Introduction

The purpose of this document is to provide clear expectations of a BrisDoc team member if they should come across a road traffic collision (RTC), when travelling in a branded BrisDoc vehicle, at which first aid might be required as they could be the first clinician/person on the scene.

BrisDoc has no expectation that an on-duty clinician should stop and help:

1. as this may impact on timely service delivery to, and therefore clinical safety of, BrisDoc patients waiting for their home visit,
2. because BrisDoc is not an emergency service and the vehicles are not equipped to manage RTCs and casualties, and
3. because our training expectation of our staff is in basic life support only.

BrisDoc has no expectation that a Driver or Clinician, using a BrisDoc vehicle for their daytime or non-clinical duties, should feel obliged to stop at a RTC for reasons b and c above.

Definitions

GMC guidelines state that “You must offer help if emergencies arise in clinical settings or in the community, taking account of your own safety, your competence and the availability of other options for care”

A Good Samaritan act is where medical assistance is given in a bona fide medical emergency, which a healthcare professional may happen upon in a personal rather than professional situation. While there is no legal duty to assist (in UK law), clinicians have an ethical and a professional duty to help.

The Social Action, Responsibility and Heroism Act 2015 came into force in England and Wales. It sets out some additional factors that a court must consider when assessing a negligence claim or alleged breach of duty.

These factors essentially outline a new legal test that is especially pertinent in the case of a Good Samaritan act. They are:

• Social action – whether the alleged negligence or breach of statutory duty occurred when the person was acting for the benefit of society or any of its members.
• Responsibility – whether the person, in carrying out the activity in the course of which the alleged negligence or breach of statutory duty occurred, demonstrated a predominantly responsible approach towards protecting the safety or other interests of others.
• Heroism – whether the alleged negligence or breach of statutory duty occurred when the person was acting heroically by intervening in an emergency to assist an individual in danger.

As clinicians in such a situation, you can only do the best you can in the circumstances with the resources available, working within the limitations of your competence.

Vicarious liability

In the United Kingdom there is no legal obligation for anyone to stop and help at a road accident. However, ethical guidance is provided in the GMC’s Handbook “Good Medical Practice” which states: ‘In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence and the availability of other options for care’.

If a clinician stops, they are legally responsible for their actions and omissions. The “Good Samaritan” is not covered by the Clinical Negligence Scheme for General Practice (CNSGP) or BrisDoc insurance policies but the main defence unions include in their basic policies medico-legal cover for accidents. It is recognised by most authorities that a doctor willing to stop is acting out of beneficence for the casualties and, in this country, legal repercussions are fortunately rare.

The CNSGP covers NHS primary care provided to patients whose care services come under an NHS contract i.e. GMS/PMS/AMPS or Standard Contract including schedule 2L. None of BrisDoc’s contracts include the provision of a first aid service to the general public at the scene of an RTC.

Offering help

In exceptional circumstances, If you decide to stop at a RTC you must inform the Shift Manager.  Exceptional circumstances would be very rare, for instance it could be that you are first on scene.

When an emergency arises, it is vital to take into account your safety – do not put yourself or your colleagues at risk.

• Carefully consider your own competence and expertise.
• Work within the confines of your expertise and training, except in a critical emergency
• Delegate and communicate appropriately.

If in exceptional circumstances you decide to stop at a RTC because you are the first person/s on the scene, you should develop a clear and logical plan of your approach to providing first aid. What is the likely scale of injury in terms of numbers and severity?

• Ensure that the emergency services have been called.

• Is the road safe or is oncoming traffic a further threat?
• Is there fire, chemical spillage or risk from ruptured fuel tanks?
• Is there chaos or order?
• Have an aura of calm, competence and authority. Do not be afraid to organise people.
• Ask the Driver to liaise with the Shift Manager to keep the Control Room informed of your plan so BrisDoc patients’ needs can be managed. If alone, see below

If, as a lone Driver (or Clinician), you decide to stop at a RTC you must make it clear that a). you are not an emergency service, b). the BrisDoc vehicle is not equipped as one and in daytime carries no equipment or drugs and c). you can offer basic life support only or, if clinical, basic triafe..

Safety

Accident scenes can be dangerous places and the dangers come in several ways.

