British Medical Journal Volume 294 Aids Counselling and Informed Consent

assess the ability of ambulance staff to achieve successful outcomes using existing training. All the patients included in the study were emergency cases-that is, either 999 calls or cases classed as an emergency by a general practitioner-and all had "hands on" assessment by ambulance and medical staff. To suggest that this prospectively performed study was a "table top theoretical exercise" is therefore far from the truth. All of the patients admitted to a resuscitation area were assessed in detail, not merely the 396 who died. The patients in resuscitation areas constituted 4-6% of all the emergency cases studied in Edinburgh and 4-3% of the Glasgow cases. These figures are similar to those reported for accident and emergency departments elsewhere in Britain. Though "abundant evidence in favour of extended ambulance skills" exists in the United States, the situation in Britain is very different. Drs Baskett and Sleet claim that "hard data" are available from centres that-have had years of experience with ambulancemen trained to paramedic level. We do not know of studies of this kind that compare basic and advanced ambulance skills, and we note that Drs Baskett and Sleet do not give references for such results. As we indicated in our paper, the benefits of advanced training will be seen mainly in patients requiring cardiopulmonary resuscitation. We do not dispute the role of early defibrillation for ventricular fibrillation, and we agree with Mr William Rutherford (28 February, p 578) that there is a strong case for concentrating resources in this area. In the absence of cardiopulmonary resuscitation by a bystander, however, the limiting factor is the tirne the ambulance service takes to respond. We refute the comment that "the journey times ... leave something to be desired." The time referred to as "journey time" in fact represents the time from the initial 999 call to arrival in hospital and not the response time of the ambulance service. We in no way denigrated the fact that "only 54" lives might have been saved; this figure represented the maximum possible benefit, and to suggest that over 2500 lives could be saved in Britain every year is an inappropriate interpretation ofour results. As the authors indicate, we took no account of the effect of extended training on morbidity. We would be delighted to hear of a scientific and reproducible assessment for morbidity in patients before they reach hospital.