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Introduction to pre hospital care and in
1. Introduction to emergency
PRE-HOSPITAL &
in-hospital care
Dr Ismail Mohd Saiboon
Emergency Department HUKM
Assoc Prof Dr Ismail Mohd Saiboon
Emergency Department
UKMMC
2. What is Pre-Hospital Care?
โข Giving medical care to patients beyond the wall of
Hospital (emergency dpt.)
โข Wide range of activities
- ground ambulance service
- battlefield medicine
- medical cover of gatherings
- sports event- motor- cross, Rallies,
F-1, soccer etc
- disaster relief efforts
- first responder/ first aider
3. Pre-hospital care
โข Aim: reduce morbidity and mortality in those seriously
injured or in dangerously ill patients outside hospital
โข *39% - 47%** of pre-hospital fatalities are
preventable
โข Involve - rapid attendance (ambulance personnel)
- performed life-saving@ limb saving
(basic @ advance) procedures
- stabilized patients condition, prevent
deterioration, maximized chances of
good definitive care.
4. Immediate care
โข Provision of skilled medial help
โข At scene and
โข During transport
โข By doctors or paramedic that have receive
special training, use specific equipment
โข Adapted to PHC situation
6. How does it started?
โข Evolves from warfare
โข Early organized civilian PHC group
JF Pantridge โ Ireland ( Ambulance Coronary Care Unit)
UK โ BASIC
US- DOT (1960โs)- EMS
Germany โ Notrazt
Now, Faculty of Pre- Hospital Care, RCS Edinburgh)
โข Dip. IMC
โข FIMC
7. The philosophy
โ appropriate intervention at appropriate timeโ
โ short and safe, never be prolongedโ
Aim of treatment: produce neurologically intact
survivor & reasonable quality of life
Need careful judgment of when to intervene and
when not to.
8. The practice of Pre-Hospital Care
โข Uncomfortable
โข Less ideal
โข Any weather- bad weather
โข ?Safety โ depends on working
together effectively
with other emergency
service agencies.
9. Pre-Hospital Care: How does it
start?
History
โข During Battles of Uhud and Hunain,
Arabian Peninsula (> 14 centuries ago)
โข Sir Robert Jones, Manchester-Liverpool
canal, UK (1888)
โข More organised system, US & Ireland
(1960s)
10. Who is involve?
โข Doctors โ General Physician
-- E Ps
-- Surgeons
-- Anesthetic
โข Paramedic โ MAs, S/Ns
โข Uniform bodies- BOMBA, JPA3, Police, Army
โข NGO- PBSM, St John, Mercy others
โข Volunteers
Undergone basic training
14. TRAUMA IN MALAYSIA
โข Trauma is the 2nd cause of mortality in
Malaysia
โข Road injury is a leading cause of premature
death of age group 12 โ 45 (young adult:
31.2%, adolescents: 21.5%)
โข Road injury causes 25 to 30 deaths per 100
000 population, 6000 deaths per annum, 15
deaths/day
โข Pre Festival week: 15 to 20 deaths per day
Epidemiology of injury in Mโsia, Dec 1997
15. 10 Principal causes of deaths in
MOH hospitals, Malaysia 2001
1.ย Heart Diseases & Diseases of
Pulmonary Circulation 15.99 %
2. Septicaemiaย 14.51 %
3. Malignant Neoplasm 9.16 %
4. Cerebrovascular Diseases 4.48 %
5. Accident 6.76 %
6. Conditions Originating In The Perinatal Period 5.56 %
7. Pneumonia 4.98 %
8. Diseases of the Digestive System 4.38 %
9. Nephritis, Nephrotic, Syndrome and Nephrosis 3.72 %
10.Ill-defined conditions 2.74 %
16. 10 principal causes of hospitalization in M0H
hospitals, Malaysia 2001
1. Normal Deliveryย ย 18.91
%
2. Complications of Pregnancy 11.84 %
3. Accident 9.16 %
4. Diseases of the Circulatory System 6.94 %
5. Diseases of the Respiratoryย System 6.61 %
6. Conditions Ori. In The Perinatal Periodย 5.62 %ย
7. Diseases of the Digestive System 4.87 %
8. Ill-defined conditions 3.57 %
9.ย Diseases of the Urinaryย System 3.49
%
10.Malignant Neoplasms 2.62 %
17. โTransportation of critically ill
