EMERGENCY MEDICAL SERVICE SYSTEM, A STEP IN RESCUE

                                                                                

UGWUBUJO CALEB (RN, DEAN,)

Department of Accident and Emergency unit

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Emergency medical service system (EMSS) is a “coordinated community based system, designed to provide comprehensive emergency rescue, resuscitation, transportation and medical care from the first response to the completion of certain specific emergency procedures on the scene of the incidence and en-route to the hospital for the acutely ill or injured patient”.(Greenfield,1997)

                                                            AIMS OF EMSS

1-    To rescue victims of accident

2-    To save life thus reducing mortality rate

3-    To prevent irreparable and irreversible damage

4-    To respond to distress call promptly.

 History of Emergency Medical Services

                 EARLY EMSS                                        

The history of EMSS extends back to the biblical story of the Good Samaritan. Account of ancient wars reveals organized methods of transportation and care of the sick and injured.

In 1500 B.C, the development of EMS has been based on tradition and, to some extent, on scientific knowledge. Its roots are deep in history. For example, the Good Samaritan bound the injured traveler’s wounds with oil and wine at the side of the road, and evidence of treatment protocols exist.

1797 - Although the Romans and Greeks used chariots to remove injured soldiers from the battlefield, most credit Baron Dominique-Jean Larry, chief physician in Napoleon’s army, with institution of the first pre-hospital system designed to triage and transports the injured from the field to aid stations.

1860’s - Flying ambulances (dressing stations) were made to effect transport, and protocols dictated much of the treatment. In the United States, organized field care and transport of the injured began after the first year of the Civil War, when neglect of the wounded had been abysmal. 

1922 - The first volunteer rescue squads organized in Roanoke, Virginia, and along the New Jersey coast. Gradually, especially during and after World War II, hospitals and physicians faded from pre-hospital practice, yielding in urban areas to centrally coordinated programs. These were often controlled by the municipal hospital or fire department, whose use of “inhalators” was met with widespread public acceptance. Sporadically, funeral home hearses, which had been the common mode of transport, were being replaced by fire department, rescue squad and private ambulances.

1960 - Cardiopulmonary resuscitation (CPR) was shown to be efficacious. Shortly thereafter, model EMS programs were developed based on successes in Belfast, where hospital-based mobile coronary care unit ambulances were being used to treat pre-hospital cardiac patients. American systems relied on fire department personnel trained in the techniques of cardiac resuscitation. These new modernized EMS systems spurred success stories from cities such as Columbus, Los Angeles, Seattle, and Miami.

 

 MODERN EMSS IN THE U.S.

Demonstration of the effectiveness of mouth-to- mouth ventilation in 1958 and closed cardiac massage in 1960 led to the realization that rapid response of trained community members to cardiac emergencies could help improve outcomes. The introduction of CPR provided the foundation on which the concepts of advanced cardiac life support (ACLS), and subsequently EMS systems, could be built. The result has been EMS systems designed to enhance the “chain of survival”.

In 1966 “The white paper, Accidental Death and Disability: The Neglected Disease of Modern Society” prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences- National Research Council, provided great impetus for attention to be turned to the development of EMS. This document pointed out that the American health care system was prepared to address an injury epidemic that was the leading cause of death among persons between the ages of 1 and 37 years. It noted that, in most cases, ambulances were inappropriately designed, ill-equipped, and staffed with inadequately trained personnel; and that at least 50% of the nation’s ambulance services were being provided by 12,000 morticians.

The paper made recommendations for ultimately improving care for injured victims; related directly to out-of-facility EMS. They were:

Ø  Extension of basic and advanced first aid training to greater numbers of the lay public;

Ø  Preparation of nationally acceptable texts, training aids, and courses of instruction for rescue squad personnel, policemen, firemen, and ambulance attendants;

Ø  Implementation of recent traffic safety legislation to ensure completely adequate standards for ambulance design and construction, for ambulance equipment and supplies, and for the qualifications and supervision of ambulance personnel;

Ø  Adoption at the state level of general policies and regulations pertaining to ambulance services;

Ø  Adoption at district, country, and municipal levels of ways and means of providing ambulance services applicable to the conditions of the locality, control and surveillance of ambulance services, and coordination of ambulance services with health departments, hospitals, traffic authorities, and communication

Ø  Initiation of pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas and in regions where many communities lack hospital facilities adequate to care for seriously injured persons;

Ø  Delineation of radio frequency channels and of equipment suitable to provide voice communication between ambulances, emergency department, and other health-related

Ø  Pilot studies across the nation for evaluation of models of radio and telephone installations to ensure effectiveness of communication facilities;

Ø  Day to day use of voice communication facilities by the agencies serving emergency medical needs; and

Ø  Active exploration of the feasibility of designating a single nationwide telephone number to summon an ambulance.

