Dr Ismail Mohd Saiboon

Emergency Department HUKM

Introduction to emergency

PRE-HOSPITAL & in-hospital care

Assoc Prof Dr Ismail Mohd SaiboonEmergency Department UKMMC

What is Pre-Hospital Care?• Giving medical care to patients beyond the wall of

Hospital (emergency dpt.)

• 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

Pre-hospital care

• Aim: reduce morbidity and mortality in those seriously injured or in dangerously ill patients outside hospital

• *39% - 47%** of pre-hospital fatalities are preventable• Involve - rapid attendance (ambulance personnel) - performed life-saving@ limb saving

(basic @ advance) procedures - stabilized patients condition,

prevent deterioration, maximized chances

of good definitive care.

Immediate care

• Provision of skilled medial help

• At scene and

• During transport

• By doctors or paramedic that have receive special training, use specific equipment

• Adapted to PHC situation

• gambar

How does it started?• Evolves from warfare• Early organized civilian PHC group JF Pantridge – Ireland ( Ambulance Coronary Care Unit) UK – BASIC US- DOT (1960’s)- EMS Germany – Notrazt

Now, Faculty of Pre- Hospital Care, RCS Edinburgh) • Dip. IMC• FIMC

The philosophy

“ appropriate intervention at appropriate time”

“ short and safe, never be prolonged”

Aim of treatment: produce neurologically intact survivor & reasonable quality of life

Need careful judgment of when to intervene and when not to.

The practice of Pre-Hospital Care

• Uncomfortable• Less ideal • Any weather- bad weather• ?Safety – depends on working

together effectively

with other emergency

service agencies.

Pre-Hospital Care: How does it start?

History• During Battles of Uhud and Hunain,

Arabian Peninsula (> 14 centuries ago)• Sir Robert Jones, Manchester-Liverpool

canal, UK (1888)• More organised system, US & Ireland

(1960s)

Who is involve?

• Doctors – General Physician -- E Ps -- Surgeons -- Anesthetic• Paramedic – MAs, S/Ns• Uniform bodies- BOMBA, JPA3, Police, Army• NGO- PBSM, St John, Mercy others • Volunteers

Undergone basic training

Why do we need PHC?

Medical emergencies

TRAUMA IN MALAYSIA• Trauma is the 2nd cause of mortality in

Malaysia

• Road injury is a leading cause of premature death of age group 12 – 45 (young adult: 31.2%, adolescents: 21.5%)

• Road injury causes 25 to 30 deaths per 100 000 population, 6000 deaths per annum, 15 deaths/day

• Pre Festival week: 15 to 20 deaths per dayEpidemiology of injury in M’sia, Dec 1997Epidemiology of injury in M’sia, Dec 1997

10 Principal causes of deaths in MOH hospitals, Malaysia 2001

1.  Heart Diseases & Diseases of Pulmonary Circulation 15.99 %2. Septicaemia  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 %

10 principal causes of hospitalization in M0H hospitals, Malaysia 2001

1. Normal Delivery   18.91 %2. Complications of Pregnancy 11.84 %3. Accident 9.16 %4. Diseases of the Circulatory System 6.94 %5. Diseases of the Respiratory  System 6.61 %6. Conditions Ori. In The Perinatal Period  5.62 % 7. Diseases of the Digestive System 4.87 %8. Ill-defined conditions 3.57 %9.  Diseases of the Urinary  System 3.49 %10.Malignant Neoplasms 2.62 %

“Transportation of critically ill patients to EDHKL does not follow a standard guideline”

(inadequate communication, ineffective liaison, untrained & inexperienced staff)

Ridzuan Isa. A study on inter hospital ambulance Ridzuan Isa. A study on inter hospital ambulance transportation of critically ill patients to GHKL, May 2003 transportation of critically ill patients to GHKL, May 2003

TIME TO CARE VS SURVIVAL

TRAUMA CHAIN OF SURVIVAL

Rapid Access

Pre-hospital

CareED

ResuscitationDefinitive

care

Rehabilitation

The practice

Malaysian ‘EMS’ Available service MOH hospitals University hospitals St. John Ambulance of Malaysia Malaysian Red Crescent Society JPA 3 Private ambulance services

Malaysian PHC Providers Assistant Medical Officer EMTs JPAM NGOs- First Aider (SJAM, PBSM)

~ Deciding the best option for ~ Deciding the best option for the patient on the field requires the patient on the field requires knowledge of the potential knowledge of the potential detriments and the means to detriments and the means to correct the situation in the right correct the situation in the right time frame ~time frame ~

