Concepts of Injury
Definition of Injury A discussion of injury prevention should begin with a definition of the term injury. The wide variability of the causes of injury initially represented a major hurdle in its study and prevention. For example, what does a fractured hip caused by an elderly person’s fall have in common with a self-inflicted gunshot wound to the head of a young adult? All possible causes of injury— from vehicle crash, to stabbing, to suicide, to drowning— have one factor in common: energy transfer. Injury is now commonly defined as a harmful event that arises from the release of specific forms of physical energy or barriers to normal flow of energy. 11 Typically, energy exists in five physical forms: mechanical, chemical, thermal, radiation, or electrical.
Mechanical energy is the energy that an object contains when it is in motion. For example, mechanical energy, the most common cause of injury, is transferred from a vehicle when an unrestrained driver collides with the windshield during a vehicle crash.
Chemical energy is the energy that results from the interaction of a chemical with exposed human tissue. For instance, chemical energy occurs when a curious child drinks ammonia found in an unlocked cabinet in the kitchen.
Thermal energy is the energy associated with increased temperature and heat. For example, thermal energy causes injury when a cook sprays lighter fluid on actively burning charcoal in an outdoor grill, which then flashes in his face.
Radiation energy is any electromagnetic wave that travels in rays (such as x-rays) and has no physical mass to it. Radiation energy produces sunburn to the teenager searching for a golden tan for the summer.
Electrical energy results from the movement of electrons between two points. It is associated with direct injury as well as thermal injury and, for example, damages the skin, nerves, and blood vessels of a prehospital care provider who fails to do a proper scene assessment before touching a vehicle that hit a power pole.
The body requires basic elements, such as oxygen and heat, to produce the internal energy needed to function properly. If conditions arise that prevent the body from using these necessary elements, injury can result. Suffocation and hypothermia are physical injuries that result from an interruption of the body’s normal energy flow. Any form of physical energy in sufficient quantity can cause tissue damage. The body can tolerate energy transfer within certain limits; however, an injury results if this threshold is breached. A bullet fired from a pistol at point-blank range easily passes through skin and soft tissue, causing massive injury . If the intended victim is far enough away, theoretically, the potential victim can simply stick out a hand, and the bullet would hit his palm and fall harmlessly to the ground . As the energy dissipates in the air on its flight, the bullet does not have enough energy on impact to exceed the body’s tolerance level. Such a situation rarely happens.
Energy Out of Control
People harness and use all five forms of energy in many productive
Wednesday, September 10, 2014
Tuesday, September 9, 2014
Ch 2 - Injury Prevention - Scope of the Problem
Scope of the Problem
Death from injuries is a major health problem worldwide, resulting in more than 14,000 deaths daily ( Figure 2-1 ). In most countries, regardless of their level of development, injuries appear among the five leading causes of death. 4 Although causes of injury deaths vary little between countries, wide variability does exist between which causes have the greatest impact on specific age groups . Because of economic, social, and developmental issues, the cause of injury-related death varies from country to country and even region to region within the same country.
FIGURE 2-1 Worldwide Injury-Related Statistics, 2004
All figures compiled from World Health Organization data.
FIGURE 2-2 Distribution of global injury mortality by cause, 2000. (From World Health Organization: The Injury Chart Book, Geneva, 2002, WHO.)
For example, in low-income and middle-income countries of the western Pacific, the leading injury-related causes of death are road traffic injuries, drowning, and suicide, whereas in Africa the leading causes are road traffic injuries, war, and interpersonal violence. In high-income countries of the Americas, the leading cause of death among people between 15 and 29 years of age is road traffic injuries. In low-income and middle-income countries of the Americas, the leading cause is interpersonal violence for the same age group. 4 Figure 2-2 demonstrates that injury plays a leading role in the global burden of disease. In the United States, injuries are the fifth leading cause of death, accounting for more than 179,000 deaths annually 3 ( Figure 2-3 ). Injury is an especially serious problem for the youth of America as well as of most industrialized nations of the world. In the United States, injury kills more children and young adults than all diseases combined (over 32,000 in 2006). 3 Unfortunately, deaths from injury are only the tip of the iceberg. The “injury triangle” provides a more complete picture of the public health impact of injury ( Figure 2-4 ). In the United States in 2006, in addition to the 167,000 people who died from injury, another 1.9 million were hospitalized because of nonfatal injuries. Injury also resulted in more than 31 million emergency-department visits. 3 The impact can be further realized by examining the number of years of potential life lost (YPLL) as a result of injury. YPLL is calculated by subtracting age-at-death from a fixed age of the group under examination, usually 65 or 70 years or the life expectancy of the group. Injury unnecessarily kills or disables people of all ages, but it disproportionately affects children, youth, and young adults, especially in industrialized nations. Because injury is the leading killer of Americans between 1 and 44 years of age, it is responsible for more YPLL than any other cause. In 2006, injury stole an estimated 3.68 million years from its victims compared with 1.8 million years for cancer, even though cancer claims more lives than injury. 3 A third measure of injury severity can be demonstrated financially. The economics of injury are felt far beyond the patient and the immediate family. The cost of injury is spread across a wide spectrum. All members of society feel the effect because the costs of injury are borne by federal and other agencies, private insurance programs that pass the expense on to other subscribers, and employers as well as the patient. As a result, everyone pays when an individual is seriously injured. Cost estimates for injury run as high as $ 325 billion annually, which includes the direct cost of medical care and indirect costs such as lost earnings. 6 Data from the World Health Organization (WHO) indicate that prevention activities are a good investment:
FIGURE 2-3 Ranking of Causes of Injury-Related Deaths by Age Groups, 2006 *Data not applicable or available Extracted from: National Vital Statistics System, National Center for Health Statistics, CDC, Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC: Ranking of Causes of Injury-Related Deaths by Age Groups, 2006.
FIGURE 2-4 Injury triangle. (Data from the US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Injury in the United States 2007 Chartbook.)
Every US dollar invested in motorcycle helmets results in a $ 32 savings of medical costs.
Seatbelts decrease the risk of ejection and suffering serious or fatal injury by 40– 65%.
The toll of injury in terms of morbidity, mortality, and economic stress is excessive: Injuries have always been a threat to the public’s well-being, but until the mid-twentieth century, infectious diseases overshadowed the terrible contribution injury made to human morbidity and mortality. Public health’s success in other areas has left injury as a major public health concern, one that has been termed “the neglected epidemic.” 6 Society is calling on all segments of the medical community to increase its prevention activities. With more than 600,000 prehospital providers in the United States alone, EMS systems can make a tremendous contribution to community-based injury-prevention efforts. Injury in EMS Obtaining a clear picture of the impact of injury on the EMS provider is difficult because no single, national data-gathering process deals with the industry. Even determining how many providers are in the United States is only an estimate of 600,000 to 832,000. However, several studies and publications have sought to answer this question. EMS personnel are undoubtedly exposed to a wide variety of situations that can result in worker injury. They go where people are hurt and sick. Sometimes those scenes are unsecured, despite the best efforts of EMS personnel and law enforcement, because these scenes involve people in emotional and physical crisis. Even the very nature of the work presents opportunities for injury. Just driving to the scene can be hazardous. Lifting, exposure to environmental hazards and infectious diseases, and the stress of the job also present opportunities for injury. For the years 1992 through 1997, an estimated 12.7 fatalities occurred per 100,000 workers per year in EMS. 7 , 8 This compares with a national average fatality rate of 5.0 per 100,000 for all workers over the same period. More than 58% of those EMS fatalities involved ambulance crashes; 9% involved assault or homicide. As with fatalities, estimating nonfatal injury can be difficult as well. However, one serious, disabling injury requiring hospitalization per 31,616 dispatches has been documented among urban providers. 9 These numbers reveal a disturbing truth. “The most dangerous times for EMS personnel are when they are inside their truck when it is moving or when they are working at a crash scene near other moving vehicles.” 10 It is critical that EMS personnel know and understand the concepts of injury and injury prevention so that the risks inherent in EMS can be identified and corrected. From almost the first day of EMT education, students are taught that no one is more important at the scene than the EMT, so his or her safety must come first. Seat belt use in the ambulance is the first step of safety.
