Objective To assess the impact of on‐scene treatment by an experienced critical care physician on prehospital resuscitation, the initial hospital phase and early survival of patients with major blunt trauma. Design, setting and participants (i) Historical cohort of patients with trauma treated on scene by a helicopter emergency medical service (HEMS), 1986–1994, comparing medical and paramedical treatment and outcomes. (ii) Comparison of a subgroup of 77 patients (injury severity score [ISS] ≥ 15) treated by the air medical team (AMT) with (a) an ISS‐matched group of 308 patients treated by ground paramedics (GPMs) and (b) the Major Trauma Outcome Study cohort. Main outcome measures Procedural requirements assessed by the Therapeutic Intervention Scoring System (TISS), comparing resuscitation by medical and ambulance personnel; and observed versus expected mortality. Results (i) Of 445 patients treated on scene, 270 (61%) had sustained trauma, and 215 of these received early management by the AMT. Problems with ventilation or with volume resuscitation were encountered by general duties ambulance personnel (40%) and paramedics (60%) before arrival of the AMT. (ii) Matched patients treated by GPMs required significantly more emergency department interventions on arrival at hospital (P<0.01), and were possibly more likely to die in the first 48 hours (relative risk of death, 1.43; 95% confidence interval, 0.74–2.78) than patients treated by the AMT. Comparing the AMT‐treated patients with the Major Trauma Outcome Study cohort, 9 deaths occurred of the 18 that were predicted — a 50% reduction in predicted deaths (Z=3.38; P<0.001) — and there were 11 unexpected survivors and one unexpected death. The adjusted “W” statistic was 12.18 (ie, there were 12 more survivors per 100 patients than the Major Trauma Outcome Study prediction, after adjustment for casemix. Conclusions As part of the air medical team for response to major blunt trauma, a physician can provide significantly improved prehospital stabilisation, especially in airway and ventilatory control. Our results suggest improvement in mortality in AMT‐treated patients, probably due to the enhanced procedural capabilities of physicians, despite longer prehospital times.

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A mobile intensive care module has been developed for aeromedical transport of the critical care patient. It incorporates monitoring, ventilator, oxygen and suction, and infusion pumps. The device clips to a lightweight stretcher, over the patient at hip to knee level. This system is compatible with nearly all patient transport vehicles and allows monitors to be run from vehicle power. An assessment of the system after more than 500 transports is that it represents a significant advance over systems used previously. The advantages and disadvantages of the system compared with unmounted or vehicle-mounted equipment are discussed.

Nonrebreathing valves have become widely used in conjunction with self-inflating bags and portable ventilators. The ease of use of these devices compared with Mapleson systems and more complex ventilators has led to their use by a wide range of medical, nursing and paramedical staff. There may be an erroneous tendency to regard these systems as foolproof. Four different critical events arising from IPPV with three different models of nonrebreathing valves are described. Casel A 67-year-old male who had remained unconscious since a cerebrovascular accident two weeks before, was discovered in cardiorespiratory arrest. Cardiopulmonary resuscitation was commenced. Ventilation was with an Ambu Mk I resuscitation bag with Ruben nonrebreathing valve, initially by mask, then endotracheal tube. His pupils remained fixed and dilated despite CPR. ECG showed slow idioventricular rhythm refractory to adrenaline. At this point, additional staff arrived and reassessment revealed inadequate ventilation. Investigations disclosed that the Ambu resuscitator was misassembled. The bag was attached to the patient connection and vice versa. Each delivered breath thereby passed out the expiratory port (Figure I). The system was immediately reassembled correctly, but the patient's heart rhythm and pupils remained unchanged and resuscitation was later discontinued.

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