Emergency Medicine Lesson 1: Teodoro Javier Herbosa MD FACS

EMERGENCY MEDICINE
Lesson 1
Teodoro Javier Herbosa MD FACS

Past Chairman, Dept. of Emergency Medicine
Associate Professor, Div. of Trauma, Dept. of Surgery
College of Medicine-Philippine General Hospital
University of the Philippines
UPCM
Objectives
● Define EM & selected terms used in Emergency
Medicine.
● State the principles of the organization and
management of an Emergency Department.
● List logistic of requirements for emergencies
Department of Emergency Medicine

UPCM
Definitions
Emergency
is any situation that requires immediate action.
WHO
Medical Disaster
is an occurrence “when the destructive effects of
natural or manmade forces overwhelm the ability
of a given area or community to meet the demand
for health care”.
ACEP

UPCM
Definitions
● Emergency Medicine (EM) - A branch of
medicine that deals with the appropriate
management of all forms of acute illness
or injury.
● Specialization in EM will lessen unwanted
morbidity or mortality due to a sudden
illness or injury.
● In the British System this is known as
Accident and Emergency (A&E).

UPCM
Definitions
● Emergency Department (ED) or Emergency
Room (ER) - A unit of the hospital composed of
staff and organized to address management of
acute illness or injury.
● The older terminology "Emergency Room"
is abandoned because the word room is
misleading when compared to the complex
processes and organization of such a hospital
department.

UPCM
The Emergency Department

The current trend in Emergency
Medicine is to establish the ED as a
separate and distinct department
within the hospital, complete with its
own management and staff.

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EMS System
Emergency Medical Services
System (EMSS) – The total
system intended to care for a
casualty from the site of incident
to definitive care.

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What are the

components of EMSS?

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EMS System includes
● Triage
● On-site care
● Initial resuscitation and treatment
● Medical transport
● Definitive care or Trauma Center

UPCM
EMS System Components

● Transport
● Personnel
● Communications System
● Medical Control
● Equipment and Supplies
● Legislation and advocacy

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Early Access
By calling first, you

join a team of The Bystander
Emergency Service
dispatchers and
responders.
Each member has The Dispatcher

a vital role.
The EMS Responders
UPCM
EMS System COMPONENTS

● Transport - system of ambulances which
may vary from (BLS) to (MICU) or (ALS)
vehicles. Also connotes air transport either
through fixed wing aircraft or rotary wing
type air transports.
● Personnel - Medical First Responders (MFR),
Emergency Medical Technicians (EMT's),
Paramedics, Ambulance Nurses, and
Flight Paramedics.

UPCM
PGH EMS

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Communications System - connotes

the
ability to relay information about an
emergency response and to receive
information or instruction as to what
further
actions should be taken.
UPCM

Medical Control - use of on-line
communications with a specialized physician or
through off-line protocols of care for emergency
situations. Off-line (indirect) medical control is the
responsibility of the service medical director.
Three components of off-line medical director are:

(1) development of protocols,
(2) development of medical accountability (QA)
(3) development of ongoing education.

UPCM

Equipment and Supplies - all the necessary
tools which EMT's need
Legislation and Advocacy - stipulates the
regulation of the practice of pre-hospital and
emergency medicine in a locality. Secures the
high standards of care needed. The financial
aspects of the EMS System may also be
included.

UPCM
Regional Trauma Care System

An organized approach in the
management of acute injury utilizing the
components of an EMSS and trauma
centers or definitive care centers, trauma
specialists and other aspects of trauma
care in a locality, province, region or
country.