Death from injuries is a major health problem worldwide, resulting in more than 14,000 deaths daily ( Figure 2-1 ). In most countries, regardless of their level of development, injuries appear among the five leading causes of death. 4 Although causes of injury deaths vary little between countries, wide variability does exist between which causes have the greatest impact on specific age groups . Because of economic, social, and developmental issues, the cause of injury-related death varies from country to country and even region to region within the same country.
FIGURE 2-1 Worldwide Injury-Related Statistics, 2004
All figures compiled from World Health Organization data.
FIGURE 2-2 Distribution of global injury mortality by cause, 2000. (From World Health Organization: The Injury Chart Book, Geneva, 2002, WHO.)
For example, in low-income and middle-income countries of the western Pacific, the leading injury-related causes of death are road traffic injuries, drowning, and suicide, whereas in Africa the leading causes are road traffic injuries, war, and interpersonal violence. In high-income countries of the Americas, the leading cause of death among people between 15 and 29 years of age is road traffic injuries. In low-income and middle-income countries of the Americas, the leading cause is interpersonal violence for the same age group. 4 Figure 2-2 demonstrates that injury plays a leading role in the global burden of disease. In the United States, injuries are the fifth leading cause of death, accounting for more than 179,000 deaths annually 3 ( Figure 2-3 ). Injury is an especially serious problem for the youth of America as well as of most industrialized nations of the world. In the United States, injury kills more children and young adults than all diseases combined (over 32,000 in 2006). 3 Unfortunately, deaths from injury are only the tip of the iceberg. The “injury triangle” provides a more complete picture of the public health impact of injury ( Figure 2-4 ). In the United States in 2006, in addition to the 167,000 people who died from injury, another 1.9 million were hospitalized because of nonfatal injuries. Injury also resulted in more than 31 million emergency-department visits. 3 The impact can be further realized by examining the number of years of potential life lost (YPLL) as a result of injury. YPLL is calculated by subtracting age-at-death from a fixed age of the group under examination, usually 65 or 70 years or the life expectancy of the group. Injury unnecessarily kills or disables people of all ages, but it disproportionately affects children, youth, and young adults, especially in industrialized nations. Because injury is the leading killer of Americans between 1 and 44 years of age, it is responsible for more YPLL than any other cause. In 2006, injury stole an estimated 3.68 million years from its victims compared with 1.8 million years for cancer, even though cancer claims more lives than injury. 3 A third measure of injury severity can be demonstrated financially. The economics of injury are felt far beyond the patient and the immediate family. The cost of injury is spread across a wide spectrum. All members of society feel the effect because the costs of injury are borne by federal and other agencies, private insurance programs that pass the expense on to other subscribers, and employers as well as the patient. As a result, everyone pays when an individual is seriously injured. Cost estimates for injury run as high as $ 325 billion annually, which includes the direct cost of medical care and indirect costs such as lost earnings. 6 Data from the World Health Organization (WHO) indicate that prevention activities are a good investment:
FIGURE 2-3 Ranking of Causes of Injury-Related Deaths by Age Groups, 2006 *Data not applicable or available Extracted from: National Vital Statistics System, National Center for Health Statistics, CDC, Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC: Ranking of Causes of Injury-Related Deaths by Age Groups, 2006.
FIGURE 2-4 Injury triangle. (Data from the US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Injury in the United States 2007 Chartbook.)
Every US dollar invested in motorcycle helmets results in a $ 32 savings of medical costs.
Seatbelts decrease the risk of ejection and suffering serious or fatal injury by 40– 65%.
The toll of injury in terms of morbidity, mortality, and economic stress is excessive: Injuries have always been a threat to the public’s well-being, but until the mid-twentieth century, infectious diseases overshadowed the terrible contribution injury made to human morbidity and mortality. Public health’s success in other areas has left injury as a major public health concern, one that has been termed “the neglected epidemic.” 6 Society is calling on all segments of the medical community to increase its prevention activities. With more than 600,000 prehospital providers in the United States alone, EMS systems can make a tremendous contribution to community-based injury-prevention efforts. Injury in EMS Obtaining a clear picture of the impact of injury on the EMS provider is difficult because no single, national data-gathering process deals with the industry. Even determining how many providers are in the United States is only an estimate of 600,000 to 832,000. However, several studies and publications have sought to answer this question. EMS personnel are undoubtedly exposed to a wide variety of situations that can result in worker injury. They go where people are hurt and sick. Sometimes those scenes are unsecured, despite the best efforts of EMS personnel and law enforcement, because these scenes involve people in emotional and physical crisis. Even the very nature of the work presents opportunities for injury. Just driving to the scene can be hazardous. Lifting, exposure to environmental hazards and infectious diseases, and the stress of the job also present opportunities for injury. For the years 1992 through 1997, an estimated 12.7 fatalities occurred per 100,000 workers per year in EMS. 7 , 8 This compares with a national average fatality rate of 5.0 per 100,000 for all workers over the same period. More than 58% of those EMS fatalities involved ambulance crashes; 9% involved assault or homicide. As with fatalities, estimating nonfatal injury can be difficult as well. However, one serious, disabling injury requiring hospitalization per 31,616 dispatches has been documented among urban providers. 9 These numbers reveal a disturbing truth. “The most dangerous times for EMS personnel are when they are inside their truck when it is moving or when they are working at a crash scene near other moving vehicles.” 10 It is critical that EMS personnel know and understand the concepts of injury and injury prevention so that the risks inherent in EMS can be identified and corrected. From almost the first day of EMT education, students are taught that no one is more important at the scene than the EMT, so his or her safety must come first. Seat belt use in the ambulance is the first step of safety.
Ch 2 - Injury Prevention - Scenario
SCENARIO
Jose and Gwen are putting their rig back in service after a car crash that ended with three fatalities, including an infant and a child. “Jose, I just can’t stop thinking about how this would have had a very different ending if this woman had put her babies in infant and child seats. She might have survived herself if she had used her seat belt and shoulder harness.” “I’m with you, Gwen. Someone needs to do something about compliance with seat belt and child seat laws around here.” “Do you think it’s just ignorance of the dangers, or is it an economic issue, Jose?” “Well, I suppose buying the seats might be an economic issue, but the unrestrained driver made a conscious decision not to use seat belts. There must be a way to get the message out.” Is prevention a realistic approach in preventing injury and death in car crashes and other causes of traumatic injury? Is there evidence that compliance with seat belt and safety seats has an impact in preventing injury and death? What can we as providers do to prevent these types of deaths and injuries?
A major impetus in the development of modern emergency medical services (EMS) systems was the publication of the 1966 white paper by the National Academy of Sciences/ National Research Council (NAS/ NRC), Accidental Death and Disability: the Neglected Disease of Modern Society . The paper spotlighted shortcomings in injury management in the United States and helped launch a formal system of on-scene care and rapid transport for patients injured as a result of “accidents.” This educational initiative was instrumental in the creation of a more efficient system to deliver prehospital care to sick and injured patients. 1 Death and disability from injury in the United States have fallen since the publication of the white paper. 2 Despite this progress, however, injury remains a major public health problem. More than 179,000 Americans die from injuries annually, and millions more are adversely affected to some degree. 3 However, injury is a global problem as well. Over 5 million people worldwide died from injuries in 2002, accounting for 9% of deaths worldwide. Injuries remain a leading cause of death for all age groups. 4 For some age groups, particularly children, teenagers, and young adults, injury is the leading cause of death. The desire to care for patients stricken by injury draws many into the field of EMS. The Prehospital Trauma Life Support (PHTLS) course teaches prehospital providers to be efficient and effective in injury management. The need for well-trained prehospital providers to care for injured patients will always exist. However, the most efficient and effective method to combat injury is to prevent it from happening in the first place. Health care providers at all levels play an active role in injury prevention to achieve the best results for not only the community at large but for themselves as well. Even in 1966, the authors of the NAS /NRC white paper recognized the importance of injury prevention when they wrote: The long-term solution to the injury problem is prevention … Prevention of accidents involves training in the home, in the school, and at work, augmented by frequent pleas for safety in the news media; first aid courses and public meetings; and inspection and surveillance by regulatory agencies. 1 Prehospital personnel can easily play an active role in most, if not all, of the current recommendations for injury prevention. Prevention of some diseases, such as rabies, has been so effective that the occurrence of a single case makes front-page news. Public health officials recognize that prevention results in the greatest reward toward the amelioration of disease. Emergency medical technician (EMT ) curricula have long included formal instruction in scene safety and personal protective equipment as a means of self-injury prevention for the EMT. To spur EMS systems to take a more active role in community prevention strategies, the EMS Agenda for the Future, developed by and for the EMS community, lists prevention as one of 14 attributes to develop further in order to “improve community health and result in more appropriate use of acute health resources .” 5 To this end, the US Department of Transportation (DOT) paramedic curriculum and now the National EMS Core Content include community injury-prevention training. EMS systems are transforming themselves from a solely reactionary discipline to a broader, more effective discipline that includes more emphasis on prevention. This chapter introduces key concepts of injury prevention to the prehospital care provider.
