Prehospital Emergency Preparedness
Synonyms
Definition
Prehospital emergency care consists of any initial medical care given to an ill or injured patient by a trained professional (paramedic or EMT) or other person before the patient reaches the hospital Emergency Department (ED) (Mosby Inc. 2008). Prehospital emergency preparedness is comprised of those activities that enhance readiness for and the ability to manage an incident before it occurs. These activities involve planning, organizing, training, equipping, exercising, evaluating, and taking corrective actions to ensure proper coordination during an emergency (Federal Emergency Management Agency 2012).
Preexisting Condition
A patient requires prehospital emergency care when an injury or accident occurs. Injuries may range from minor illnesses or injuries to life-threatening emergencies. Prehospital interventions may range from simple first aid services to advanced emergency care.
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Basic Life Support – this type of care is often performed by first responders and EMS personnel. Those practitioners’ primary duties are to assess the situation, call for further help if needed, provide basic first aid, cardiopulmonary resuscitation (CPR), and/or use an automated external defibrillator (AED).
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Advanced Life Support – this type of care is often performed by trained paramedics. Paramedics are trained to provide more procedures that may benefit the patient including (but not limited to) intravenous cannulation, providing drugs to relieve pain or correct cardiac or respiratory abnormalities, assisting with airway management such as intubation, applying and evaluating cardiac monitoring, and performing needle decompression.
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Hospital Care – this type of care is often performed by registered nurses, midlevel providers, and physicians in the hospital setting. In the hospital, a patient will receive needed critical care and can be attended to by several different providers of all specialties including medical and surgical as necessary.
Prehospital emergency care can be provided in urban, rural, or remote settings and is often combined with hospital care if necessary.
Application
Each year, nearly five million people worldwide die from injuries (Holder et al. 2000). According to the Center for Disease Control, in 2009 the most common injuries in the United States of America included accidents, self-inflicted harm,diseases of the heart, cerebrovascular disease, and lower respiratory diseases (Heron 2009).
The severity of many fatal injuries can be reduced by appropriate prehospital emergency care (Anderson and Taliaferro 1998). Timely provision of care can limit or significantly halt the cascade of events that may otherwise lead to death or lifelong disability. Without prehospital care, many people who might otherwise die at the scene survive their injuries.
Most deaths that occur within the first hours following an injury are due to issues of airway compromise, respiratory failure or uncontrolled bleeding (Sasser et al. 2005). Prehospital care can significantly impact these issues, especially if it is provided within a few minutes of injury. And training is an important factor in managing the care of the most common causes of death, thus reducing mortality in the field.
Emergency care in the field has been provided for centuries, although the system did not become as sophisticated as it is currently until the mid-1800s. According to documentation, the first use of an emergency transportation vehicle was during the battle of the Spires between the French and the Prussians. Napoleon Bonaparte’s chief physician, Dominique Jean Larrey, developed a system of horse-drawn wagons to transport fallen soldiers from the field to areas where they could be evaluated and treated by medical providers (Skandalakis et al. 2006). Similarly, during a large cholera outbreak in London in 1832, transport carriages were used to move ill patients to the hospital more efficiently. In the United States, the first known hospital-based ambulance services were created at Commercial Hospital in Cincinnati, Ohio, in 1865 and by Bellevue Hospital in New York in 1869. These first ambulances carried medical equipment such as splints, pain medication, and stomach pumps. Finally, the first documented use of a motorized ambulance occurred in 1899 in Chicago (Barkley 1978).
Due to the mass injury created by war, several advances in prehospital emergency care evolved during and after the world wars. Traction splints were implemented as common emergency treatments for leg fractures in the field and communication systems were enhanced with two-way radios allowing a more efficient way to contact for emergency assistance (Kuehl 2002).
In the 1960s, there were significant advances to the type of prehospital emergency care provided. This is in large part due to the development of cardiopulmonary resuscitation and defibrillation as the standard form of treatment of out-of-hospital cardiac arrest. In the United States, governmental regulations and standardization of training of ambulance personnel began in the 1970s. Since this time, significant efforts have improved prehospital emergency care services to what they are today – a mix of bystanders and first responders, highly trained medical providers, emergency ground and air transportation efforts fully equipped with life support equipment and trained personnel, and highly effective emergency communication systems in place.