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COMPARATIVE DESIGNS OF
EMERGENCY RESPONSE
SERVICES
USA Asian Nations
Funding Well Funded Scarce Funding
Infrastructure Uniform federal Not Uniform
Support
National Safety
stats. Vehicles, Exists Does not Exist
equipment's
Minimum standard Recognition Requires
care provided present recognition
Minimum guidelines Existing Not existing
for education &
training
UPCM
COMPARATIVE DESIGNS OF
EMERGENCY RESPONSE SERVICES
USA Asian Nations

Support Professional Minimal Voluntary
Improvements in Organizations Organizations
System Design
Cost of Med. & Heightened Lack of
Trauma Care awareness awareness
Public Health Continued Non existent
Prevention Prog. Awareness
Network for Disaster Structured Partially
Response structured
System Flexibility Existent No System
UPCM
Human Resources in the

Emergency Medical Services System
Medical First Responder

Emergency Medical Technician - Basic
EMT - Intermediate
EMT – Paramedic
EMS Medical Director
Emergency Department Nurse
Emergency Medicine Physician
General Surgeon/Trauma Surgeon
Emergency Manager/Emergency Department
Coordinator

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Emergency Department

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Principles of Managing the
●Policies and Procedures
●Equipment and Supplies
●Management Unique to the ED
●Staffing requirements unique to
the ED
●Overcrowding

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Principles of Managing the
To understand how a hospital responds

to a disaster,
one may have to look into how
the Emergency Department functions
in a given hospital and
how it adapts to overcrowding.

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Policies and Procedures

● Emergency Departments must have
clearly written policies and procedures.
● This has to be constantly reviewed and
revised.
● It must be reviewed after each major
emergency.

UPCM
Emergency Medicine, Trauma Surgery
and
Disaster Medicine aim to:
Prevent unnecessary
mortality and morbidity from
disasters and emergencies

UPCM
What are the roles of

hospitals
in emergencies?
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Hospital roles in an Emergency

● Provision of Disaster Medical Teams
● Acting as the receiving hospital for
casualties from a disaster

● Triage in multiple/mass casualty incidents
● Receiving hospital for patients transferred
from other disaster affected health-care

facilities

UPCM
Hospital Emergency Plans must consider
many casualties may arrive quickly.

But if a hospital is unable to handle
day to day emergencies in the ED,
it will not be able to cope with
demands of multiple casualty incidents
The Key is Preparedness

UPCM
Hospital Emergency Planning
Developing and
implementing plans,
procedures and
training to ensure
that the hospital’s
capacity to respond to
disaster is maximized.

UPCM
Emergency or Disaster Plan

Contains elements such as:
Who needs to be prioritized for
definitive care?
● triage criteria
Who is in charge?
What are the functions of each and every
member of the emergency team?
● incident command system (ICS)

UPCM

The goals:
● To control the large number of
patients and problems with the best
possible care.
● Enhance the capacities for admission
and treatment.
● Treat patients based on the rules of
good medical practice despite great
numbers of victims.

UPCM

The goals:
● Ensure an ongoing proper treatment for all
patients who are already in the hospital.
● A smooth handling of all additional tasks
caused by large number of patients in an ED.
● To support the damaged area by means of
medical consultation, medicaments, infusions,
dressing material and any other necessary
medical equipment.
Hershe, B. and O.C. Wenker. Principles of Hospital Disaster
Planning. The Internet Journal of Rescue and Disaster Medicine 2000
vol 1N2 (http://www.icaap.org/86.1.2.19)

UPCM
Mass Casualty Incident (MCI)
An incident wherein the trauma care system

is stressed due to a large number of acutely
injured needing definitive care.
Connotes a decrease in the resources
available to the ideal management of the
injured victims.
Any event resulting in a number of victims
large enough to disrupt the normal course of
emergency health care services.
– Establishing a Mass Casualty Management System
– (PAHO-OPS, 1995, 58 p.)

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Bombing

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Contingency
Planning is the key to the proper
response to a
multiple casualty incident
or disaster.

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Observation and Holding Area

Temporary patient care areas
● Lobby
● Conference rooms
● Corridors
● Parking
● Prayer areas

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Referral and Transfer

● Human resources, logistics or
holding areas are not available
transfer to other hospitals
● Prearranged mutual aid
agreement
between hospitals

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Staffing Requirements of the ED
ED Nurses
- training in triage, injury care and
disaster management.
- must be able to work with the emergency
medicine physicians and the trauma
surgeons treating injured patients.
- ensures that resuscitation equipment
and drugs are available help triage
patients

UPCM
Emergency Medicine Physicians (EMP)

● great help in improving the health care
during MCI’s.
● help triage and institute initial management
of injured patients while the surgeons deliver
definitive care.
● this specialist may be those certified in other fields
of specialization like general surgery, orthopedics,
internal medicine, or family medicine.