Jose and Gwen are putting their rig back in service after a car crash that ended with three fatalities, including an infant and a child. “Jose, I just can’t stop thinking about how this would have had a very different ending if this woman had put her babies in infant and child seats. She might have survived herself if she had used her seat belt and shoulder harness.” “I’m with you, Gwen. Someone needs to do something about compliance with seat belt and child seat laws around here.” “Do you think it’s just ignorance of the dangers, or is it an economic issue, Jose?” “Well, I suppose buying the seats might be an economic issue, but the unrestrained driver made a conscious decision not to use seat belts. There must be a way to get the message out.” Is prevention a realistic approach in preventing injury and death in car crashes and other causes of traumatic injury? Is there evidence that compliance with seat belt and safety seats has an impact in preventing injury and death? What can we as providers do to prevent these types of deaths and injuries?
A major impetus in the development of modern emergency medical services (EMS) systems was the publication of the 1966 white paper by the National Academy of Sciences/ National Research Council (NAS/ NRC), Accidental Death and Disability: the Neglected Disease of Modern Society . The paper spotlighted shortcomings in injury management in the United States and helped launch a formal system of on-scene care and rapid transport for patients injured as a result of “accidents.” This educational initiative was instrumental in the creation of a more efficient system to deliver prehospital care to sick and injured patients. 1 Death and disability from injury in the United States have fallen since the publication of the white paper. 2 Despite this progress, however, injury remains a major public health problem. More than 179,000 Americans die from injuries annually, and millions more are adversely affected to some degree. 3 However, injury is a global problem as well. Over 5 million people worldwide died from injuries in 2002, accounting for 9% of deaths worldwide. Injuries remain a leading cause of death for all age groups. 4 For some age groups, particularly children, teenagers, and young adults, injury is the leading cause of death. The desire to care for patients stricken by injury draws many into the field of EMS. The Prehospital Trauma Life Support (PHTLS) course teaches prehospital providers to be efficient and effective in injury management. The need for well-trained prehospital providers to care for injured patients will always exist. However, the most efficient and effective method to combat injury is to prevent it from happening in the first place. Health care providers at all levels play an active role in injury prevention to achieve the best results for not only the community at large but for themselves as well. Even in 1966, the authors of the NAS /NRC white paper recognized the importance of injury prevention when they wrote: The long-term solution to the injury problem is prevention … Prevention of accidents involves training in the home, in the school, and at work, augmented by frequent pleas for safety in the news media; first aid courses and public meetings; and inspection and surveillance by regulatory agencies. 1 Prehospital personnel can easily play an active role in most, if not all, of the current recommendations for injury prevention. Prevention of some diseases, such as rabies, has been so effective that the occurrence of a single case makes front-page news. Public health officials recognize that prevention results in the greatest reward toward the amelioration of disease. Emergency medical technician (EMT ) curricula have long included formal instruction in scene safety and personal protective equipment as a means of self-injury prevention for the EMT. To spur EMS systems to take a more active role in community prevention strategies, the EMS Agenda for the Future, developed by and for the EMS community, lists prevention as one of 14 attributes to develop further in order to “improve community health and result in more appropriate use of acute health resources .” 5 To this end, the US Department of Transportation (DOT) paramedic curriculum and now the National EMS Core Content include community injury-prevention training. EMS systems are transforming themselves from a solely reactionary discipline to a broader, more effective discipline that includes more emphasis on prevention. This chapter introduces key concepts of injury prevention to the prehospital care provider.
Ch 2 - Injury Prevention - Chapter Objectives
CHAPTER OBJECTIVES
At the completion of this chapter, the reader will be able to do the following:
Describe the concept of energy as a cause of injury.
Build a Haddon Matrix for a type of injury of interest.
Relate the importance of accurate, attentive scene observations and documentation of data by emergency medical services (EMS) providers to the success of injury prevention initiatives.
Assist in the development, implementation, and evaluation of injury prevention programs in his or her community or EMS organization.
Describe and advocate for the role of EMS in injury prevention, to include: Individual, Family, Community, Professional, Organizational, and Coalitions of organizations
Identify strategies that prehospital care providers can implement that will reduce the risk of injury.
At the completion of this chapter, the reader will be able to do the following:
Describe the concept of energy as a cause of injury.
Build a Haddon Matrix for a type of injury of interest.
Relate the importance of accurate, attentive scene observations and documentation of data by emergency medical services (EMS) providers to the success of injury prevention initiatives.
Assist in the development, implementation, and evaluation of injury prevention programs in his or her community or EMS organization.
Describe and advocate for the role of EMS in injury prevention, to include: Individual, Family, Community, Professional, Organizational, and Coalitions of organizations
Identify strategies that prehospital care providers can implement that will reduce the risk of injury.
Ch 1 - PTHLS: Past, Present, & Future - Summary
SUMMARY
Trauma is the leading cause of death in patients under the age of 44 years. An organized, systematic approach to the care of these patients can improve patient survival. This organized approach begins initially with efforts to prevent injury from occurring. When injury does occur, the organized and systematic response of the entire health care delivery team, beginning in the prehospital setting, will help decrease the morbidity and mortality of traumatic injury.
Trauma is the leading cause of death in patients under the age of 44 years. An organized, systematic approach to the care of these patients can improve patient survival. This organized approach begins initially with efforts to prevent injury from occurring. When injury does occur, the organized and systematic response of the entire health care delivery team, beginning in the prehospital setting, will help decrease the morbidity and mortality of traumatic injury.
Ch 1 - PHTLS: Past, Present, & Future - Reading the EMS Literature
Reading the EMS Literature
A major goal of PHTLS has been to ensure that the practice recommendations presented in this text accurately represent the best medical evidence available at the time of publication in support of these recommendations. To that end, PHTLS began this process with the 6 th edition and it is expanded in the 7th edition . We continue to add, as References and Suggested Readings, those manuscripts , sources, and resources that are fundamental components of each chapter and recommendation. (See Suggested Readings at the end of this chapter for further information on evaluating the EMS literature.) Every practitioner and health care provider should obtain, read, and critically evaluate the publications and sources that make up the basis for all the components of daily practice. To accomplish this, an understanding of exactly what constitutes the medical literature and of how to interpret the various sources of information is essential. In many cases the first place that is accessed for information about a particular topic is a medical textbook. As our level of interest and sophistication grows, a search is undertaken to find the specific references that are referred to in those book chapters or to find what, if any, primary research studies have been performed and published. Then, after reviewing and analyzing the various sources, a decision can be made about the quality and strength of the evidence that will guide our decision making and patient care interventions.