Despite these advances, there is little evidence that advanced prehospital interventions benefit more than a small subset of the most critically ill or injured victims – and there is a wide variation in the rates of recovery from region-to-region (Neumar et al. 2011). Through greater standardization and improved communication, the possibility for improved overall survival rates exists.
First Responder
When an emergency occurs, the first and most straightforf level of care will be established by the first person on the scene. First responders should be trained to properly identify emergencies, call for assistance, and provide basic treatment until formally trained health-care personnel arrive to provide additional care. This group of people can also be taught the basic principles of safe rescue and transport. This can help provide a primary level of emergency care in rural areas where access to emergency services may be limited.
The foundations of an effective prehospital emergency care system can be created by training volunteers and nonmedical personnel as well as providing basic supplies and equipment; the personnel may need to provide effective prehospital care. This type of training often only lasts a few hours and includes teaching the following five simple concepts: (1) stop to help, (2) call for help, (3) assess the victim, (4) start the breathing, and (5) stop the bleeding (National Highway Traffic Safety Administration 2000). In addition, first responders should be taught basic life support (BLS) skills. Basic life support (BLS) as it is known today consists of mouth to mouth, with closed chest compression, and defibrillation when indicated and available.
There is evidence that outcomes have been improved significantly after bystanders and health-care providers have provided basic first aid following an injury (Ali et al. 1997; Razzak and Kellermann 2002).
Emergency Medical Services
Once a bystander or first responder has called for help, the emergency medical services (EMS) personnel are notified. EMS personnel include trained medical providers who can assess the situation at hand and provide stabilizing efforts as well as transportation to a hospital if needed. In some situations, firefighters or police officers may be the first officials to reach the scene. In these instances they may provide the basic level of services needed and call for additional help if needed.
Paramedic or Emergency Medical Technician
A paramedic or emergency medical technician (EMT) is a trained professional who has extensive education in prehospital care, management of the emergency scene, rescue, stabilization, and transport of injured people. In the United States, there are differing levels of training that identify the skills the provider has. EMT-B is the most basically trained provider, followed by EMT-I which has a greater level of training, and EMT-Paramedic has the most advanced level of training for prehospital emergency care. The training requirements for providers of this level of care requires professional instruction including both theory of clinical experiences ranging in duration from 110 h to greater than 1,000 h. In addition, these individuals are required to participate in continuing medical education activities in order to maintain their certification (Mistovich et al. 2004).
EMTs and paramedics can provide advanced life support (ALS) services. The cornerstone for ALS is the early initiation of excellent cardiopulmonary resuscitation (CPR) and defibrillation (Field et al. 2010). Additionally, advanced life support can include intravenous fluids and medications, endotracheal intubation, and even more skilled interventions such as needle decompression or cricothyroidotomy.
In rural communities where hospitals are distant and access to physicians might be limited, the most experienced paramedic or EMT should fill the role and provide advanced life support as appropriate.
However, despite having the appropriate training to provide ALS services, there is little evidence that advanced services improve mortality rates more than when basic care is quickly and consistently applied. With the exception of early defibrillation for victims of cardiac arrest, most advanced interventions have not been scientifically proven to be effective. This is in large part due to the fact that necessary randomize trials have not been conducted.
Ambulance Care
In the ideal situation, an individual who has suffered a serious injury should be transported from the accident scene to a hospital or setting where more definitive care can be initiated. In the United States of America, this type of ground transportation is often provided by an ambulance or emergency vehicle that is appropriately designed, equipped, and staffed for such instances. Ambulance vehicles should include the following (at a minimum): safety features for the emergency personnel riding in the vehicle as well as for the injured victim, equipment needed to provide basic first aid, common medications given in emergencies, medication administration supplies such as intravenous lines and equipment, basic and advanced life support equipment, and a place for basic extrication tools if necessary.
