This chapter looks through the earliest establishment of immediate care, from historical records and the beginnings of some of the longest running pre-hospital services, especially those in the UK. It outlines an understanding of the foundations from which the advances in technology and clinical practice for modern pre-hospital emergency medicine are built. It outlines trauma care, and the evolution of treatments, equipment, and resources. It examines each facet of immediate care to encompass the range of triage and dispatch, lifesaving interventions, medicines, cardiac arrest management, and training and non-technical skills. Also examined are the potential developments in the equipment and strategies for resuscitation, along with aspects of what may be on the horizon for research and service development in the near future. It provides the most up-to-date overview of immediate care, which forms a vitally important component of each trauma patient’s journey from injury to recovery.

This chapter explores the moral dimensions of work in emergency and pre-hospital medicine, with an emphasis on protecting the workforce and maintaining optimal functioning of teams. It explores the concepts of moral distress and moral injury from the literature and as they apply to emergency and pre-hospital medicine, but also in the light of the COVID-19 pandemic. It includes reference to the experience of one helicopter emergency medical service (HEMS) organisation attempting to make changes to its culture.

There is increasing awareness that working within the field of pre-hospital care can have psychosocial effects on clinicians. This chapter describes a systematic review of current knowledge of the psychosocial consequences of working in pre-hospital care. A considerable amount of research has been conducted, examining in particular whether practitioners develop burnout and psychiatric disorders, especially symptoms of post-traumatic stress and post-traumatic stress disorder (PTSD), as a result of their work. However, most studies did not fully assess whether practitioners developed clinically significant symptoms.. Instead, cross-sectional surveys and self-report questionnaires were used, which considerably overestimate the incidence of these problems. Perhaps the high scores on these questionnaires indicate that practitioners who work in pre-hospital care often suffer considerable stress and distress that can be the result of daily organisational and operational hassles, a high volume of work, lack of resources, and, less than has often been thought, attending unusual and high-profile incidents.

The survival rate of 90% among wounded UK troops in Afghanistan (2004–2014) was the highest in the history of warfare. Foremost among these were severely disabled amputees, who emerged as an unexpected cohort of survivors of critical injuries. Soldiers who would have died from injuries in earlier wars were kept alive thanks to fellow soldiers highly trained in trauma medicine, paramedics who accompanied the helicopters, and the trauma care that the troops later received in hospital. We discuss our UK experience of learning from warfare, what made a difference, and how new knowledge could be used to improve physical injury and mental health related to trauma care in the UK. For the sake and sacrifice of our fallen and injured soldiers and for the benefit of our future NHS patients, an obligation rests with the NHS to allow the lessons learned from past conflicts to benefit the injured of the future.

Key Learning Points

1. 1. The principles of emergency out-of-hospital care include attending the scene and initiating immediate medical care (primary retrieval), and transferring between geographical locations, often to more specialist tertiary medical centres (secondary retrieval).

2. 2. Models of care delivery used by helicopter emergency medical services (HEMS) include both doctor–paramedic and paramedic-only response teams.

3. 3. Both land and air service delivery have associated pros and cons.

4. 4. HEMS systems are tightly governed and work to standard operating procedures.

5. 5. Pre-hospital traumatic injury management broadly follows similar principles to those of in-hospital management; however, life-threatening injuries are managed on scene, sometimes with the addition of pre-hospital blood transfusion.