Bernie Commins talks to Dr David Menzies, who heads up Wicklow Rapid Response, about the importance of a specialist pre-hospital emergency care service in rural Ireland.
In trying to understand the role and significance of Wicklow Rapid Response (WWRR), the comment, ‘we bring the hospital to the patient’ provides great clarity. This advanced, pre-hospital, emergency service, operating on a purely voluntary basis, can mean the difference between life and death in certain scenarios – and in certain geographical locations across Co Wicklow. “We operate with, and complement, the National Ambulance Service (NAS). We are tasked by them to respond to calls they feel would be appropriate for us,” Dr Menzies tells Irish Farmers Monthly. “Largely, as the doctor, I provide the care, but a number of paramedics and advanced paramedics also volunteer with WWRR and respond when they are off duty,” he says. Dr Menzies and the official WWRR vehicle are declared assets of the NAS, and work with all frontline emergency services, when needed. The aim is to put the right people with the right skills in the right place at the right time.
“WWRR might be the closest resource available at the time, particularly as you go south into Wicklow, it becomes quite rural quite quickly. “And, even if we are not closest at the time, if a patient needs a higher level of care than might be provided by the NAS, then, if I can get to the scene to help out, that is important,” he explains. This is key. The rurality of much of Wicklow demands the kind of specialist service offered by WWRR, which provides an ‘extra layer of care’, says Dr Menzies. Cardiac arrest, head injuries, major trauma, agricultural injuries, entrapment, seizures and brain haemorrhages are just some examples of the kinds of emergency situations that WWRR responds to. “Sometimes, the patient is so sick that you wish they were in hospital an hour ago, but that may not be possible because of where they. So, we bring the hospital to the patient,” says Dr Menzies. And that patient, he says, is not your typical patient. “These are the exceptional patients who really need to be in a resuscitation room or intensive care unit or, sometimes, even in surgery. “So, the types of things that we do that are currently beyond the scope of practice of the advanced paramedic, include delivering a general anaesthetic, for example, to someone who has a head injury, or who has got a blocked airway. Essentially, putting that person on a life-support machine allows us to stabilise them, to ensure they are getting oxygen and, then, allows us to package them and get them straight to the hospital for a computed tomography (CT) scan. “We would also respond to situations where a patient has been involved in an industrial accident, for example. Perhaps they are trapped, perhaps there is a limb caught in a machine. We can give that patient a level of sedation that will keep them comfortable and allow us to free them, something currently not within the scope of practice of the NAS. It is about delivering an extra layer of care to patients.”
In 2017, WWRR responded to 225 callouts, treating more than 200 patients. At the request of the NAS, it responded to: 30 cardiac arrests, of which five survived to hospital discharge, with a complete recovery; 17 paediatric cases; 40 road-traffic collisions; four multiple casualty incidents; two agricultural injuries; and one stabbing. Additionally, WWRR administered nine general anaesthetics, inducing a medical coma to place a patient on life support to protect their airway (this can happen in cases of severe head injury or where a patient is deeply unconscious); and 26 patients were discharged at the scene, avoiding the need to transport them to the emergency department (ED), freeing up ambulance resources and ED capacity.
WWRR is a community service in the purest sense of the word. It gives, but the community certainly gives back. Receiving no State funding, the service relies on fundraising efforts and donations to keep it operational and afloat. “There is a lot to be said for communities looking after themselves,” says Dr Menzies. “When people fundraise for WWRR, they are invested in it and that is really important – it is not just a handout.” Understandably, support for WWRR is strong. “Our costs are mainly associated with the vehicle, the equipment and the medication. Our biggest cost is the Rapid Response vehicle, which allows us to carry the kit and get to the scene quickly. “We have been very fortunate in that Sinnott Autos in Wicklow Town has sponsored that vehicle for us, no strings attached, for the last three years, for which we are very grateful. After that, insurance and equipment would be costly. “Medication is an ongoing cost and it depends on the amount of work that we do. We are not talking about huge money – although it can be tough to raise – but we would probably be in a very steady state with €40-50,000 per year,” says Dr Menzies. WWRR is currently fundraising to replace its defibrillator, which costs in the region of €20,000.
On average, WWRR responds to four callouts per week. Although based in Co Wicklow for the most part, there are no boundaries to the dissemination of this level of critical care, if called upon, and if feasible. “Geographically, where we are, we are able to service our immediate area. In some cases, it is worth travelling that bit further. I, and the other doctors involved in Rapid Response in other areas, try to be available as much as possible. Even if we are not in our usual area, if we are able to respond, and we have the car with us, we can be tasked to anywhere in the country. “For example, if there has been a car crash, and someone is trapped, it might be an hour or two before the Fire Service extricates them. Sometimes, it is worth our while travelling to the scene to be there when they get that patient out, and to be able to help at that point.”
In his day job, Dr Menzies works as a consultant in emergency medicine at St Vincent’s University Hospital, Dublin. While the nature of WWRR’s work is challenging, but very rewarding, knowing when to take a breather is very important, particularly with such a full-on full-time job. “It is something that is professionally satisfying and you get to see fairly instant results a lot of the time. But the potential for this work is endless, you could be responding all the time and it is important to limit that. We are all guilty at times of doing too much and there is a need to switch off, to rebalance, and not to feel that you have to respond to everything.”
The nature of the care provided by WWRR sees Dr Menzies and the team encounter some potentially distressing emergency cases. How does he deal with the traumatic themes that can dominate? “Over the years, you learn to manage a lot of things which are distressing, and with experience, you get a little better at dealing with these things. There is stress management support in place if we need it, and we tend to look out for each other as well, by picking up the phone to others involved in the service. There aren’t many people who understand exactly what it is like, so it's good to bounce things off someone who is in that same headspace. “What you try to do is stay removed from it. Even though you are going to a call because you are passionate about what you are doing and you believe that you can make a difference, when you get there you have to just view it as a job and you have to be quite clinical about it. It can be difficult, because of the community-based nature of the work, to be completely removed from it but, for me, I try to divorce the two. Although you see things that are upsetting – not all the time, however – you have to just park it, it is not personally upsetting unless I actually know the person. There are very few that would get under my skin in that way.”
The positive outcomes are what sustains him, he says. “Any good outcome is when someone survives, who probably wouldn’t have if the service wasn’t available. It is hard to say what is the one intervention that has led to that survival, and often it is a team effort of the medical chain joining up together. But, if someone has had a cardiac arrest and you are first on the scene and you defibrillate that person and their heart rhythm returns to normal, there is very little, professionally, that is more obvious than that, where you have made a difference. You don’t do this for the personal satisfaction, but it does help to sustain you.” If you would like to help WWRR achieve its fundraising target for a new lifesaving defibrillator, you can donate on www.wwrr.ie/donate