In the same year, the Highway Safety Act of 1966 which established and the Department of Transportation (DOT) was passed. The DOT was given authority to improve EMS, including program implementation and development of standards for provider training. States were required to develop regional EMS systems, and costs of these systems were funded by the Highway Safety Program. Over the next 12 years the DOT contributed more than $142 million for EMS system development.

In 1969, paramedic education began, but training focused heavily on cardiac care and cardiac arrest resuscitation, almost to the exclusion of other problems.

In 1972, the Department of Health, Education, and Welfare allocated $16 million to EMS demonstration programs in five states.

In 1978 the law established that there should be 15 components of the EMS systems. They are commonly referred to as:

Ø  Manpower

Ø  Training;

Ø   Communications

Ø  Transportation

Ø  Facilities

Ø  Critical care units

Ø  Public safety agencies

Ø  Consumer participation

Ø  Access to care

Ø  Patient transfer

Ø  Coordinated patient record keeping

Ø  Public information and education

Ø  Review and evaluation

Ø  Disaster plan

Ø  Mutual aid

.

In 1972 the development of emergency medicine as a medical specialty was instituted and it has parallel with that of EMS. The first residency program to train new physicians exclusively for the practice of emergency medicine was established at the University of Cincinnati. There were 32 such programs, and there are currently 112 accredited emergency medicine residency programs graduating in excess of 800 emergency medicine physicians each year. Although emergency physicians often fulfill the medical direction needs of EMS systems, other groups of physicians continue to significantly and positively influence EMS. They include pediatricians, cardiologists, surgeons, family practitioners, nurses and others.

Efforts to improve EMS care for specific groups of patients have included development and successful implementation of standardized courses as components of EMS curricula or to supplement personnel education in focused areas. These include cardiac, pediatric, and trauma life support courses.

The American Heart Association, through adoption and promotion of the “Chain of Survival” concept, has provided leadership to improve emergency cardiac care. It continues to explore ways to increase survival from cardiac emergencies. 

 Development of trauma care systems became a renewed focus of attention with passage of the Trauma Care Systems Planning and Development Act of 1990. HRSA Division of Trauma and EMS (DTEMS) was created to administer this legislation, which supported the concept of a trauma system that addresses the needs of all injured patients and matches them to available resources. The act encouraged the establishment of inclusive trauma systems and called for the development of a model trauma care system plan, which was completed in 1992. More inclusive trauma care better serves the population’s needs. Local EMS authorities assumed responsibility for establishing trauma systems and designating trauma centers in an effort to improve care for trauma victims. However, one survey concluded that by 1993 only five states met criteria for having a complete trauma system.

Most critically injured patients were brought to the hospital by a time consuming two way transportation process which causes delay. Even those that are transported by the ambulance were left alone to the ambulance driver who had no training in handling injured patients. In most cases the receiving hospital often lack 24hrs physician coverage and the emergency department were frequently closed at night, even those that are open often lack qualified doctors to handle emergencies. This indicates a high mortality rate of the people being involved in either road traffic accident or those who suffered acute systemic emergencies.

    According to the federal road safety corps, approximately 100,000 deaths occur every year in Nigeria due to trauma. (Half involving road traffic accidents) many of these deaths occurred within one hour of injury usually before effective medical care could be given or started. This statistical analysis shows that many lives could be saved if an efficient system of providing care to the sick and injured is available. It is obvious that such care could be given if the rescue team had knowledge of what to do first and do it at the right time such as be began an effective treatment or resuscitation before the patient reached the hospital. This approach form the basis of pre hospital care system that began to evolve in the USA and other countries, but still has not found its way fully in Nigeria.