Types of Evidence
There are a number of different systems for rating the quality and strength of medical evidence. Regardless of the exact rating system used, several common assessments can be found among them. The highest-quality source that leads to the strongest recommendation about the treatment under study is the randomized, double-blind controlled study. Studies of this type are usually referred to as Class I evidence. This type of study is considered to be the best type of study because: all patients entered into the study are randomized (meaning each patient has an equal chance of assignment to whatever type of treatment is being studied); the researchers as well as the patients do not know which type of treatment the subject is receiving (double blinding); and investigators are controlling as many other aspects of the study as possible. These factors minimize the chances of any bias entering into the study or affecting the results or interpretation of the results. Class II evidence generally includes the other types of studies that can be found in the medical literature, including nonrandomized non-blinded studies, retrospective case-control series, and cohort studies. Finally, Class III evidence consists of case studies , case reports, consensus documents, textbook material, and medical opinion. Class III evidence is the weakest source of evidence, although often the easiest to obtain. Unfortunately, if the literature related to prehospital care is critically reviewed, the majority qualifies as Class III evidence. There has been remarkably little research that would qualify as Class I. Much of the practice of medicine that has been applied to the prehospital setting has been adopted from and adapted to the out-of-hospital environment from the in-hospital delivery of emergency care. The result is that most of the prehospital care provided today is based on Class III evidence. However, more and more Class I and II studies related to prehospital care are being conducted. Unfortunately, Class I studies are limited in the United States by rigid informed-consent regulations. Specifically, with few exceptions, the medical practice of prehospital care is based on “expert” opinion usually found in textbook chapters, the credentials and qualifications of the individual offering that opinion, and the forcefulness and “volume” of the delivery of that opinion. type of treatment the subject is receiving (double blinding); and investigators are controlling as many other aspects of the study as possible. These factors minimize the chances of any bias entering into the study or affecting the results or interpretation of the results. Class II evidence generally includes the other types of studies that can be found in the medical literature, including nonrandomized non-blinded studies, retrospective case-control series, and cohort studies. Finally, Class III evidence consists of case studies , case reports, consensus documents, textbook material, and medical opinion. Class III evidence is the weakest source of evidence, although often the easiest to obtain. Unfortunately, if the literature related to prehospital care is critically reviewed, the majority qualifies as Class III evidence. There has been remarkably little research that would qualify as Class I. Much of the practice of medicine that has been applied to the prehospital setting has been adopted from and adapted to the out-of-hospital environment from the in-hospital delivery of emergency care. The result is that most of the prehospital care provided today is based on Class III evidence. However, more and more Class I and II studies related to prehospital care are being conducted. Unfortunately, Class I studies are limited in the United States by rigid informed-consent regulations. Specifically, with few exceptions, the medical practice of prehospital care is based on “expert” opinion usually found in textbook chapters, the credentials and qualifications of the individual offering that opinion, and the forcefulness and “volume” of the delivery of that opinion. Recently, consensus seems to be building to utilize a system for grading the quality of evidence and the strength of a resulting clinical practice recommendation known as The Grades of Recommendation, Assessment, Development and Evaluation (GRADE). This system appraises the quality of evidence available and the benefits versus the risks of the intervention, and then develops a judgment about the strength of a particular treatment recommendation or intervention. Evidence is rated into one of four categories: high, moderate, low, very low quality. Based upon the quality of the evidence and the benefit/ risk evaluation, the resulting recommendation is categorized as strong or weak.
Steps in Evaluation
Every medical practitioner should read the medical literature and critically evaluate every study published that might alter treatment decisions in order to distinguish useful information and therapy from that which is useless or potentially even harmful. How, then, does one go about reading and The first step in this process is to develop a list of journals that will form the foundation of a regular literature review. This list should comprise not only those journals with the desired specialty in their name, but also those publications that address related specialties or topics and have a high likelihood of also publishing applicable studies ( Figure 1-7 ). An alternative to reviewing multiple journals is to perform a computerized literature search if there is a particular topic of interest. The use of computerized search engines such as Medline or Ovid allows the computer to search a massive database of multiple medical journals and automatically develop a list of suggested studies and publications ( Figure 1-8 ). The next step is to review the title of every article in the table of contents of each of the selected journals to narrow down the article choices to those that clearly relate to the topic of interest. It would be impossible to read each of the selected journals from cover to cover, nor is it necessary. By reviewing the table of contents, articles that are of no interest can be immediately dismissed. Once the selection has been narrowed, there are still a number of preliminary actions to take before reading the text of the article. Look at the authors listed on the articles to see if any are already known for their work in this area. Next, read the summary or abstract of the article to see if this overview of the article fulfils the expectations generated when the title was first reviewed. Then, review the site where the study was conducted to assess the similarities, differences, and applicability to the setting in which the results of the study may be subsequently applied. It must be stressed that reading the abstract alone is not enough. It serves only as the “teaser” to determine whether the full article should be reviewed. Medical practice should never be changed based on the abstract. Once these initial points have been evaluated , the full text of the article is now read and critically assessed. In doing so, several specific issues are important to determine. The first issue is to evaluate the study and the randomization of the patients entered into the study. Every patient included should have had the same probability of receiving one or the other treatments or interventions being compared in the study, and that probability should be known beforehand. The method for assigning patients to their treatment should be described and should be similar to the flip of a coin. Next, the patient population entered into the study is assessed to determine the similarities or differences with the target population for which the study conclusions will be implemented. To do so, adequate information must be provided in the text describing the clinical and sociodemographic makeup of the study population. Ideally, studies that will be used to alter the care provided in the prehospital setting should have been performed in the prehospital setting. As Dan Spaite, MD, stated “Strong evidence for efficacy of an intervention does not mean that it will be effective when applied in the field.” The next issue for consideration is the outcome measure selected by the authors. All outcomes that are clinically relevant should be considered and reported in the study. For example, cardiac arrest studies may describe such endpoints or outcomes as cardiac rhythm conversion, return of spontaneous circulation, survival to hospital admission, or survival to discharge from the hospital. Analysis of the results section also requires critical review. Just as it is important to evaluate the study population and entry criteria, it is equally important to see if all patients entered into the study at the beginning are accounted for at the end of the study. Specifically, the authors should describe any criteria used to exclude patients from the study analysis. Simple addition by the reader of the various treatment groups or subgroups will quickly confirm if all patients were accounted for. The authors should also describe occurrences that might introduce bias into the results. For example, the authors should report mishaps such as control patients accidentally receiving the treatment or study patients receiving other diagnostics or interventions. In addition, the clinical, as well as the statistical, significance of the results are important to consider. Although the statistical analyses may be difficult to understand, a basic comprehension of statistical test selection and utilization will validate the statistical tests performed. Equal to and perhaps more important than the statistical significance of a result is the clinical significance of the reported result. For example, in evaluating the effect of a new antihypertensive medication, the statistical analysis may show that the new drug causes a statistically significant decrease in blood pressure of 4 mm Hg. Clinically, however, the reported decrease is insignificant. Thus, the health care provider must assess not only the statistical significance of the result but also the clinical significance. If all the prior issues have been answered satisfactorily, the last issue relates to the implementation of the study results and conclusion in the reader’s health care system. To determine the practicality of applying the therapy, the authors needed to describe the treatment in sufficient detail, the intervention or therapy must be available for use, and it must be clinically sensible in the planned setting. Some differences exist in the evaluation of consensus statements, overviews, and textbook chapters. Ideally, the statement or overview should address a specific, focused question. The authors should describe the criteria used to select the articles included as references, and the reader will determine the appropriateness of these criteria. This in turn will help determine the likelihood that important studies were included and not missed. In addition, the reference list should be reviewed for known studies that should have been included. A high-quality overview or consensus statement will include a discussion of the process by which the validity of the included studies was appraised. The validity assessment should be reproducible regardless of who actually performed the appraisal. Also, multiple studies with similar results help support the conclusions and ultimate decision about whether or not to change current practice. Similar to the review of individual studies , the review and assessment of consensus statements, overviews, and textbook chapters include a determination of whether all clinically relevant outcomes were considered and discussed and whether the results can be applied to the reader’s patient-care setting. This also includes an analysis of the benefits versus the potential risks and harm. The final step in evaluation is to determine when a publication should cause a change in daily medical practice. Ideally, any change in medical practice will result from a study of the highest quality, specifically a randomized, controlled, double -blind study. The conclusion of that study will be based on results that have been critically evaluated, have both statistical and clinical significance, and have been reviewed and judged to be valid. The study should be the best information currently available on the issue. In addition, the change in practice must be feasible for the system planning to make the change, and the benefit of making the change must outweigh the risks. All the medical practice in the out-of -hospital setting should be based on high-quality, Class I evidence that supports practice. As noted, however, most of the EMS literature qualifies as Class III evidence.