UPCM

Trauma Team (Surgeons, Anesthesiologists,
Trauma Nurses)
● Different specialties mitigate effects of MCI
● Experience with day to day trauma cases
● Can work readily in MCI
● Minimize preventable mortalities
● Each country - different composition of their
Trauma Team
● Trauma Systems also vary

UPCM
Operating Theater
● Access to functioning
operating theaters
● Early definitive care
● Minimizes unwanted
morbidity or preventable
mortality.
● Lack of these in the
hospital -- system of
transport and referral is
a must.

UPCM
Overcrowding
● Overcrowding in the ED - in most Asian & African
countries, state-funded hospitals have
crowded ED’s.
● Survey done of countries in Asia
– lack of resources on a day to day emergency services
already exist even before an actual MCI.
– There was a very rudimentary form of Prehospital
Care
– Much of the modern principles of EMS are
not existent

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Equipment and Supplies of the ED
Several basic supplies are necessary in

smoothly operating an efficient ED.
The following groups of devices gives

idea of what supplies may run short
during an actual disaster

UPCM
Airway Devices
oxygen tanks
non-rebreather masks
nasal cannula
oropharyngeal airway devices of different sizes
nasopharyngeal airway devices
Intubation equipment like laryngoscopes
endotracheal tubes
LMA's (laryngeal mask airway)
tracheostomy instruments
tracheostomy tubes and suction machines
Cervical immobilization devices

UPCM
Endotracheal Intubation
EQUIPMENTS
laryngoscope (F)
endotracheal tube (J/M)
stylet (I)
additional equipment
10 ml syringe (L)
Magill forceps (G)
water-soluble lubricant
L
suction unit
M
UPCM
Management of Hypovolemic Shock
Devices for hemorrhage control

Surgical gauze packs
Elastic and rolled bandages
IV access, IV cannulas of different sizes, central
lines, cutdown sets, intra-osseous infusion needles.
Crystalloids & colloids for fluid replacement.
Access to blood bank facilities or blood retrieval.
Traction splints for long bone fractures.

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IV Access Training

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Defibrillation
● Automated external defibrillators (AED's)
– Manual defibrillators
● personnel are trained in ACLS and
defibrillation.
● Biphasic defibrillators
● Newer generation cardiac monitors
offer biphasic AED's incorporated into
one machine.

UPCM
Defibrillator

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Monitoring
Critical monitoring devices should include
● pulse oximetry
● non-invasive blood pressure readings,
heart rate and cardiac rhythm
● Point of care testing devices like arterial
blood gas determinations (ABG) and
electrolytes are useful.
● End Tidal carbon dioxide tension (ETCO2) is
also beneficial.

UPCM
Diagnostics
● Access to hematology and chemistry

laboratories.
● These are usually overstressed during a
deluge of patients during MCI’s.

● Reagents & personnel are easily depleted.
● Imaging machines like radiology and
ultrasongraphy must be available for the

injured patient.

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Emergency Drugs
● All emergency drugs must be in ample

supply.
● WHO shows a list of critical drugs.
● New Essential drug list published by
the WHO for disasters.

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Scenario
75/M, Known Diabetic & hypertensive
10 mins PTC, found unconscious inside
the bathroom with a 2 cm laceration on
his occiput

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Scenario
Young male found unconscious.
Brought in by good samaritans. No
informant.
17/F, cc:RLQ pain, comes in pale,

weak looking, LMP: 6 weeks ago

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Emergency
● Medical Situation wherein
– Proposed intervention is deemed necessary
– Delay in treatment may jeopardize life or
result in disfigurement or impaired
faculties

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What is Emergency Medicine?