patients to EDHKL does not
follow a standard guidelineโ
(inadequate communication, ineffective liaison,
untrained & inexperienced staff)
Ridzuan Isa. A study on inter hospital ambulance transportation of
critically ill patients to GHKL, May 2003
21. Malaysian โEMSโ
Available service
C MOH hospitals
C University hospitals
C St. John Ambulance of Malaysia
C Malaysian Red Crescent Society
C JPA 3
C Private ambulance services
22. Malaysian PHC
Providers
C Assistant Medical Officer
C EMTs
C JPAM
C NGOs- First Aider (SJAM, PBSM)
23. PRINCIPLE OF PRE
HOSPITAL TRAUMA CARE
~ Deciding the best option for the
patient on the field requires knowledge
of the potential detriments and the
means to correct the situation in the
right time frame ~
24. Key element in administering a PHC
system
1) Lead by a national agency (MOH, MOT)
- govern the system
- legislative & regulatory oversight
- organization
- financing
6) Regional or local support โ member of
community
7) Local administration
8) Medical direction โeducation, training, quality
improvement
9) Political support
25. System of PHC
โข National systems
โข Local or regional systems
โข Private systems
โข Hospital based systems
โข Volunteer system
โข Hybrid system
27. Key aspects in PHC systems
โข Personnel
โข Training
โข Communication systems
โข Transportation
โข Receiving facilities
โข Documentation of care
โข Legislation & regulation
28. Personnel
โQuality of a PHC is determine by the ability and
attitudes of provider couple with knowledge and
skills requiredโ
โข Come from different walks of life
โข Full-time or part-time
โข Paid or volunteer
โข Different level of knowledge and care
โข Need good coordination and understanding
โข Good command and control
29. Training
Interested physician need to be involve in training
โข FRLS/ FALS- Fire & Rescue, Police, ? Tow-Truck
driver
โข EMT-B / Post basic - Paramedic.
โข Dip. IMC
โข Degree Emerg. Paramedic
โข FIMC
Other courses they should undergone
BLS, BTLS/BTC, ATLS (MTLS, ATRC), ACLS, MIMMS
30. Communication
โข Emergency number: 991, 911, 999, 000, 994 ???
โข Cellular phones: 121, 112, 122, 999???
โข We need to know and same goes with the public?
โข Communication Center
โข Able to communicate among all PHC providers
โข Priority dispatch / pre-arrival instruction/ phone triaging
โข Able to communicate with hosp. of destination
31. Transportation
โข Air ambulance โ helicopter, fixed wing
โข Ground ambulance- type 1, 2, 3
โข Sea ambulance
Simple transport vehicle ๏ Sophisticated-
specialized-efficient mobile
patient care unit
32.
33. Able to provide lifesaving maneuvers
Design: Ambulance personnel must be able to
provide airway & ventilatory support while
transporting
BLS- equipped
ALS- equipped
35. Facilities
โข Transport to the closest appropriate
hospital.
โข Specific dedicated hospitals for the special
conditions.
โข Patient demand?? To consider or not.
โข In life-threatening condition- NOT
36. Critical care unit
โข Must identify the hospital that have tertiary care
facilities
i.e. Trauma
NICU
High risk Obstetric
Burns
Spine unit
Neurosurgery
Cardiac care
Do NOT load one hospital with everything unless
there is only one
38. Consumer participation
โข Lay person
โข Political
โข Consumer association
โข Need their support and corporation in order
to have successful PHC service
manpower/ financial/ legislative
39. Access to care
โข Ensure public have access to emergency care
โข Must develop system that discourage public from
accessing the PHC system for wrong reason or
perceived emergency.
โข Political back-up and their understanding of the
system
โข Principle: all individual deserve timely access to
the emergency PHC system.
40.
