
hypotension and hypoxia in the prehospital setting in
patients with potentially survivable brain injuries. In
addition, the association of these secondary insults with
mortality and disability at hospital discharge was
examined. The authors concluded that 40% of patients
with TBI sustained a secondary insult in the prehospital
setting. This led to a greater degree of disability at dis-
charge and required longer hospital stay compared
with those without secondary insults. The presence of
prehospital hypoxia significantly increased the odds
224
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of mortality after TBI, highlighting the necessity for
adequate oxygenation and hemodynamic treatment pro-
vided by a well trained emergency physician.
Recently, prehospital on-scene times and the relationship
between length of on-scene time and mortality were
comparedin patientstreated by a nurse-staffed EMS with
those treated by a combination of EMS and physician-
staffed HEMS. Retrospective analysis of 1457 trauma
patients revealed that combined EMS/HEMS assistance
at an injury scene was associated with longer on-scene
times, but had no influence on mortality [48]. Clinically
irrelevantprolongationofthemedianon-scenetimewhen
an anaesthesiologist is present was also reported by Hoyer
et al. [49].
Contradictory data also exist. For blunt trauma, a retro-
spective study including 81 patients [50?] suggested
that while physicians treated patients more aggressively,
withoutdelayinghospitalarrival,abeneficialeffectofthis
aggressive treatment could not be seen in immediate
physiological parameters or later health-related quality
of life.
In trauma care, manual skills (e.g. airway management,
invasive procedures) as well as detailed understanding of
physiology and pharmacology of the respiratory, cardiac
and nervous system are of critical importance. The
anaesthesiologists, because of their training and experi-
ence, therefore seem most suitable for the prehospital
management of critically injured patients.
Cardiac disorders
The number of emergency calls for medical conditions
such as myocardial infarction, respiratory insufficiency or
CPR is continuously increasing [51]. While treatment
ofcardiacarrestisstraightforwardandoftenfollowsguide-
lines [11],myocardial ischemiaor respiratoryinsufficiency
(e.g. due to left ventricular decompensation) requires
profound medical knowledge and expertise in terms of
correct differential diagnosis and adequate pharmacologi-
cal therapy.
Early data from 2003 by Fischer and coworkers [52] com-
pared a paramedic-based EMS in the UK with an emer-
gencyphysician-basedEMSinGermany.Figure1showsa
significantlybetteroutcomeforpatientswithcardiacarrest
undergoing CPR under an emergency physician-based
EMS. These data support the results from Bottiger et al.
[53] proposing higher survival rates for out-of-hospital
cardiac arrest treated by an emergency physician-based
EMS compared with a paramedic-based EMS.
Estneret al.[54] comparedtheoutcomeaftercardiacarrest
depending on the person who initiated the resuscitation
attempt (physician, emergency medical technician or
bystander). Out of 412 patients with cardiac arrest, the
cerebral performance score at hospital discharge of the
survivors was significantly better for those initially resus-
citated by emergency physicians (14.5%) compared with
paramedics (2.8%) or bystanders (9.3%), although para-
medics arrived a mean of 3min earlier on the scene than
the emergency physicians. Despite these results, the
authors concluded that an emergency physician-based
EMS was not identified as an independent factor of
improved survival.
Acute myocardial ischemia urgently requires correct
diagnosis because adequate therapy has to be initiated
as soon as possible [55–57]. Many efforts are made to
reduce the ‘door-to-needle time’ and therapy [58,59].
Encouraging results have been gained for a paramedic-
basedEMSusinga12-leadECGwithautomateddiagnosis
ortelemetriccommunicationwithanin-hospitalphysician
in order to verify diagnosis at an early stage [59,60]. We
presume, however, that theses devices and the required
infrastructure will only be available in a few systems.
Furthermore, a physician usually has to be contacted by
telemetry and by direct communication to report the
patient’s medical history as well as criteria for possible
fibrinolytic therapy [60]. This may be time delaying and
utilizes in-hospital resources.
In summary, patients with cardiac arrest can benefit from
an emergency physician-based EMS. Great efforts, like
Paramedic versus emergency physician Timmermann et al.
225
Figure 1 Comparison of two different emergency medical
service (EMS) systems: survival after cardiac arrest
*
*
*
*
45.2
50
40
30
Percentage
20
10
0
40.4
29.4
16.4
ROSC
Admission
24 h
Discharge
10.7
6.04
14.7
3.99
?P<0.01, x2-test; ROSC, return of spontaneous circulation at the
scene; admission, survival at the time of admission to the hospital;
24h, survival after 24h; discharge, survival and discharge from hospital.
Data from Fischer et al. [52].
Emergency physicians: Bonn, North.
Paramedics: Birmingham, Coventry and West Midlands.

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the establishment of a telemetry system, have to be made
to initiate adequate therapy for patients suffering from
severe cardiac disorders, such as myocardial infarction,
when relying on a paramedic-based EMS.
Conclusion
Although there are no convincing level I studies showing
that an emergency physician-based EMS leads to a
decrease in overall mortality or morbidity of prehospital-
treated patients [59], there is some evidence supporting
this system for the critically ill patient. For those patients
requiring advanced airway management or other invasive
procedures, well directed fluid management and pharma-
cotherapy as well as fast diagnostic-based decisions
(e.g. to select the appropriate admitting hospital), adding
an emergency physician to the EMS can increase survival
and improve outcome.
If society is willing to pay ‘a little more’ (s4.49 per
inhabitant and year, according to a study by Fischer
et al. [52]) for an EMS system consisting of well trained
emergency physicians, particularly anaesthesiologists, the
safety of our out-of-hospital patients can be improved.
These emergency physicians, however, are valuable
resources which should not be used in all cases. The
importance of a well structured and censoring dispatching
system is important therefore to reduce the number of
unnecessary emergency physician services and to identify
those patients critically dependant on the best possible
care to improve outcome.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
?
??
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 256).
of special interest
of outstanding interest
1
??
In this multicentre trial, trauma patient outcome was compared within and between
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226
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