COMPONENTS OF EMERGENCY MEDICAL SERVICE SYSTEM

The US public Law 93-154 identified the following component as essential in order for an           EMSS to be fully operational and highly effective. They are:

           1. Effective communication

2. Effective transportation

3. Adequate training

4. Adequate emergency care facility

5. Personnel

6. Education of the public

7. Finance.

1- EFFECTIVE COMMUNICATION:-Emergencies include not only medical emergencies but also fire and police emergencies. A comprehensive communication plan is essential to the community access to system dispatch. The communication system should therefore link up these areas which may function inter-dependently under the EMSS.

It is important for an emergency dial or code for national use to be easy and simple to remember, so that members of the public can utilize it to activate the system. Numbers such as 911, 222, 999 etc can be adopted for use. The emergency calls are received by the triage operator who sorts the call out in order to decide which of the services to call first. For instance, a distress call may reach the triage operator reporting a case of fire outbreak. The operator will immediately call the fire service before calling the medical team to respond to the emergency. The police are also involved in reporting and documentation of all emergencies for statistical purposes.

In the communication network telephone booths should be strategically located and easily accessible to the public and this should be free of charge. It should also link ambulance stations to enable the passage of vital information as necessary. Portable radio voice transmitters and mobile phones can be used to communicate emergencies. This service should be free to the public as this will motivate the public to call immediately there is an emergency.

2-EFFECTIVE TRANSPORTION:-This is an essential aspect of EMSS. The patient needs to be transported in relative comfort and life must be maintained while extreme precaution is taken to prevent complications. Transportation of patient in an emergency can be by road, air and water depending on the prevailing circumstances.

Varieties of ambulance includes-

·         Road ambulance

·         Heli-ambulance

·         Marine ambulance

ROAD AMBULANCE-This is the means of transporting patients to the health care facility to the hospital by road. A Police escort is sometimes required to clear the road and ensure safe arrival of the patient to the hospital. A road ambulance is ideal for journey up to 0-20km; however the advantage of road ambulance is that it can stop at any time to pick up injured patients on the way.

The only problem is that it cannot stop on its way to pick other victim and it can increase intracranial pressure and therefore is contraindicated with patient with head injury.

                                 

HELI AMBULANCE-

This is the use of a helicopter in the transportation of patients during emergencies, the heli-ambulance is equipped with basic life support and advance life support required for an ambulance. It is ideal and preferable where the distance to be covered is greater than 20km.Its advantages includes-Rapid response three(3) times faster than road, it utilizes the “golden hour”, it travels on a low plane as such there is no altitude problem.

HELI AMBULANCE

MARINE OR BOAT AMBULANCE-This is used in riverside areas. Accident or emergency cases are transported by boat ambulance to land where the road ambulance can take over.

MARINE AMBULANCE

Resuscitative components in an ambulance:

The following are essential in a typical paramedic ambulance. Air ways; endotracheal tubes, oxygen function devices mask, oral and nasal airways, normal saline, ringers lactate, needles and syringes, neck collars, splints, cardiac monitor and defibrillators, manual and electrical suction machine. Drugs like aminophyline, atropine, sodium bicarbonate, diazepam, epinephrine etc. can also be used.

MICU: This is the mobile intensive care unit. This is an advanced version of the road ambulance used for more critically ill patients. It is well stocked with drugs and equipments of advanced cardiac life devices (ACLS). In this MICU some minor surgeries can be carried out inside and some procedures like intubation.

INTERIOR OF A MICU

3-ADEQUATE TRAINING- Members of the emergency medical service system who are the care providers must be trained to meet expectations and requirements in programs that comply with regional and national standards. Training should include clinical, didactic and field components, example basic and advanced life support, cardiopulmonary resuscitation health safety and environment. Additionally, EMTs are required to receive continuing didactic and clinical education before certification. All members of the EMSS should always be sent for a course after a while to update their knowledge on recent trend in emergency treatment and care.

4-ADEQUATE EMRGENCY CARE FACILITY-There should be adequate emergency care facility in the form of well equipped accident unit, emergency department and trauma centers. This is where the patients’ are taken to after field team resuscitation. The facility should be prepared to render 24 hours a day, 7 days in a week and 52 weeks in a year care to all injured and acutely ill patients. The emergency unit should never be closed up for effective functioning of the unit. The facility should be well equipped, spaced and able to accommodate all categories of staff, patient and equipment.