A major goal of PHTLS has been to ensure that the practice recommendations presented in this text accurately represent the best medical evidence available at the time of publication in support of these recommendations. To that end, PHTLS began this process with the 6 th edition and it is expanded in the 7th edition . We continue to add, as References and Suggested Readings, those manuscripts , sources, and resources that are fundamental components of each chapter and recommendation. (See Suggested Readings at the end of this chapter for further information on evaluating the EMS literature.) Every practitioner and health care provider should obtain, read, and critically evaluate the publications and sources that make up the basis for all the components of daily practice. To accomplish this, an understanding of exactly what constitutes the medical literature and of how to interpret the various sources of information is essential. In many cases the first place that is accessed for information about a particular topic is a medical textbook. As our level of interest and sophistication grows, a search is undertaken to find the specific references that are referred to in those book chapters or to find what, if any, primary research studies have been performed and published. Then, after reviewing and analyzing the various sources, a decision can be made about the quality and strength of the evidence that will guide our decision making and patient care interventions.
Types of Evidence
There are a number of different systems for rating the quality and strength of medical evidence. Regardless of the exact rating system used, several common assessments can be found among them. The highest-quality source that leads to the strongest recommendation about the treatment under study is the randomized, double-blind controlled study. Studies of this type are usually referred to as Class I evidence. This type of study is considered to be the best type of study because: all patients entered into the study are randomized (meaning each patient has an equal chance of assignment to whatever type of treatment is being studied); the researchers as well as the patients do not know which type of treatment the subject is receiving (double blinding); and investigators are controlling as many other aspects of the study as possible. These factors minimize the chances of any bias entering into the study or affecting the results or interpretation of the results. Class II evidence generally includes the other types of studies that can be found in the medical literature, including nonrandomized non-blinded studies, retrospective case-control series, and cohort studies. Finally, Class III evidence consists of case studies , case reports, consensus documents, textbook material, and medical opinion. Class III evidence is the weakest source of evidence, although often the easiest to obtain. Unfortunately, if the literature related to prehospital care is critically reviewed, the majority qualifies as Class III evidence. There has been remarkably little research that would qualify as Class I. Much of the practice of medicine that has been applied to the prehospital setting has been adopted from and adapted to the out-of-hospital environment from the in-hospital delivery of emergency care. The result is that most of the prehospital care provided today is based on Class III evidence. However, more and more Class I and II studies related to prehospital care are being conducted. Unfortunately, Class I studies are limited in the United States by rigid informed-consent regulations. Specifically, with few exceptions, the medical practice of prehospital care is based on “expert” opinion usually found in textbook chapters, the credentials and qualifications of the individual offering that opinion, and the forcefulness and “volume” of the delivery of that opinion. type of treatment the subject is receiving (double blinding); and investigators are controlling as many other aspects of the study as possible. These factors minimize the chances of any bias entering into the study or affecting the results or interpretation of the results. Class II evidence generally includes the other types of studies that can be found in the medical literature, including nonrandomized non-blinded studies, retrospective case-control series, and cohort studies. Finally, Class III evidence consists of case studies , case reports, consensus documents, textbook material, and medical opinion. Class III evidence is the weakest source of evidence, although often the easiest to obtain. Unfortunately, if the literature related to prehospital care is critically reviewed, the majority qualifies as Class III evidence. There has been remarkably little research that would qualify as Class I. Much of the practice of medicine that has been applied to the prehospital setting has been adopted from and adapted to the out-of-hospital environment from the in-hospital delivery of emergency care. The result is that most of the prehospital care provided today is based on Class III evidence. However, more and more Class I and II studies related to prehospital care are being conducted. Unfortunately, Class I studies are limited in the United States by rigid informed-consent regulations. Specifically, with few exceptions, the medical practice of prehospital care is based on “expert” opinion usually found in textbook chapters, the credentials and qualifications of the individual offering that opinion, and the forcefulness and “volume” of the delivery of that opinion. Recently, consensus seems to be building to utilize a system for grading the quality of evidence and the strength of a resulting clinical practice recommendation known as The Grades of Recommendation, Assessment, Development and Evaluation (GRADE). This system appraises the quality of evidence available and the benefits versus the risks of the intervention, and then develops a judgment about the strength of a particular treatment recommendation or intervention. Evidence is rated into one of four categories: high, moderate, low, very low quality. Based upon the quality of the evidence and the benefit/ risk evaluation, the resulting recommendation is categorized as strong or weak.
Steps in Evaluation
Every medical practitioner should read the medical literature and critically evaluate every study published that might alter treatment decisions in order to distinguish useful information and therapy from that which is useless or potentially even harmful. How, then, does one go about reading and The first step in this process is to develop a list of journals that will form the foundation of a regular literature review. This list should comprise not only those journals with the desired specialty in their name, but also those publications that address related specialties or topics and have a high likelihood of also publishing applicable studies ( Figure 1-7 ). An alternative to reviewing multiple journals is to perform a computerized literature search if there is a particular topic of interest. The use of computerized search engines such as Medline or Ovid allows the computer to search a massive database of multiple medical journals and automatically develop a list of suggested studies and publications ( Figure 1-8 ). The next step is to review the title of every article in the table of contents of each of the selected journals to narrow down the article choices to those that clearly relate to the topic of interest. It would be impossible to read each of the selected journals from cover to cover, nor is it necessary. By reviewing the table of contents, articles that are of no interest can be immediately dismissed. Once the selection has been narrowed, there are still a number of preliminary actions to take before reading the text of the article. Look at the authors listed on the articles to see if any are already known for their work in this area. Next, read the summary or abstract of the article to see if this overview of the article fulfils the expectations generated when the title was first reviewed. Then, review the site where the study was conducted to assess the similarities, differences, and applicability to the setting in which the results of the study may be subsequently applied. It must be stressed that reading the abstract alone is not enough. It serves only as the “teaser” to determine whether the full article should be reviewed. Medical practice should never be changed based on the abstract. Once these initial points have been evaluated , the full text of the article is now read and critically assessed. In doing so, several specific issues are important to determine. The first issue is to evaluate the study and the randomization of the patients entered into the study. Every patient included should have had the same probability of receiving one or the other treatments or interventions being compared in the study, and that probability should be known beforehand. The method for assigning patients to their treatment should be described and should be similar to the flip of a coin. Next, the patient population entered into the study is assessed to determine the similarities or differences with the target population for which the study conclusions will be implemented. To do so, adequate information must be provided in the text describing the clinical and sociodemographic makeup of the study population. Ideally, studies that will be used to alter the care provided in the prehospital setting should have been performed in the prehospital setting. As Dan Spaite, MD, stated “Strong evidence for efficacy of an intervention does not mean that it will be effective when applied in the field.” The next issue for consideration is the outcome measure selected by the authors. All outcomes that are clinically relevant should be considered and reported in the study. For example, cardiac arrest studies may describe such endpoints or outcomes as cardiac rhythm conversion, return of spontaneous circulation, survival to hospital admission, or survival to discharge from the hospital. Analysis of the results section also requires critical review. Just as it is important to evaluate the study population and entry criteria, it is equally important to see if all patients entered into the study at the beginning are accounted for at the end of the study. Specifically, the authors should describe any criteria used to exclude patients from the study analysis. Simple addition by the reader of the various treatment groups or subgroups will quickly confirm if all patients were accounted for. The authors should also describe occurrences that might introduce bias into the results. For example, the authors should report mishaps such as control patients accidentally receiving the treatment or study patients receiving other diagnostics or interventions. In addition, the clinical, as well as the statistical, significance of the results are important to consider. Although the statistical analyses may be difficult to understand, a basic comprehension of statistical test selection and utilization will validate the statistical tests performed. Equal to and perhaps more important than the statistical significance of a result is the clinical significance of the reported result. For example, in evaluating the effect of a new antihypertensive medication, the statistical analysis may show that the new drug causes a statistically significant decrease in blood pressure of 4 mm Hg. Clinically, however, the reported decrease is insignificant. Thus, the health care provider must assess not only the statistical significance of the result but also the clinical significance. If all the prior issues have been answered satisfactorily, the last issue relates to the implementation of the study results and conclusion in the reader’s health care system. To determine the practicality of applying the therapy, the authors needed to describe the treatment in sufficient detail, the intervention or therapy must be available for use, and it must be clinically sensible in the planned setting. Some differences exist in the evaluation of consensus statements, overviews, and textbook chapters. Ideally, the statement or overview should address a specific, focused question. The authors should describe the criteria used to select the articles included as references, and the reader will determine the appropriateness of these criteria. This in turn will help determine the likelihood that important studies were included and not missed. In addition, the reference list should be reviewed for known studies that should have been included. A high-quality overview or consensus statement will include a discussion of the process by which the validity of the included studies was appraised. The validity assessment should be reproducible regardless of who actually performed the appraisal. Also, multiple studies with similar results help support the conclusions and ultimate decision about whether or not to change current practice. Similar to the review of individual studies , the review and assessment of consensus statements, overviews, and textbook chapters include a determination of whether all clinically relevant outcomes were considered and discussed and whether the results can be applied to the reader’s patient-care setting. This also includes an analysis of the benefits versus the potential risks and harm. The final step in evaluation is to determine when a publication should cause a change in daily medical practice. Ideally, any change in medical practice will result from a study of the highest quality, specifically a randomized, controlled, double -blind study. The conclusion of that study will be based on results that have been critically evaluated, have both statistical and clinical significance, and have been reviewed and judged to be valid. The study should be the best information currently available on the issue. In addition, the change in practice must be feasible for the system planning to make the change, and the benefit of making the change must outweigh the risks. All the medical practice in the out-of -hospital setting should be based on high-quality, Class I evidence that supports practice. As noted, however, most of the EMS literature qualifies as Class III evidence.