● Takes the most difficult cases from all
medical specialties
● Multidisciplinary
● Defined by the demands of the Emergency
Department
● Involves both Medical and Non-Medical
Problems
● Includes all Medically-related incidents
outside
the hospital
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Emergency Medicine
International Federation for Emergency Medicine, 1991
● knowledge and skills required for the prevention,
diagnosis and management of acute and urgent
aspects of illness and injury
● all age groups
● spectrum of episodic undifferentiated physical
and
behavioral disorders
● encompasses pre-hospital and in-hospital
emergency medical systems

UPCM
History of Emergency Care

Before Emergency Medicine
● War
– 18th Century
– Field Hospitals
– Medics during Korean & Vietnam Wars
● Emergency Rooms (in the 1960’s)

– Staffed by nurses and interns
– On-call physicians from other specialties

UPCM
History of Emergency Care
Development of EM
● 1960s – Creation of “Casualty Department” in
UK & Australia
● 1968 – American College of Emergency
Physicians founded
● 1969 – 1st ACEP scientific assembly held
● 1970 – 1st EM residency established in
Univ. of Cincinnati

UPCM
Development of EM
● 1972 – Casualty Surgeons Association

restructured as British Association for
Accident & Emergency Medicine
● 1972 – Journal of ACEP published
● 1973 – Emergency Medical Services Systems
Act
signed into law
● 1973 – AMA establishes section on EM
● 1974 – EMRA established
● 1976
Department
– American Board of EM established
of Emergency Medicine
UPCM
Development of EM
● 1979 – EM established as 23rd medical

specialty
● 1981 --Australasian Society for
Emergency Medicine established
● 1985 – EM Treatment & Labor Act
(anti-dumping law) signed
● 1986 – 1st International Conference on EM
● 1989 – ABEM given primary board status

UPCM
Development of EM
● 1990 – International Federation for EM founded

● 1992 – ABEM and American Pediatric Society
establish Subspecialty Board for Pediatric EM
● 1994 – 1st Subspecialty Board for Toxicology
● 1995 – EM recognized as medical specialty in
New Zealand
● 1997 – Hong Kong College of EM adopted by
Ministry of Health
● 1998 – 1st Asian Congress of EM held in Singapore.
Asian Society of EM Founded

UPCM
Emergency Medicine
in the Philippines
● 1988 –Emergency department created at

Makati Medical Center
● 1989 -- Philippine Society of Emergency
Care Physicians formed

● 1991 -- Emergency Rescue Unit Foundation,
Cebu

UPCM
Emergency Medicine in the Philippines
● 1991 –Departmentalization of
Emergency Services, Philippine General
Hospital
● 1996 – Setting up of PGH
● 1997 – Establishment of Residency Program
at DEMS, PGH
● 2001 – Department of EM established as
Academic unit of UP College of Medicine

UPCM
Emergency Doctrine
● Implied Consent for patients in the ED who

cannot give consent for actions to save or
preserve life
● Serves to protect emergency personnel who
act in good faith
● Encourages personnel to act decisively in
the patient’s best interest

UPCM
Characteristics of the
Specialty
● Triage, Stabilize, Prioritize, Refer,
Observe
● ABCs
● Limited resources
– Time
– Information
– Space
● Technology dependent
● Cutting-edge medicine
UPCM
Difference with other
Specialties
● Not necessary to arrive at diagnosis
● Does not follow sequence of SOAP
– Assess  Action  Reassess  Action
● Always thinks of worst-case scenario
– Chest pain is MI!
● AMPLE history
● Don’t believe everything you hear!

UPCM
Pillars of EM
● Chain of Survival
● ABCDs . . .
– BLS
– RSI, ACLS
– PALS / NALS
– ATLS
● Pain Management
● EMSS

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Characteristics of the Practice

● Low overhead
– No clinic to rent
– No staff to hire
– Minimal equipment necessary
● Flexible Work Hours
– Choose your hours
– Maximum 60-hours/week
– Not necessary to file for leave

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Characteristics of the Practice
● High Stress
– Kinds of cases seen
– Kinds of patients seen
– Limited resources
● No Follow-ups
– Do not admit to the hospital
● Prone to Legal & Ethical situations

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Characteristics of EM Physicians
● Type A personality
● Adrenaline junky
● Multi-tasker
● Able to make quick decisions
● Willing to work nights, weekends, holidays