Protect yourself :

• One risk is that oncoming traffic may plough into those there. It may be best to park obliquely behind the incident to fend off oncoming traffic.
• Use the car’s green and hazard lights.
• If you have access to a high visibility jacket, wear it.
• Protect yourself: cover exposed skin, wear gloves if available.
• Unless people are trapped or unable to move, get them off the road and out of the way of further harm.
• Has anyone called the emergency services? If not, make a very brief survey of the scene to be able to give them more information but do not delay getting help. If the emergency services have been called, who has been called? The ambulance service is obvious. However, the police may be required to make the area safe and the fire service may be required if there is a need to extract victims from vehicles, tackle fires or deal with other hazards like chemical spillage.
• Most RTCs do not result in fire but a “no-smoking rule” should still be enforced. Unleaded petrol is far more inflammable than Diesel as Diesel is difficult to burn without a wick. Liquid petroleum gas (LPG) is potentially explosive. If an engine is still running, switch off the ignition.

Triage

This is a matter of putting demands in order of priority.

• Immediate – e.g. aortic deceleration injury, severe head injury – e.g. hypoxia and hypovolaemia
• Delayed – e.g. sepsis / multiple organ failure

Triage is used to divide the injured into 4 colour-coded groups:

• Immediate – colour code RED: will die in a few minutes without treatment, e.g. obstructed airway, tension pneumothorax
• Urgent – colour code YELLOW: may die in an hour or two without treatment, e.g. hypovolaemia
• Delayed – colour code GREEN: can wait, e.g. minor fractures
• Dead – colour code WHITE

Triage is a dynamic process. If someone deteriorates suddenly this will change the assessment. If you are present, not as a fully equipped expert in trauma and emergency but as a passing GP using your first aid skills and knowledge, remember your limitations. Your assessment may still be very helpful in terms of helping the ambulance crews decide who needs urgent removal to hospital, who can wait and who does not need the services of an emergency department.

Remember: English law does not currently require a doctor to confirm death has occurred or that “life is extinct”. Apply your skills to the living.

Assessment

• Talk to the patient or patients if conscious. Come over as competent and reassuring as they may be very anxious.
• Ask where it hurts to get an idea of injuries.
• Read the wreckage – relate the damage of the vehicle to potential injuries

• Steering wheel deformed = chest injury
• Dashboard intrusion = patella/femur fracture ± posterior dislocation of the hip
• Bodies are softer than metal: major bodywork distortion = major injury

• Assess the degree of pain.
• Fractures and abdominal trauma may produce considerable concealed haemorrhage. Check for signs of hypovolaemic shock.
• Identify the time-critical patient – some will die unless rapidly removed from the vehicle, at whatever cost. Entrapped patients should be removed in under half an hour.
• When the patient is unconscious remember the ABC of airway, breathing, circulation. If there is sudden deterioration, check ABC again for a possible cause.
• Whether the person is conscious or not beware of neck injuries and spinal cord compression.
• Is everyone accounted for? Sometimes people can be thrown well clear of an accident and may be lying dead or severely injured a little way away and, especially at night, they may have been missed.

Treatment

• What you can do will depend not just on personal skills but on what is available to you. You may have just your doctor’s bag or not even that. You may have the IUC service car kit or a well-equipped ambulance may be on the scene.
• Paramedics have been well trained and, if it is many years since you last set up an intravenous infusion, then they will probably do it rather better than you. Let them do what they do well.
• Consider intervention beyond basic triage only if it is time-critical and/or ambulance is likely to be delayed
• Be careful about extracting those trapped in vehicles before the fire service arrives. They are the experts with the equipment and injudicious extraction can cause further injury. There are times when urgency has to take precedence over caution.
• Clinician should not “ok” IV opiates.  Paramedics should manage analgesia.
• If you can help to stabilise a patient’s condition before transfer to hospital this is usually beneficial but there is a balance to be made between achieving what you can at the site and delay in reaching greater expertise and resources. If there is any doubt at all about cervical spine fracture, support the neck.

The information in sections 4.1-4.4 is taken from  https://patient.info/doctor/road-accidents-attending-as-a-passing-doctor

Debrief and accident raising

• After the event a debrief should be held as soon as possible.
• There should be a low threshold for raising an incident so that the event can be captured and any learning discerned

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