Ch 1 - PHTLS: Past, Present, & Future - History of Trauma Care in Emergency Medical Services
History of Trauma Care in Emergency Medical Services
The stages and development of the management of the trauma patient can be divided roughly into four time periods as described by McSwain in the Scudder Oration of the American College of Surgeons in 1999. 32 This text, the PHTLS course, and care of the trauma patient are based on the principles developed and taught by the early pioneers of prehospital care. The list of these innovators is long; however, a few especially deserve recognition.
Ancient Period
All of the medical care that was accomplished in Egypt, Greece, and Rome, by the Israelites, and up to the time of Napoleon is classified as premodern EMS. There is much to be learned here, but most of the medical care was accomplished within some type of medical facility. Little was done by prehospital providers in the field.
Larrey Period
In the late 1700s, Baron Dominick Jean Larrey, Napoleon’s chief military physician, recognized the need for prompt prehospital care. In 1797, he noted that “the remoteness of our ambulances deprive the wounded of the requisite attention. I was authorized to construct a carriage which I call flying ambulances.” 33 He developed these horse-drawn “flying ambulances” for timely retrieval of warriors injured on the battlefield and introduced the premise that individuals working in these “flying ambulances” should be trained in medical care to provide on-scene and en route care for patients. By the early 1800s, he had established the theory of prehospital care that we continue to use to this day: the “flying” ambulance proper training of medical personnel move into the field during battle for patient care and retrieval field control of hemorrhage transport to a nearby hospital provide care en route develop frontline hospitals He also developed hospitals that were close to the front lines (much like the military of today) and stressed the rapid movement of patients from the field to medical care. Baron Larrey is now recognized as the father of EMS in the modern era. Unfortunately, the type of care developed by Larrey was not used 60 years later at the beginning of the War Between the States by the Union Army in the United States. At the First Battle of Bull Run in August 1861, the wounded laid in the field— 3000 for three days, 600 up to a week. 33 , 34 Jonathan Letterman was appointed Surgeon General and created a separate medical corps with better organized medical care . At the Second Battle of Bull Run a year later, there were 300 ambulances and attendants collected 10,000 wounded in 24 hours. 34 In August 1864, the International Red Cross was created at the First Geneva Convention. 29 The convention recognized the neutrality of hospitals, of the sick and wounded, of all involved personnel, and of ambulances and guaranteed safe passage for ambulances and medical personnel to move the wounded. This was the first step in what we utilize today within the military as our Code of Conduct. This is an important component of the Tactical Combat Casualty Care Course, which is now an integral part of the PHTLS program.
Hospitals, Military, and Mortuaries
In 1865, the first private ambulance in the United States was created in Cincinnati, Ohio, at Cincinnati General Hospital. 34 Several EMS systems soon developed in the United States: Bellevue Hospital Ambulance 34 followed in New York in 1867; Grady Hospital Ambulance Service (the oldest continuously operating hospital-based ambulance) in Atlanta in the 1880s; Charity Hospital Ambulance Services created in 1885 by a surgeon, Dr. A. B. Miles in New Orleans; and many other facilities in the United States. These ambulance services were run basically by hospitals, by the military, or by mortuaries up until 1950. 32 Some changes in medical care occurred during the various wars up until the end of World War II, but generally the system and the type of care rendered prior to arrival in the Battalion Aid station (Echelon II) or at the back door of the civilian hospital remained unchanged until the mid 1950s. Many ambulances in the major cities with teaching hospitals were staffed by interns beginning their first year of training. The last ambulance service to require physicians on the ambulance runs was Charity Hospital in New Orleans in the 1960s. Despite the fact that physicians were present, most of the trauma care was primitive. The equipment and supplies were not changed from that used during the War Between the States. 32
Farrington Era
The era of J.D. “Deke” Farrington, MD, began in 1950. Dr. Farrington, the father of EMS in the United States, stimulated the development of improved prehospital care with his landmark article, “Death in a Ditch.” 35 In the late 1960s, Farrington and other early leaders, such as Oscar Hampton, MD, and Curtis Arts, MD, brought the United States into the modern era of EMS and prehospital care. 41 Dr. Farrington was actively involved in all aspects of ambulance care. His work as chairman of the committees that produced three of the initial documents establishing the basis of EMS— the essential equipment list for ambulances of the American College of Surgeons (ACS), 36 the KKK 1822 ambulance design specifications of the US Department of Transportation, 37 and the first emergency medical technician (EMT) basic training program— also propelled the idea and development of prehospital care. In addition to the efforts of Dr. Farrington, others actively helped promote the importance of prehospital care for the trauma victim. Robert Kennedy, MD, was the author of “Early Care of the Sick and Injured Patient.” 38 Sam Banks, MD, with Dr. Farrington, taught the first prehospital training course to the Chicago Fire Department in 1957, which initiated proper care of the trauma patient. A 1965 text edited and compiled by George J. Curry, MD, a leader of the ACS and its Committee on Trauma, stated: “Injuries sustained in accidents affect every part of the human body. They range from simple abrasions and contusions to multiple complex injuries involving many body tissues. This demands efficient and intelligent primary appraisal and care, on an individual basis, before transport. It is obvious that the services of trained ambulance attendants are essential. If we are to expect maximum efficiency from ambulance attendants, a special training program must be arranged.” 38 Although prehospital care was rudimentary when Curry wrote this passage, the words still hold true as prehospital care providers address the specific needs of the trauma patient in the field. The landmark white paper, “Accidental Death and Disability: the Neglected Disease of Modern Society,” further accelerated the process in 1967. 39 The National Academy of Sciences/ National Research Council issued this paper just one year after Curry’s call.