5-EDUCATION OF THE PUBLIC- Public support is invaluable in constructing a successful EMS system. Involvement is required to plan a system that works for everyone. The public needs to be informed of the benefits of having a system and how to gain access to it. Public education programs are essential to inform the community on ways to access the EMS system properly. They are also aimed at preparing the lay person on the street on how to render first aid care to an accident victim. The EMS must have strong ties with many agencies inside and outside the community. Cooperation is essential with public safety agencies which are frequently the first to respond to an emergency and may provide all or part of the EMS. Mutual aid agreement should be developed with neighboring communities to provide assistance when one system is not functioning or disabled or overburdened. These arrangements ensure uninterrupted patient care in the event of natural disaster or other emergency situations.  

6-FINANCE: The emergency medical service system is a very laudable project, very important so as to attract the attention of the federal Government for the benefit of the citizens. It involves a lot of money to secure equipments, payment of the emergency crew, training of personnel etc. It is very important like all other components of the EMSS, so it should not be overlooked. This is because without adequate funding all other component will not function.EMSS is not a one man affair, it should involve the federal government, state and local government with cooperative and collaborative efforts ensure its success. At the local level the local level the community should strive to provide moral and financial support to keep the project viable and successful.

7-TRAINED PERSONNEL:  In EMSS, the type of care basically carried out are; pre-hospital and the hospital base care.

The pre-hospital care: These are care rendered to the acutely ill or injured patient/ victim outside the hospital. It involves the rescue, resuscitative and transportation of the patient to the hospital and proper handing over of the patient to the hospital base team. They are made of:

(i)                  The first response rescue team

(ii)               The first response medical team

 FIRST RESPONSE RESCUE TEAM. They are the first to arrive at the scene of an accident or illness. They consist of the police, federal road safety, fire fighters, the wild wife officers and the local citizens.

Police: The police have the responsibility to wall off the area of accident or disaster , protect life’s and property of victim from criminal around, provide escort for the ambulance carrying the patient to the hospital and also to record data for statistical purposes.

Fire fighters: The fighters control fire, prevent explosion and extricate victim trapped from steel wreckage using highly specialized cutting equipments. They also rescue victims from great height or down deep well.

Wild life control officer: The wildlife control officers rescue victims who are attacked by wide animal in the forest. The composition of the team depends on the geographical and topographical area of the place.

The federal road safety corps: They have responsibility relating to highway safety with emphasis on the prevention of road accident. They have on many occasions of mishap rescued victims of accident, transfer them to the hospital and also protect their valuables.

The divers: They are trained specially to rescue victims first before the medical team take over and resuscitate.

The local citizen: They are useful in the rescue team by virtue of the fact that they are familiar with the terrain of the environment and can therefore provide useful information and guard during rescue operation. It also provides the opportunity for the community to participate in training in other to work effectively with other team members.

FIRST RESPONSE MEDICAL TEAM:

They are the health professionals who arrive at the scene of the accident /incident and they include trained personnel such as emergency medical technician, emergency medical technician paramedics (EMTP), nurses, doctors, members of the Red Cross. They resuscitate by using BLS (basic life support) and cardiopulmonary resuscitation to establish the patient’s airway before transporting him to the hospital.

Emergency medical technician: These individual are required to undergo 6 months of training and after successful completion, they are certified by the state emergency service board. They carry simple procedure of basic life support like initiation of cardiopulmonary resuscitation, monitoring of vital signs, insertion of oral or nasal airway, bandaging and splinting of fractured limb and extrication of victims from the scene.

The emergency medical Technicians paramedics (EMTPs): This group of personnel undergoes training for eighteen months. They can carry out advanced life support. They do cardiopulmonary resuscitations and stabilize the patients before they are transferred to the hospital. They document all treatment given and the patient’s response to treatment for effective handing over to the hospital based team.

Hospital Base Team: This team provides care in an organized hospital setting starting from accident and emergency department of the hospital. The hospital based team and field team get in touch through the means of their communication facilities. Doctors, nurses and other members of the hospital based team work collaboratively to provide definitive care for the patient. It is important to note that the success of the hospital based team depends on the pre-hospital care given.

