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Home - Critical Care - Article

Pre-hospital Emergency Care - a Top Priority

The goal of an ideal pre-hospital emergency care system should be to match the needs of the patients to the available resources so that optimal, prompt and cost-effective care can be offered, says Dr D P Samaddar, HOD Anaesthesia and Critical Care, Tata Main Hospital, while pointing out that there is an immediate need to improve the existing one in the country


Dr D P Samaddar

Trauma is the neglected disease of modern developing nations.1 Inadequate evacuation of casualties had been identified as the main cause of delay in offering medical attention, resulting in higher mortality since World War II. “Bring the doctor to the patient” approach was implemented in Germany in 1957, which very soon became the accepted norm in the European countries.2 Similar approach was adopted in the US but, instead of doctors, trained paramedical staffs were provided in ambulances.

In India, every 1.9 minutes one trauma related death takes place, affecting the most productive age group (20-40 years) and leading to 2-2.5 per cent GDP loss. Lack of medical attention had been attributed to 30 per cent of deaths at the site and 80 per cent of the remaining patients dying within an hour of injury.3 Most of these deaths are due to airway problem, respiratory failure or continuing heamorrhage which can be prevented to a great extent with appropriate pre-hospital emergency care.4 Considering the urgency of immediate treatment the ‘golden hour’ and ‘platinum minutes’ concepts had been developed to minimise the gap between the time of injury and initial medical attention.5 Unfortunately, pre-hospital trauma care is not available to most of the world’s population4 and India is no exception. Apart from trauma emergency care, it is also necessary following natural calamities, radiation exposure, near drowning and other medical emergencies. Basic principles of pre-hospital emergency care remain the same with certain specific issues related to each type of emergency.

Objectives of Pre-hospital Emergency Care (PHEC)

Objectives of PHEC are to offer fastest possible basic support, control of bleeding, and evacuation of the patient to medical centre at the earliest. 2,5

Care levels: Level of care, offered at the site, varies according to the facilities available in a given situation.4

First responder care: Interested community persons trained to provide initial first aid can only offer fastest possible care. Best possible PHEC will fail to deliver the desired result if bystanders are not capable of appreciating seriousness of emergency, call for help and extend initial care. Expected actions from the bystanders are : 1. Stop to help 2. Call for help 3. Assess the victim 4. Start the breathing 5. Stop the bleeding.

Basic pre-hospital care: This care is provided by the community members exposed to formal training in pre-hospital basic life support, scene management, rescue, stabilisation and transportation of injured persons. Approximately 100-400 hours of training had been advocated for skill enhancement to ensure control of external hemorrhage, protection of spine, provision of artificial respiration, circulatory support, oxygen therapy and extrication.

Advanced pre-hospital emergency care: Advanced life support at pre-hospital level is resource intensive and is expected to be provided by highly skilled medical professionals or paramedical staff. Advanced life support includes intravenous fluid therapy, endotracheal intubation, and highly invasive interventions such as needle decompression or cricothyroidotomy. More than thousand hours of classroom and field training had been recommended for this group. Despite the enormous cost involved, this kind of care has not been proved to be beneficial except for small subset of very critically ill patients. Cost benefit analysis, therefore, is necessary before planning to introduce such facility.4,6

Controversies in Pre-hospital Trauma Management

Scoop and run versus field stabilisation: Proponents of both the approaches had been making claims and counter claims. In real life situation a balance is necessary based on the transport distance, pre-hospital resources, and mechanisms of injury (blunt vs. penetrating trauma). Decision should be taken by the healthcare provider accordingly at the site of the incidence.

Airway management: Airway management had been advocated in patients with traumatic brain injury, cervical spine, or thoracic trauma before evacuation unless the same can be performed easily en route.7 Despite the claimed advantages, pre-hospital endotracheal intubation and rapid-sequence induction (RSI) performed by less experienced paramedical staff leads to higher mortality and poorer neurologic outcomes. 2,8 Laryngeal mask airway should be considered as an alternative to intubation in field situations.2

Fluid replacement: Pre-hospital fluid resuscitation for major trauma is controversial. Beneficial impact of limited fluid resuscitation had been claimed for penetrating torso injuries with hemorrhagic shock, particularly in urban settings. Maximum attention should be on preventing the lethal triad of trauma: hypothermia, acidosis, and coagulopathy.2,8

PHEC status in India: Centralised Accident & Trauma Services (CATS), an autonomous body formed in 1991 by the Delhi government was probably the first comprehensive initiative to improve pre-hospital trauma service. Emergency Management and Research Institute (EMRI), Hyderabad, Ambulance Access for All (AAA), Foundation and Emergency and Accident Relief Centre (EARC) are other service providers in Andhra Pradesh, Maharashtra and Tamil Nadu respectively. For faster response Ambulance Motorbike and Rescue Service (AMARS) was initiated in March 2003 by Christian Medical College, Ludhiana to offer support in Punjab, Himachal Pradesh, Jammu and Delhi. Trained paramedical staffs had been involved by all the above agencies for offering pre-hospital emergency care.5