Modern Era of Prehospital Care
The modern era of prehospital care began with the Dunlap and Associates report to the EMS Department of Transportation in 1968 defining the curriculum for EMT Ambulance Training. This training is now known as EMT-Basic. The National Registry of EMTs was established in 1970 and developed the standards for testing and registration of trained EMS personal as advocated in the NSF/ ACS white paper. Rocco Morando was the leader of the NREMT for many years and was associated with Drs. Farrington, Hampton, and Artz. Curry’s call for specialized training of ambulance attendants for trauma was initially answered by using the educational program developed by Drs. Farrington and Banks, by the publication of the “orange book” by the American Academy of Orthopedic Surgeons (first edited by Dr. Walter Hoyt), by the EMT training programs from NHTSA, and by the PHTLS training program during the past 25 years. The first training efforts were primitive but have progressed significantly in a relatively brief time. The first textbook of this era was Emergency Care and Transportation of the Sick and Injured. This was the brainchild of Walter A. Hoyt Jr., MD, and was published in 1971 by the American Association of Orthopedic Surgeons. 32 This text is now in its 9th edition. During this same period , the Glasgow Coma Scale was developed in Glasgow, Scotland, by Dr. Graham Teasdale and Dr. Bryan Jennett for research purposes. Dr. Howard Champion (the author of the Blast chapter in the military version of this textbook) brought it into the United States and incorporated it into the care of the trauma patient for assessment of the continued neurological status of the patient. 40 The Glasgow Coma Scale is a very sensitive indicator of improvement or deterioration of such patients. In 1973, federal EMS legislation was created. Dr. David Boyd was in charge of this system. He divided the components of trauma care into 15 segments. One of these segments was education. This became the basis for the development of EMT-Basic, EMT-Intermediate, and EMT-Paramedic care throughout the United States. The curriculum was initially defined by the US Department of Transportation in the National Highway Traffic Safety Administration and became known as the National Standard Curriculum or the DOT curriculum. Dr. Nancy Caroline defined the standards and the curriculum for the first EMT-Paramedic program and wrote the initial textbook used in the training of EMT paramedics. The Blue Star of Life was designed by the American Medical Association as the symbol of the “Medic Alert” indication that a patient had an important medical condition the EMS should note. It was given to the National Registry of EMTs (NREMT) by the AMA as the logo of that registration and testing organization. Because the American Red Cross would not allow the “Red Cross” logo to be used on ambulances as an emergency symbol, Lew Schwartz (chief of NHTSA’s EMS branch) asked Dr. Farrington, who at the time was the chairman of the NREMT board, to allow NHTSA to use the emblem for ambulances . Permission was granted by Dr. Farrington and Rocco Morando (executive director of NREMT). It has since become an international symbol of Emergency Medical Services. 32 The National Association of EMTs was developed in 1975 by Jeffrey Harris with the financial support of NREMT. The accomplishments of these great physicians, EMS providers, and organizations stand out; however, there are many more, too numerous to mention, who contributed to the development of EMS. To all of them, we owe a great debt of gratitude. The modern era of EMS in the United States can essentially be divided into four periods 32 : Grab and run No care— either in the field or en route, with rapid transportation to the hospital, frequently without anyone in the patient-care compartment— was the system prior to the 1950s. Field management and care This period began with the publication of the national standard curriculum in 1969 continued until approximately 1975. Stay and play From 1975 until mid-1980s, the trauma patient and the cardiac patient were treated exactly alike; that is, attempts to stabilize the patient in the field, often for prolonged amounts of time, were provided. No delay trauma care In the mid-1980s it became apparent that the trauma patient was different from the cardiac patient. Trauma surgeons such as Frank Lewis, MD, and Donald Trunkey, MD, realized that, unlike the cardiac patient for whom all or most of the tools needed for re-establishment of cardiac output— CPR, external defibrillation , and supportive medications— were available to the properly trained EMT in the field, for the trauma patient, the most important tools— surgical control of internal hemorrhage and replacement of blood— were not available in the field. The importance of moving the patient rapidly to the correct hospital became apparent to both the field providers and the medical directors. This includes a facility with a well -trained trauma team comprised of emergency physicians, surgeons, trained nurses, O.R. staff, blood bank, registration and quality assurance processes, and all of the steps necessary for the management of the trauma patient. All of these resources are awaiting the arrival of the patient with the surgical team standing by to take the patient directly into the operating room. Over time, these standards have been modified to include such concepts as permissive hypotension (Dr. Ken Mattox) and Red Blood Cell: plasma transfusion (1: 1) (Dr. John Holcomb). However, the bottom line of rapid availability of a well-equipped OR has not changed. Rapid treatment of the trauma patient depends on a prehospital care system that offers easy access to the system. This access is aided by a single emergency phone number (e.g., 9-1-1 in the United States, other numbers in other countries), a good communication system to dispatch the emergency medical unit , and well-prepared and well-trained prehospital care providers. Many people have been taught that early access and early CPR save the lives of those experiencing cardiac arrest. Trauma can be approached the same way. The principles just listed are the basis for good patient care; to these basic principles has been added the importance of internal hemorrhage control, which cannot be accomplished outside of the trauma center and operating room. Thus, rapid assessment, proper packaging, and rapid delivery of the patient to a facility with OR resources immediately available has become the additional principle that was not understood until the mid-1980s.
The stages and development of the management of the trauma patient can be divided roughly into four time periods as described by McSwain in the Scudder Oration of the American College of Surgeons in 1999. 32 This text, the PHTLS course, and care of the trauma patient are based on the principles developed and taught by the early pioneers of prehospital care. The list of these innovators is long; however, a few especially deserve recognition.
Ancient Period
All of the medical care that was accomplished in Egypt, Greece, and Rome, by the Israelites, and up to the time of Napoleon is classified as premodern EMS. There is much to be learned here, but most of the medical care was accomplished within some type of medical facility. Little was done by prehospital providers in the field.
Larrey Period
In the late 1700s, Baron Dominick Jean Larrey, Napoleon’s chief military physician, recognized the need for prompt prehospital care. In 1797, he noted that “the remoteness of our ambulances deprive the wounded of the requisite attention. I was authorized to construct a carriage which I call flying ambulances.” 33 He developed these horse-drawn “flying ambulances” for timely retrieval of warriors injured on the battlefield and introduced the premise that individuals working in these “flying ambulances” should be trained in medical care to provide on-scene and en route care for patients. By the early 1800s, he had established the theory of prehospital care that we continue to use to this day: the “flying” ambulance proper training of medical personnel move into the field during battle for patient care and retrieval field control of hemorrhage transport to a nearby hospital provide care en route develop frontline hospitals He also developed hospitals that were close to the front lines (much like the military of today) and stressed the rapid movement of patients from the field to medical care. Baron Larrey is now recognized as the father of EMS in the modern era. Unfortunately, the type of care developed by Larrey was not used 60 years later at the beginning of the War Between the States by the Union Army in the United States. At the First Battle of Bull Run in August 1861, the wounded laid in the field— 3000 for three days, 600 up to a week. 33 , 34 Jonathan Letterman was appointed Surgeon General and created a separate medical corps with better organized medical care . At the Second Battle of Bull Run a year later, there were 300 ambulances and attendants collected 10,000 wounded in 24 hours. 34 In August 1864, the International Red Cross was created at the First Geneva Convention. 29 The convention recognized the neutrality of hospitals, of the sick and wounded, of all involved personnel, and of ambulances and guaranteed safe passage for ambulances and medical personnel to move the wounded. This was the first step in what we utilize today within the military as our Code of Conduct. This is an important component of the Tactical Combat Casualty Care Course, which is now an integral part of the PHTLS program.