41. SCOPE OF PRE HOSPITAL
TRAUMA CARE
โข Scene size up
โข Triage, treatment (ABC I)
โข En route management
โข Patientโs Transportation
โข Communication and Dispatching
โข Pathway of care; sending and receiving
protocol.
42. EMERGENCY
INTERVENTION
โข Airway maintenance/Cervical Spine
Control
โข Breathing and ventilation
โข Circulation with hemorrhage control
โข I mmobilization
43. CARING FOR THE PATIENT WHILE
EN ROUTE TO THE HOSPITAL
3. Continue to provide emergency care
4. Continue monitoring vital signs
5. Communicate with ED personnel using two way radio
6. Give a description of what happened
7. Describe patient age, sex and his condition
8. What type of injury suspected
9. Patient vital signs
โข Emergency care that has been provided
โข Estimated time of arrival
45. Public Information & Education
โข Public must be informed and educate regarding
good emergency PHC system.
โข Public can contribute by
- understand how a good system can benefit
them.
- Prepare to give first aid care
- Know how and when to access the system
rapidly
46. Disaster Preparedness
โข Any PHC system is an integral part to disaster
response effort.
โข Need to be involve in planning & practice drill
47.
48. In-hospital emergency care
โข Receive patients
โข Triage
โข Resuscitation and stabilization
โข Registration
โข Investigation
โข Treatment โ definitive care, observation
โข Disposal
49. Bystander
interventions Early Definitive
Care/Trauma Center/ED
Emergency Service
Dispatch
Transportation
On scene
interventions
This is a picture of mass casualty accident. It involved multiple vehicles. 35 casualties with 5 deaths. Who is going to manage this type of scenario? How are we going to manage it if it occurs in KB? Do you think it is as easy as managing ICU patients or prof Jafri patients who are already on the OT table? Who is the expert here? Last year, during the fasting month, it was raining during time. There was an accident between the a car and a truck. I followed the ambulance to dispatch the victims. The area flooded by a villagers and other emergency service personnel (BOMBA/POLIS). There was also a reporter and photographer around, snapped the pictures at different angle. Nobody cares the trapped victims. The BOMBA busy cutting the roof of the car and they hold it for me and ask me to take the patient out. I did a quick triage & I found out only one survivors. The victim had respiratory distress and poor circulation. It was not easy to remove the patient. It was not easy to manage the patient at the field. I decided to practice scoop & run rather than scoop and play. Run and playโฆ fuh!!! Donโt want to talk about itโฆ
Questions? Why?
Most of Trauma strategy & management were started by the military/army. Their exposure & experiences managing trauma victims during war made them more concern & the needs of trauma care. They learn the through a hard way, hard time & do not imagine the prize they have to pay. This slide shows a relationship between evacuation time and mortality rate during the different type of war. Mortality rate goes down whenever the evacuation time is reduced. The reduction of time evacuation and mortality rate were bcoz the advancement of transportation at war. For ex โ the usage of helicopter to bring soldier to the medical center diring the world war 11 7 orean war.
This is a chain of survival for trauma victim. It has 5 elementsโฆ All the component which represented by a ring are attach/link to the other in sequence & strongly connected to form a chain. The morbidity & mortality are depending on the strength of the chain not a single individual or ring. A strength of the chain as strong as the weakest link.
Prehospital management is not easy or simple. Everything is difference, inconvenience and non conducive. Hot. Noisy. Too many casualties. Everybody calls us for help. Everybody asking for help. At the same time we have to take care of own safety. Decision made is very difficult. Wrong decision may jeopardy patientโs life. Yet, our enemy is a time. We re fighting with the time. We are against the time. Delayed definitive management means death. Nowadays, too fast also not very good. Too fast may compromised our safety/victimsโs safety โ eg sept eleven, ambulance collision.
Trauma center and availability of trauma surgeon do improve the survival of trauma patients. Trauma center is just a name. We donโt have to create a trauma center if we can coordinate and communicate among ourself. It is about mobilization of resources.
This slide is to illustrated to you there was o major organization involved in management of trauma @ even medical patients. Both of them are equally important in order to save patient life.
In order patient life we required to strengthened above chain. It is a team expert not an individual expert. Everybody has a role.