PRINCIPLE OF PRE PRINCIPLE OF PRE HOSPITAL TRAUMA CAREHOSPITAL TRAUMA CARE

Key element in administering a PHC system

1) Lead by a national agency (MOH, MOT) - govern the system - legislative & regulatory oversight - organization - financing2) Regional or local support – member of community3) Local administration4) Medical direction –education, training, quality

improvement5) Political support

System of PHC

• National systems

• Local or regional systems

• Private systems

• Hospital based systems

• Volunteer system

• Hybrid system

Tiers in PHC provider

• 1st tier – First responder

- Basic first aider (lay people)

- Advance first aider (police/FR/ SJAM etc)• 2nd tier – Basic PHC provider

- paramedic / nurse /EMT-B• 3rd tier - Advance PHC provider

- doctors

- trained paramedic

Key aspects in PHC systems

• Personnel

• Training

• Communication systems

• Transportation

• Receiving facilities

• Documentation of care

• Legislation & regulation

Personnel

“Quality of a PHC is determine by the ability and attitudes of provider couple with knowledge and skills required”

• Come from different walks of life• Full-time or part-time• Paid or volunteer• Different level of knowledge and care• Need good coordination and understanding• Good command and control

Training

Interested physician need to be involve in training• FRLS/ FALS- Fire & Rescue, Police, ? Tow-Truck driver• EMT-B / Post basic - Paramedic.• Dip. IMC• Degree Emerg. Paramedic• FIMC

Other courses they should undergone

BLS, BTLS/BTC, ATLS (MTLS, ATRC), ACLS, MIMMS

Communication

• Emergency number: 991, 911, 999, 000, 994 ???• Cellular phones: 121, 112, 122, 999???• We need to know and same goes with the public?• Communication Center• Able to communicate among all PHC providers• Priority dispatch / pre-arrival instruction/ phone triaging• Able to communicate with hosp. of destination

Transportation

• Air ambulance – helicopter, fixed wing• Ground ambulance- type 1, 2, 3• Sea ambulance

Simple transport vehicle Sophisticated-specialized-efficient mobile

patient care unit

Able to provide lifesaving maneuvers

Design: Ambulance personnel must be able to provide airway & ventilatory support while transporting

BLS- equipped

ALS- equipped

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Facilities

• Transport to the closest appropriate hospital.

• Specific dedicated hospitals for the special conditions.

• Patient demand?? To consider or not.

• In life-threatening condition- NOT

Critical care unit

• Must identify the hospital that have tertiary care facilitiesi.e. Trauma NICU High risk Obstetric Burns Spine unit Neurosurgery Cardiac careDo NOT load one hospital with everything unless there is

only one

Public safety agencies

• Need strong ties with them

Police

Fire & Rescue

JPA3

Consumer participation

• Lay person

• Political

• Consumer association

• Need their support and corporation in order to have successful PHC service

manpower/ financial/ legislative

Access to care

• Ensure public have access to emergency care• Must develop system that discourage public from

accessing the PHC system for wrong reason or perceived emergency.

• Political back-up and their understanding of the system

• Principle: all individual deserve timely access to the emergency PHC system.

SCOPE OF PRE HOSPITAL TRAUMA CARE

• Scene size up• Triage, treatment (ABC I)• En route management• Patient’s Transportation • Communication and Dispatching• Pathway of care; sending and receiving

protocol.

EMERGENCY INTERVENTION

• Airway maintenance/Cervical Spine Control

• Breathing and ventilation

• Circulation with hemorrhage control

• I mmobilization

CARING FOR THE PATIENT WHILE EN ROUTE TO THE HOSPITAL

1. Continue to provide emergency care2. Continue monitoring vital signs3. Communicate with ED personnel using two way radio 4. Give a description of what happened5. Describe patient age, sex and his condition6. What type of injury suspected7. Patient vital signs8. Emergency care that has been provided9. Estimated time of arrival

DEFINITIVE MANAGEMENT

Trauma center??Trauma center??Trauma team??Trauma team??

Trauma surgeon??Trauma surgeon??

Public Information & Education

• Public must be informed and educate regarding good emergency PHC system.

• 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

Disaster Preparedness

• Any PHC system is an integral part to disaster response effort.

• Need to be involve in planning & practice drill

In-hospital emergency care

• Receive patients

• Triage

• Resuscitation and stabilization

• Registration

• Investigation

• Treatment – definitive care, observation

• Disposal

Bystanderinterventions

Emergency ServiceDispatch

On sceneinterventions

Early DefinitiveCare/Trauma Center/ED

Transportation

Thank you