Table 1 . Essential training skill for basic first aid level of care
  Essential training skills
Able to call for help  
Assess scene safety 1.Identify physical and environmental hazards
2. Decide need for additional help
Infection control 1.Trained in universal precautions
2. Trained to prevent exposure to HIV, hepatitis B and C
Initial assessment 1.Adequacy of airway
2. Adequacy of breathing
3. Extent of external bleeding
Airway and breathing 1.Experienced to remove foreign bodies from airway (e.g., using Heimlich manoeuvre)
2. Restore open airway using manual manoeuvres (e.g., chin lift, jaw thrust)
3. Restore open airway using recovery position
Circulation, hypothermia and shock 1.Control external haemorrhage through direct pressure
Nonsurgical management of wounds 1. Dressing
Burns 1. Cool the burn area with water
2. Cover the skin with clean dressings
Injuries to extremities and fractures 1. Basic immobilisation for fractured extremities
Head and spinal injuries 2. Use of spinal precautions when extricating or moving patients

Recommendations to Improve Pre-hospital Emergency Care

Pre-hospital trauma care system should be simple, sustainable, flexible, and efficient. These expectations can be fulfilled if PHEC is integral part of the country’s health care system.4 Under mentioned recommendations were given by Goyal et al to improve pre hospital trauma care in India.5

1. Single contact number for emergency ambulance at state level
2. Accessibility through land line and mobile phones
3. Toll free call facility
4. Global positioning system to track the ambulance through single call centre with the facility to communicate with government or other agencies
5. Ambulances of specific design and facilities (BLS, ACLS) for every 1.5 million population stationed at every 50 km distance
6. Manpower: Two trained paramedical staff (certified in emergency medical service) per ambulance with ability to drive and navigate
7. Protection to the staff from the medico legal issues and death during transportation

For successful and smooth functioning of the PHEC apart from technical expertise, organisational structure, medical direction, legislative, and financial support, involvement of local community, administrators, and politicians should be ensured.4

Advances in trauma care 9

1. Video assisted laryngoscope: This might reverse the current trend of avoiding pre-hospital intubation in trauma victims.
2. Intraosseous injection of fluid and drugs: European Resuscitation Council has shown that plasma concentration of intraosseously injected drug matches with the central venous deposition, even in adults. Except blood transfusion, this route can be used for drugs and fluids if venous access is not possible.
3. Tourniquet: Use of tourniquet is being revived for control of peripheral bleeding.
4. Hemostatic dressing: Clotting agents are being impregnated in the dressing.
5. Monitoring: Endtidal CO2 monitoring is being given importance as outcome had been correlated with PaCO2 level between 30-39 mmHg.
6. Training: International trauma life support (ITLS), Advanced trauma life support (ATLS) and Trauma Nurses Core Courses (TNCC) are some of the training courses available for different category of health care workers. Simulation programme further exposes trainees to real life scenario.
7. Mental health of care providers: Post-Traumatic Stress Disorder (PTSD) among care providers needs de-briefing sessions.

Conclusion

Despite understanding the need of pre-hospital emergency care, quality of PHEC is far from satisfactory in developing countries. Considering economical, educational, infrastructural, communication, transportation related issues and deficiency of trained man power; initial focus should be on the first responder care and basic pre-hospital care. Advanced level of care is more practical in urban areas, provided skilled professional help and ambulance support are readily available. The goal of the pre-hospital emergency care system should be to match the needs of the patients to the available resources so that optimal, prompt and cost-effective care can be offered. For bridging the wide gap between the actual and expected level of care, the urgent need must be appreciated by the community, administration, medical professionals and very positive steps should be taken to meet the future challenges.

References:
1. Trauma in India-Fact file available at http://www.traumaindia.org/traumainindia.htm.
2. Peter Nagele and Michael Hüpfl, Anesthesia and Prehospital Emergency and Trauma Care. pp 2313- in Miller'Anesthesia. 7th Edition.Editor: Ronal D. Miller. Publishers: Churchill Livingstone.
3. 'In an Emergency…'.The Hindu. June 13 2002; Available at: http://www.hindu.com/thehindu/mp/2002/06/13/stories/2002061300180300.htm. accessed 7 Jan 2006.
4. Sasser S, Varghese M, Kellermann A. et al .WHO Pre-hospital trauma care systems World Health Organization Geneva 2005. Available at http://www.who.int/violence_injury_prevention/publications/services/39162_oms_new.pdf
5.H C Goyal et al. Report of a 2 day National consultation on Pre Hospital Trauma Care in India on 26th and 27th October 2006 at NIHFW, Munirka, New Delhi. Available at: http://www.whoindia.org/LinkFiles/Diability,_Injury_Prevention_&__Rehabilitation_Pre_hospital_trauma_care.pdf.
6. Liberman, Moishe; Mulder, David, Sampalis, John . Advanced or Basic Life Support for Trauma: Meta-analysis and Critical Review of the Literature. Journal of Trauma-Injury Infection & Critical Care. 2000;49(4):584-599.
7. Erika Frischknecht Christensen, Charles D. Deakin,Gary M. Vilke, and Freddy K. Lippert. Prehospital Care and Trauma Systems. pp :43-58 in TRAUMA Emergency Resuscitation Perioperative Anesthesia Surgical Management Volume 1 Editors: William C. Wilson, Christopher M. Grande, Christopher M. Grande. Publishers: Informa Health care.USA,2007.
8.Adult Advanced Life Support.Resuscitation council UK, 2010:page 58-80.
9. Kelvin Williamson, Ramaiah Ramesh, Andreas Grabinsky.Advances in prehospital trauma care. International journal of Critical Illness and Injury Science. 2011;1:44-50.

 

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