PreHospital Care


Published: Friday, January 7, 2005 at 1:47 p.m.
Last Modified: Friday, January 7, 2005 at 1:47 p.m.

Some of the earliest known utilization of prehospital emergency medical care comes from the Crusades when wounded soldiers were carried in carts from the battlefield to crude field hospital tents. Historians cite the use of horse drawn field ambulances manned by medics during the Civil War. Model T Fords provided motorized ambulance service for U.S. troops in Europe in World War I. However, while the modes of transportation were improving, there was slow progress in the quality of medical care provided in the prehospital setting.

In 1965, the U.S. addressed the state of emergency medical transportation and care in the National Academy of Sciences/National Research Council report: "Accidental Death & Disability: The Neglected Disease of Modern Society." The report was a stern indictment of the lack of attention to the issue of emergency medical services (EMS). It concluded that the U.S. lacked uniform and adequate laws and standards covering EMS. It was further stated that ambulances and equipment were poorly designed and of poor quality, as were the communication systems between these vehicles and their hospitals. The report was especially critical of the lack of training for EMS personnel and of the fact that most physicians responding to emergency rooms had no training in emergency care.

This report led to the National Traffic and Motor Vehicle Safety Act of 1966, which authorized the Federal Department of Transportation to promulgate minimum standards for emergency care and tied Federal highway funds to compliance with these standards. The first comprehensive textbook for EMS training was published by The American Academy of Orthopaedic Surgeons in 1967. Emergency medical care advanced rapidly from this point. (A chronology of major events is available at the Florida Department of Health website)

"LOAD AND GO" OR "STAY AND PLAY"

Modern prehospital care is a balance between the benefit of intervention in the field and the importance of rapid transport to a care facility. In trauma cases, the concept of the "golden hour" for the time between injury and treatment is the benchmark for trauma and treatment protocols. Cardiac and stroke victims more often survive, with fewer deficits, when they receive specialized hospital-based care within three hours of the event. However, there are drug interventions that are most effective when begun immediately, even if this means in the field. Likewise, specialized equipment is proven to save lives when used by paramedics on site; thus the struggle between the "load and go" and the "stay and play" advocates.

This controversy is at the center of the debate still raging over the death of Great Britain's Princess Diana. Some experts assert that her death from a rupture in the left pulmonary vein of her heart could have been prevented if it there had not been a delay of almost two hours in transporting the Princess to a medical facility in Paris. The French model for trauma care provides for extensive evaluation and treatment in the field. But some medical experts reviewing this case have stated that, with injuries of this great severity, patients can only survive when there is surgical intervention as soon as possible. They argue that fewer interventions should have been attempted at the site of the crash and that Diana should have been transported to a hospital much more quickly. (See "Death of a Princess" at

http://www.anes.saga-med.ac.jp/ispub/journals/IJRDM/Vol1N2/princess.htm)

In Alachua County, emergency personnel are trained to be on scene at an event for less than ten minutes. Cliff Chapman, Assistant Chief, Special Services, Alachua County Fire and Rescue, says, "We do a rapid trauma survey: Do you have an airway, are you moving air, do you have a pulse?" Then we do head-to-toe survey - ideally assessed after loading in the ambulance." This should take no longer than two minutes."

Ideal situations, in which emergency personnel can meet that ten-minute goal, do not always exist in medical emergencies in the field. Victims of trauma may be trapped in vehicles or still involved in violent situations. Bystanders, unfriendly dogs, inclement weather, and limited resources can all affect the time of transport for trauma, cardiac, or stroke victims.

The use of helicopters for transport of traumatically injured patients has significantly decreased prehospital time. Helicopters began to be used for medical rescue during World War II for combat rescue missions. During the Korean War, the helicopters and crews of the U.S. Air Force 3rd Air Rescue Squadron was credited with saving thousands of American lives. The war in Vietnam necessitated continued improvement in helicopter technology and battlefield medical care.

In our largely rural trauma region, the use of helicopters is critical. Patients come to the Shands at UF Trauma Center from as far north as the Florida/Georgia line in Hamilton County, to Citrus County in the south. The "Golden Hour" for these patients can only be met with air transport.

ShandsCair at the University of Florida was established in 1981 and currently averages 149 missions per month. They utilize helicopters, a fixed wing jet aircraft, and ambulances in the transportation of patients. The most recent addition to their helicopters was an Agusta 109 Power. Jim Howard, the coordinator of ShandsCair, states that this new helicopter is faster and more energy-efficient. "It will allow us to effectively do our job of transporting trauma patients quickly during their most critical hour of medical need," said Howard. ShandsCair personnel include flight nurses, paramedics, neonatal flight nurses, respiratory therapists, EMS pilots, communication specialists, and drivers. ShandsCair interfaces with Shands Jacksonville and other medical air transport agencies to coordinate the coverage of emergency care in North Florida.