A number of factors can impact the ability of an ambulance to arrive on the scene quickly or to transport the injured victim to the tertiary care center in a timely manner. In rural settings, delays in transportation may be related to poor quality of roads, rugged terrain, and difficulty in locating the victim due to undeveloped areas. In urban settings, delays in transportation may be primarily due to heavy traffic. And weather may impact the ability of the ambulance to arrive in a timely manner in any area.
In addition to ambulance care, many areas of the country have access to air medical transport. This type of emergency transport is often reserved for situations when an injured victim may need immediate transport to a large regional care facility to receive critical care in order to survive. In remote locations, air transport may be the only means of reaching a health-care facility.
911 Call Center
Having a reliable communication network is a key factor in providing appropriate prehospital emergency care. A call for help is often the first step in securing assistance for the injured individual. This call for help is often initiated by the first responder or a passerby. With the advancement of technology allowing most people access to mobile phones, prehospital emergency care has been enhanced significantly (Mistovich et al. 2004).
In the United States, a nationwide emergency telephone number has been established to facilitate access to emergency services: 9-1-1. This number is free to call and is available on every telephone device such as a landline or mobile phone. When someone contacts this number, they are immediately connected to a nearby emergency call center with access to emergency medical services such as emergency medical care instructions and emergency vehicle dispatch. In some instances, the call center may be able to utilize automatic location identification systems which may be able to help identify the individual caller’s exact location if he or she is unable to accurately provide this information.
The 9-1-1 call center is a resource for all public safety issues in the United States. In fact, all services – such as fire and rescue services, police, and emergency medical services – are routed through this call center. This allows the telephone dispatcher to contact the correct agency or transfer the call to the appropriate personnel to provide the best possible emergency assistance.
Disaster Management
Every prehospital care system should be prepared to respond to larger scale natural disasters or man-made incidents that can injure many people at a time. It is imperative that local agencies, governments, and organizations prepare for these types of disasters to assist residents of the affected communities in coping with those disasters. Disaster planning includes developing a way to assess the situation, coordinating care, and requesting additional outside assistance when necessary.
Federal Emergency Management Agency
The Federal Emergency Management Agency (FEMA) originated in 1803 when the first piece of disaster legislation was enacted to assist a New Hampshire town following an extensive fire. Since that period of time, the agency has provided assistance to hurricane victims, earthquake victims, flood victims, and many other people affected by natural disasters in the United States.
According to the FEMA website (2012), the agency “coordinates the federal government’s role in preparing for, preventing, mitigating the effects of, responding to, and recovering from all domestic disasters, whether natural or man-made, including acts of terror.”
American Red Cross
The American Red Cross is a charitable organization (not a government agency) designed to provide care to those in need. The organization was founded by Clara Barton and her acquaintances in Washington, D.C. in 1881. Barton modeled the idea on the Swiss global Red Cross network which helped protect those injured in the war. The American Red Cross was ratified in the United States in 1882 and provided domestic and overseas disaster relief efforts during times of war. Over the years, the organization has grown extensively and provides many other services to a greater network of people other than those affected by war. Currently, the American Red Cross is made up of donors, volunteers, and employees who share the American Red Cross’s mission of preventing and relieving suffering in the United States and around the world. The organization has five key service areas: Disaster Relief, Supporting America’s Military Families, Blood Donation, Health and Safety Services, and International Services (American Red Cross 2012).
Cross-References
References
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Recommended Reading
- American College of Surgeons/Disaster Management and Emergency Preparedness. http://facs.org/trauma/disaster/index.html. Retrieved 1 Nov 2012
- Henry M, Stapleton E (2004) EMT prehospital care, 3rd edn. Mosby, St. LouisGoogle Scholar
- Prehospital Trauma Life Support. http://www.phtls.net. Retrieved 1 Nov 2012
- Sudden Cardiac Arrest and CPR Fast Facts. http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp. American Heart Association Guidelines 2012. www.americanheart.org. Retrieved 1 Nov 2012
- United States Department of Transportation, National Highway Traffic Safety Administration. http://www.nhtsa.dot.gov. Retrieved 1 Nov 2012