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CHAPTER TWO

LITERATURE REVIEW
2.1 What is emergency healthcare ?
Emergency healthcare services are type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency. The use of the term emergency medical services may refer solely to the pre-hospital element of the care, or be part of an integrated system of care, including the main care provider, such as a hospital.

Emergency medical services may also be locally known as: first aid squad, emergency squad, rescue squad, ambulance squad, ambulance service, ambulance corps or life squad. The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital or another place where physicians are available. The term emergency medical service evolved to reflect a change from a simple system of ambulances providing only transportation, to a system in which actual medical care is given on scene and during transport. In some developing regions, the term is not used, or may be used

inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care. In most places in the world, the EMS is summoned by members of the public (or other emergency services, businesses or authority) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation. In some parts of the world, the emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one; usually to facilitate the provision of a higher level or more specialised field of care. In such services, the EMS is not summoned by members of the public but by clinical professionals (e.g. physicians or nurses) in the referring facility. Specialized hospitals that provide higher levels of care may include services such as neonatal intensive care (NICU),
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pediatric intensive care (PICU), state regional burn centres, specialized care

for spinal injury and/or neurosurgery regional stroke centers, specialized cardiac care (cardia c catherization), and specialized/regional trauma care. In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue. Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive the ambulance, with no medical

training. In contrast, most systems have personnel who retain at least basic first aid certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less commonly, physicians.

2.2 History
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaritan. Luke 10:34 (NIV) - "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." Also during the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield. The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (17661842), Napoleon Bonaparte's chief physician. Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or fourwheeled horse-drawn wagons, which were used to transport fallen soldiers

from the (active) battlefield after they had received early treatment in the field. These 'flying ambulances' were first used by Napoleon's Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon's other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt. In civilian ambulances, a major advance was made (which in future years would
come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832. The statement on the carriage, as printed in The Times, said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other". This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.

The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine.

In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modelled on a military-style command and discipline structure. The earliest emergency medical service was reportedly the rescue society founded by Jaromir V. Mundy, Count J. N. Wilczek, and E. Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ring Theater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide. Also in the late 19th century, the automobile was being
developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. This was followed in 1900 by New York city, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2 hp motors on the rear axle.

American historians claim that the first component of pre hospital care on scene began in 1928, when "Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, Virginia, which was the first land-based rescue squad in the nation." However the city of Toronto takes this claim stating "The first formal training for ambulance attendants was conducted in 1892."

During World War One, further advances were made in providing care before and during transport traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses the only available vehicle that could carry a recumbent patient - and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars. Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment. Advances in the 1960s, especially the development of CPR & defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the

ambulances. In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper.These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.

2.3 Purpose

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6 points on the Star of Life

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the 6 points. These 6 points are used to represent the six stages of high quality pre-hospital care, which are:
1.

Early Detection - Members of the public, or another agency, find

the incident and understand the problem


2.

Early Reporting - The first persons on scene make a call to the

emergency medical services and provide details to enable a response to be mounted


3.

Early Response - The first professional (EMS) rescuers arrive on

scene as quickly as possible, enabling care to begin


4.

Good On Scene Care - The emergency medical service provides

appropriate and timely interventions to treat the patient at the scene of the incident
5.

Care in Transit - the emergency medical service load the patient

in to suitable transport and continue to provide appropriate medical care throughout the journey

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6.

Transfer to Definitive Care - the patient is handed over to an

appropriate care setting, such as the emergency department at a hospital, in to the care of physicians.

2.4 Prehospital Delivery of Care


Depending on country, area within in country, or clinical need, emergency medical services may be provided by one or more different types of organisation. This variation may lead to large differences in levels of care and expected scope of practice. The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was often the case in a historical context, and is still true in the developing world, where operators as diverse as taxi drivers and undertakers may operate this service. Most developed countries now provide a government funded emergency medical service, which can be run on a national level, as is the case in the United Kingdom, where a national network of ambulance trusts operate an emergency service, paid for through central taxation, and available to anyone in need, or can be run on a more regional model, as is the case in the United States, where individual authorities have the responsibility for providing these services.

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Typical scene at a local emergency room Ambulance services can be stand alone organizations, but in some cases, the emergency medical service is operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance, such as fire truck. In some locales, firefighters are the first responders to calls for emergency medical aid, with separate ambulance services providing transportation to hospitals when necessary. Some charities or non-profit companies also operate emergency medical services, often alongside a patient transport function. These often focus on providing ambulances for the community, or for cover at private events, such as sports matches. The Red Cross provides this service in many countries across the world on a volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organizations such as St John

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Ambulance. and the Order of Malta Ambulance Corps. In some countries, these volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency, or simply to help cover busy periods. There are also private ambulance companies, with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care (i.e. non urgent), although in some places these private services are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy or to respond to non-emergency home calls. Private companies are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews. Many colleges and universities, especially in the United States, maintain their own EMS organizations. These organizations operate at capacities ranging from first response to ALS transport. Campus EMS in the United States is overseen by the National Collegiate Emergency Medical Services Foundation.

2.5 Strategies for delivering care


The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to

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the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aero medical evacuation helicopter, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit. The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and the victim is transported as fast as possible to a trauma centre. The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma

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patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient. Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab.The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent. In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.

2.6 Governance
Paramedics normally function under the authority (medical direction) of one or more physicians charged with legally establishing the emergency medical directives for a particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of a State Medical Board examination (U.S.) or the National Registry of Emergency

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Medical Technicians (U.S.). In England, and in some parts of Canada, credentialing may occur by means of a College of Paramedicine. In these cases, paramedics are regarded as a self-regulating health profession. The final common method of credentialing is through certification by a Medical Director and permission to practice as an extension of the Medical Director's license to practice medicine. The authority to practice in this semiautonomous manner is granted in the form of standing order protocols (offline medical control) and in some cases direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with clinical decision-making authority using standing orders or protocols. In some parts of Europe and the United States, most notably in Germany, those in the paramedic role are only permitted to practise many of their advanced skills while assisting a physician who is physically present, or they face cases of immediately life-threatening emergencies. In other parts of Europe, most notably in France, all ALS skills in the pre-hospital setting are performed by physicians and nurses, and the role of paramedic is unknown. In certain other jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners capable of prescribing medications. In other jurisdictions, such as Australia and Canada this expanded scope of practice is under active consideration and discussion.

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