Hospitals, Military, and Mortuaries
In 1865, the first private ambulance in the United States was created in Cincinnati, Ohio, at Cincinnati General Hospital. 34 Several EMS systems soon developed in the United States: Bellevue Hospital Ambulance 34 followed in New York in 1867; Grady Hospital Ambulance Service (the oldest continuously operating hospital-based ambulance) in Atlanta in the 1880s; Charity Hospital Ambulance Services created in 1885 by a surgeon, Dr. A. B. Miles in New Orleans; and many other facilities in the United States. These ambulance services were run basically by hospitals, by the military, or by mortuaries up until 1950. 32 Some changes in medical care occurred during the various wars up until the end of World War II, but generally the system and the type of care rendered prior to arrival in the Battalion Aid station (Echelon II) or at the back door of the civilian hospital remained unchanged until the mid 1950s. Many ambulances in the major cities with teaching hospitals were staffed by interns beginning their first year of training. The last ambulance service to require physicians on the ambulance runs was Charity Hospital in New Orleans in the 1960s. Despite the fact that physicians were present, most of the trauma care was primitive. The equipment and supplies were not changed from that used during the War Between the States. 32
Farrington Era
The era of J.D. “Deke” Farrington, MD, began in 1950. Dr. Farrington, the father of EMS in the United States, stimulated the development of improved prehospital care with his landmark article, “Death in a Ditch.” 35 In the late 1960s, Farrington and other early leaders, such as Oscar Hampton, MD, and Curtis Arts, MD, brought the United States into the modern era of EMS and prehospital care. 41 Dr. Farrington was actively involved in all aspects of ambulance care. His work as chairman of the committees that produced three of the initial documents establishing the basis of EMS— the essential equipment list for ambulances of the American College of Surgeons (ACS), 36 the KKK 1822 ambulance design specifications of the US Department of Transportation, 37 and the first emergency medical technician (EMT) basic training program— also propelled the idea and development of prehospital care. In addition to the efforts of Dr. Farrington, others actively helped promote the importance of prehospital care for the trauma victim. Robert Kennedy, MD, was the author of “Early Care of the Sick and Injured Patient.” 38 Sam Banks, MD, with Dr. Farrington, taught the first prehospital training course to the Chicago Fire Department in 1957, which initiated proper care of the trauma patient. A 1965 text edited and compiled by George J. Curry, MD, a leader of the ACS and its Committee on Trauma, stated: “Injuries sustained in accidents affect every part of the human body. They range from simple abrasions and contusions to multiple complex injuries involving many body tissues. This demands efficient and intelligent primary appraisal and care, on an individual basis, before transport. It is obvious that the services of trained ambulance attendants are essential. If we are to expect maximum efficiency from ambulance attendants, a special training program must be arranged.” 38 Although prehospital care was rudimentary when Curry wrote this passage, the words still hold true as prehospital care providers address the specific needs of the trauma patient in the field. The landmark white paper, “Accidental Death and Disability: the Neglected Disease of Modern Society,” further accelerated the process in 1967. 39 The National Academy of Sciences/ National Research Council issued this paper just one year after Curry’s call.
Modern Era of Prehospital Care
The modern era of prehospital care began with the Dunlap and Associates report to the EMS Department of Transportation in 1968 defining the curriculum for EMT Ambulance Training. This training is now known as EMT-Basic. The National Registry of EMTs was established in 1970 and developed the standards for testing and registration of trained EMS personal as advocated in the NSF/ ACS white paper. Rocco Morando was the leader of the NREMT for many years and was associated with Drs. Farrington, Hampton, and Artz. Curry’s call for specialized training of ambulance attendants for trauma was initially answered by using the educational program developed by Drs. Farrington and Banks, by the publication of the “orange book” by the American Academy of Orthopedic Surgeons (first edited by Dr. Walter Hoyt), by the EMT training programs from NHTSA, and by the PHTLS training program during the past 25 years. The first training efforts were primitive but have progressed significantly in a relatively brief time. The first textbook of this era was Emergency Care and Transportation of the Sick and Injured. This was the brainchild of Walter A. Hoyt Jr., MD, and was published in 1971 by the American Association of Orthopedic Surgeons. 32 This text is now in its 9th edition. During this same period , the Glasgow Coma Scale was developed in Glasgow, Scotland, by Dr. Graham Teasdale and Dr. Bryan Jennett for research purposes. Dr. Howard Champion (the author of the Blast chapter in the military version of this textbook) brought it into the United States and incorporated it into the care of the trauma patient for assessment of the continued neurological status of the patient. 40 The Glasgow Coma Scale is a very sensitive indicator of improvement or deterioration of such patients. In 1973, federal EMS legislation was created. Dr. David Boyd was in charge of this system. He divided the components of trauma care into 15 segments. One of these segments was education. This became the basis for the development of EMT-Basic, EMT-Intermediate, and EMT-Paramedic care throughout the United States. The curriculum was initially defined by the US Department of Transportation in the National Highway Traffic Safety Administration and became known as the National Standard Curriculum or the DOT curriculum. Dr. Nancy Caroline defined the standards and the curriculum for the first EMT-Paramedic program and wrote the initial textbook used in the training of EMT paramedics. The Blue Star of Life was designed by the American Medical Association as the symbol of the “Medic Alert” indication that a patient had an important medical condition the EMS should note. It was given to the National Registry of EMTs (NREMT) by the AMA as the logo of that registration and testing organization. Because the American Red Cross would not allow the “Red Cross” logo to be used on ambulances as an emergency symbol, Lew Schwartz (chief of NHTSA’s EMS branch) asked Dr. Farrington, who at the time was the chairman of the NREMT board, to allow NHTSA to use the emblem for ambulances . Permission was granted by Dr. Farrington and Rocco Morando (executive director of NREMT). It has since become an international symbol of Emergency Medical Services. 32 The National Association of EMTs was developed in 1975 by Jeffrey Harris with the financial support of NREMT. The accomplishments of these great physicians, EMS providers, and organizations stand out; however, there are many more, too numerous to mention, who contributed to the development of EMS. To all of them, we owe a great debt of gratitude. The modern era of EMS in the United States can essentially be divided into four periods 32 : Grab and run No care— either in the field or en route, with rapid transportation to the hospital, frequently without anyone in the patient-care compartment— was the system prior to the 1950s. Field management and care This period began with the publication of the national standard curriculum in 1969 continued until approximately 1975. Stay and play From 1975 until mid-1980s, the trauma patient and the cardiac patient were treated exactly alike; that is, attempts to stabilize the patient in the field, often for prolonged amounts of time, were provided. No delay trauma care In the mid-1980s it became apparent that the trauma patient was different from the cardiac patient. Trauma surgeons such as Frank Lewis, MD, and Donald Trunkey, MD, realized that, unlike the cardiac patient for whom all or most of the tools needed for re-establishment of cardiac output— CPR, external defibrillation , and supportive medications— were available to the properly trained EMT in the field, for the trauma patient, the most important tools— surgical control of internal hemorrhage and replacement of blood— were not available in the field. The importance of moving the patient rapidly to the correct hospital became apparent to both the field providers and the medical directors. This includes a facility with a well -trained trauma team comprised of emergency physicians, surgeons, trained nurses, O.R. staff, blood bank, registration and quality assurance processes, and all of the steps necessary for the management of the trauma patient. All of these resources are awaiting the arrival of the patient with the surgical team standing by to take the patient directly into the operating room. Over time, these standards have been modified to include such concepts as permissive hypotension (Dr. Ken Mattox) and Red Blood Cell: plasma transfusion (1: 1) (Dr. John Holcomb). However, the bottom line of rapid availability of a well-equipped OR has not changed. Rapid treatment of the trauma patient depends on a prehospital care system that offers easy access to the system. This access is aided by a single emergency phone number (e.g., 9-1-1 in the United States, other numbers in other countries), a good communication system to dispatch the emergency medical unit , and well-prepared and well-trained prehospital care providers. Many people have been taught that early access and early CPR save the lives of those experiencing cardiac arrest. Trauma can be approached the same way. The principles just listed are the basis for good patient care; to these basic principles has been added the importance of internal hemorrhage control, which cannot be accomplished outside of the trauma center and operating room. Thus, rapid assessment, proper packaging, and rapid delivery of the patient to a facility with OR resources immediately available has become the additional principle that was not understood until the mid-1980s.
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