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Subspecialties
● Pediatric EM
● Toxicology
● Emergency Health
– Emergency Medical Services
– Disaster Medicine and Mass Gatherings
– International EM
– Emergency Public Health information
● ED Administration
● Trauma / Pre-hospital & ED Care

UPCM
Areas of Special Interest

● Cardiology / Emergency Cardiac Care
● Neurology: “ Brain Attack”
● Sports Medicine / On-site Medical Care
● Research
● Domestic Violence, Child Abuse & Women’s
Issues
● Environmental & Occupational Health

UPCM
● System Components
– Communications Center
– Personnel
– Patient transport
– Receiving units
● Types of Systems
– Public vs. Private
– Single- vs Multi-Tiered
– Urban vs. Rural
– BLS vs. ALS

UPCM
Personnel
● First Responder
● EMT-B, EMT-D, EMT-I
● Paramedic
● MD, Medical Direction

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Patient Transport
● Star of Life
● Type I – cab & chassis
● Type II – van-type, modified height
● Type III – larger with walk-through passage
● BLS or ALS/ICU

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Receiving Units
● Primary, Secondary, Tertiary

● Trauma Centers / Lead Hospitals for
Trauma
– PGH, EAMC, JRRMMC, DLS-UMC
– VSMMC (Cebu), WVRH (Iloilo)
– DMC (Davao), ZRH (Zamboanga)
● Orthopedic Hospitals
● Pediatric / Neonatal Centers

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Directions in EM
● Curricular changes for

Undergraduate Medical Education
● Research and Documentation
● Training
– BLS, ACLS, ATLS
– Emergency Nursing
– Emergency Medical Technicians

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Directions in EM
● Pre-Hospital & ED reimbursement

● Emergency Public Health Information
Dissemination
● ED Design
● CQI

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Summary
● Defined selected terms used in Trauma
Surgery, Emergency Medicine and
Disaster Medicine.
● Stated the principles of the organization
and management of an Emergency
Department.
● Listed logistic of requirements for emergencies

UPCM
Conclusion
● The Emergency Department is the frontline
of the hospital response to a disaster.
● The ED plays a critical role in hospital
emergency management system

● Preparedness is the key to maximize
capacity in MCI

UPCM
Questions ?

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EMERGENCY MEDICINE

Teodoro Javier Herbosa MD FACS

Department of Emergency Medicine

Department of Emergency Medicine

Department of Emergency Medicine

Department of Emergency Medicine

The Emergency Department

Department of Emergency Medicine

Department of Emergency Medicine

What are the

Department of Emergency Medicine

EMS System includes

Department of Emergency Medicine

EMS System Components

Department of Emergency Medicine

By calling first, you

Each member has The Dispatcher

EMS System COMPONENTS

Department of Emergency Medicine

Department of Emergency Medicine

EMS System COMPONENTS

Communications System - connotes

EMS System COMPONENTS

Three components of off-line medical director are:

Department of Emergency Medicine

EMS System COMPONENTS

Department of Emergency Medicine

Regional Trauma Care System

Department of Emergency Medicine

Department of Emergency Medicine

Department of Emergency Medicine

USA Asian Nations

Human Resources in the

Medical First Responder

Department of Emergency Medicine

Department of Emergency Medicine

●Management Unique to the ED

●Staffing requirements unique to

Department of Emergency Medicine

To understand how a hospital responds

Department of Emergency Medicine

Policies and Procedures

Department of Emergency Medicine

Department of Emergency Medicine

What are the roles of

Hospital roles in an Emergency

casualties from a disaster

from other disaster affected health-care

Department of Emergency Medicine

many casualties may arrive quickly.

The Key is Preparedness

Hospital Emergency Planning

Department of Emergency Medicine

Emergency or Disaster Plan

Department of Emergency Medicine

Emergency or Disaster Plan

Department of Emergency Medicine

Emergency or Disaster Plan

Department of Emergency Medicine

An incident wherein the trauma care system

Department of Emergency Medicine

Department of Emergency Medicine

Department of Emergency Medicine