IMPORTANCE OF TRIAGE

Careful triage of trauma patients in the field is critical to the outcome for that patient. This allows not only for appropriate treatment on site and en route, but allows time for the most effective team and equipment to be prepared at the receiving hospital. This said, a 50% over triage rate (transporting borderline trauma to trauma centers) might be necessary to avoid the life threatening possibility of under triage (misdiagnosing cases of true trauma) - according to American College of Surgeons Committee on Trauma.

Trauma alert criteria assist emergency and hospital personnel in assessing patients' care needs. Blood pressure, airway stability, state of consciousness, nature of wounds, and the mechanism of injury are among the criteria assessed for a trauma patient.

Peter Gianas, M.D., emergency physician Medical Director of Alachua, Bradford, Clay and Union counties, and Director of the EMS Program at Santa Fe Community College; and the ED Director of Shands at Starke; says that evidence-based research has resulted in good progress in the evaluation and treatment of cardiac patients. "We are doing 12-lead EKGs out in the field now to help our personnel determine what immediate action is needed for the patient. It can help determine where best to take the patient and how to treat him in route." says Gianas. Nitroglycerine, morphine, and ace inhibitors are now administered in the field. But other interventions such as the delivery of thrombolytics, steroids, and IV fluids in the field are controversial, with some arguing that use of these treatments in the prehospital setting can do more harm than good.

LIFESAVING ADVANCES

Locally, emergency care facilities have evolved from the basic emergency room to state of the art emergency departments and a Level One Trauma Center. Transportation to these centers is accomplished in ambulances and helicopters equipped to evaluate and sustain critically ill and critically injured patients. Dr. Gianas points to major advances in prehospital care during the past decade that have greatly benefited patients requiring emergency services.

Those advances include:

Automatic external defibrillators (AEDs)

Better methods for airway management - i.e., capnography to show C02 levels

Revealing failed or dislodged tubes

Oxygen saturation monitors for oxygen level and hemoglobin

Drugs for cardiac and stroke events from evidence-based research

Digital cameras - can photograph patient/vehicle and transmit to ER

After more than 27 years of experience in the EMS field, Cliff Chapman feels that the greatest advances in EMS care have come in better training. Basic Trauma Life Support (BTLS) and PreHospital Trauma Life Support (PHTLS) courses have led to even more extensive paramedic training. Training for Basic Life Support (EMT) is 250 hours with a prerequisite of an 8-hour CPR class and 40 hour 1st responder class. Additional training to attain the Advanced Life Support, or paramedic level, is 1100 hours with the prerequisite of EMT certification and Anatomy & Physiology, Medical Terminology, Human Medical Science, and a basic computer class. For employment with Alachua County Fire and Rescue, the requirements include an Emergency Vehicle Operations Course (16 hours), BTLS or PHTLS (16 hours), and Advanced Cardiac Life Support (16 hours). Upon employment, candidates must pass a Safety Officer Class, an 8-hour Incident Command Class, and an 8-hour Terrorism Awareness Class.

Chapman reminisces that current equipment is much more portable than when he began his career. Early defibrillators weighed 65 pounds. Now the multifunction Life Pak 12, which includes a defibrillator, weighs about 17 pounds. He credits better cervical collars and better hydraulic removal equipment - such as the "jaws of life," with enabling emergency personnel to work more efficiently and effectively. Also of great assistance is equipment such as oxygen-powered ventilators and automatic vital signals monitors.

PREHOSPITAL CARE WITHIN A TRAUMA SYSTEM

Of utmost importance to the outcomes for patients and the success of a trauma system is the teamwork between the prehospital emergency personnel in the field and the receiving medical teams at hospitals. It is vital that emergency personnel strive for maximum communication and integration with the hospital emergency department.

Coordination of our trauma system is overseen by the North Central Florida Trauma Agency. The agency membership includes the following counties: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hernando, Lafayette, Levy, Marion, and Suwannee. The Agency serves to standardize trauma response and transport protocols, and to monitor trauma outcomes. With the opening of the new Shands at UF Level One Trauma Center, the coordination of all trauma service providers - urban and rural - becomes even more critical in order for the trauma system to operate at maximum efficiency.

THE FUTURE OF PREHOSPITAL CARE

Advances in drugs and improvement in equipment will continue to improve prehospital care. The widespread utilization of an oxygenated blood substitute is on the horizon, as is the use of a rapid blood coagulant. There is hope or the approval of intravascular fluids that maintain vascular integrity. The use of ultrasound in the field can greatly enhance the accuracy of patient injury evaluation. And telemedicine will provide a great advantage in the communication of the prehospital providers with emergency physicians.

Prehospital care is an integral part of saving lives. The training and equipment of emergency personnel providing these services has seen great improvement in the last decade, with rapidly accelerating advances on the way. But good prehospital care still depends on individuals willing to go into difficult situations and provide care with limited resources to save lives. Dr. Gianas puts this best: "People need to understand the challenges faced by paramedics treating a patient who is unconscious and upside down in a dark car that is leaking gas - at 3 a.m. in the pouring rain, at the same time they are dealing with a hysterical family member. It takes committed people, good resources, and a supportive team to do this job."

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