TRIAGE OPERATOR

           

ACTIVATION OF EMERGENCY MEDICAL SERVICE SYSTEM

This is a system where by the local citizens activate the Emergency Medical Service System through the   triage operator, provides information that will be further  transferred to the appropriate quarters for necessary rescue and appropriate medical intervention to the accident or incident victim.

Communication network is made easy by the dial code adopted for national, state and local levels to call on the triage operator in an emergency. The code numbers are catchy, simple and easy to remember. Examples are 999, 199, 121 etc. There is accessibility of the telephone booth and they are placed in strategic places.

The emergency call are received by the triage operator  who sorts them out in order of priority in order to know which service to call first e.g. the police, fire fighters, EMTs etc. A call to any of these specialties depends on the type of accident or emergency that occurred. As soon as information gets to the services concerned, they leave immediately to the scene of the accident to render their services.

The medical team will also be alerted. The communication system also links all ambulance and ambulance stations to enable them pass vital information as necessary. Portable radio, voice transmitters and GSM are used for the transmission of vital information.

Before the departure of either the first response team or the first medical team, the following must be ascertained.

1-The ambulance to be used for the operation must be in good order

2-All personnel must be on board before departure.

3-There must be good communication gadget to transmit information till the end of the rescue procedures.

4-The ambulance operator should have adherence to license restriction, confidence, mental fitness, physical fitness.

5-The team should certify the environment safe for them before entering it.

6-The team should have a special map book to locate or that precedes detailed direction of scene of accident.

TRIAGE                          

The word triage is derived from a French word “tier”, meaning to sort out or to make choice or place things in place of priority. It was first used by the military during World War 1, where victims were sorted and classified according to type and urgency of their condition for the purpose of determining medical treatment priorities. The military intent was to provide care to the most treatable casualties so that soldiers could quickly return to their war point.  Combat triage was guided by the adage “the best for the most with the least by the fewest” (Grossman, 2003).by this idea, critically injured patient are left without care or their care is delayed. Emergency Department (ED) use of triage system began in the early 1960s, when the demand for emergency services became so important. As the use of EDs increased and the waiting times became longer, the triage process evolved as a way of effectively separating those patients requiring immediate medical attention from those who could wait.

Advantages of triage:

-The patient is greeted by a registered nurse who establishes immediate rapport and promotes the image of the facility through positive client perception.

-Immediate assessment and documentation of patient problem are provided while certain diagnostic procedures and treatment are initiated without delays.

-Patients stress and anxiety are reduced when there is immediate contact with the nurse.

                                   CATEGORY OF TRIAGE

In order to determine the priority of the patient, triage is divided into three main categories namely;

1-EMERGENT CATEGORY: This group requires immediate medical attention because they have life, organ or limb threatening emergencies. The emergency nurse or doctor must stop everything he is doing in order to attend to this patient, especially patient with airway, breathing and circulatory compromise. Example includes severe head injury, open chest injuries, cardiac arrest, ruptured spleen etc.

2-URGENT CATEGORY: These are patients for which second priority are given. The urgent category patient requires medical attention within period of two hours otherwise he may die or have irreparable damage. Example includes cerebrovascular accident, altered level of consciousness and cases of suspected poison and drug overdose.

3-NON URGENT CATEGORY: In this case the patient has a condition that requires the attention of the emergency nurse but the condition is not life threatening. Such a patient can wait a little or be referred to general outpatient department or a private clinic. They do not require constant observation; the lowest priority is given to them. Example includes minor injuries, sprain and dead on arrival or brought in dead (DOA or BID).

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Reference

Hogan T. (1999) Hip and Femur handbook of Orthopedic emergencies, Lippincott Williams and Wilkins Philadelphia.

James O. (1997) Making a Difference - The History of Modern EMSS.

Judith Hopfer etal (2007) David’s drugs Guild for Nurses 8^th. David’s Company Philadelphia.

Ross and Wilson (2010) Anatomy and Physiology in health and illness 11^th ed. Church hill Elsevier New York.

Salimen etal (2009) Features Associated with Fractures. Church hill  Livingstone New York.

 Http//:www.aarexindia.com/fractures.

Http//:www.wikipedia.com/ femoral fracture