Transcript EMS PAST

EMS
PAST
PRESENT
FUTURE
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EMS PAST
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Pioneers of Prehospital
Trauma Care
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AMBROSE PARE
– French surgeon in
1500s
– Wrote first book on
trauma care
– Condemned use of
boiling oil for GSW
and reintroduced use
of ligatures for
amputations
– No organized
evacuation of
wounded at this time
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History of Prehospital
Trauma Care
• No organized medical care
for injured patients before
19th century
• On the battlefield no
organized evacuation of the
wounded and no field
hospitals to treat them
• Generally women “camp
followers” provided nursing
care
• Organized prehospital care
began with the efforts of
military surgeons to treat
battlefield casualties
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Pioneers of Prehospital Care
Early 1800s: Baron Larrey
Surgeon General, Napoleon’s Army
Baron Larrey’s “Flying Ambulance”
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Crimean War 1854-56
• Modern nursing care
introduced by
Florence Nightingale
• Casualties begin to
be evacuated by
railroad
FLORENCE NIGHTINGALE
“THE LADY WITH THE LAMP”
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Note a pattern developing: the
faster the injured arrived at a
hospital, the better the survival.
This principle has not changed
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Linda Richards
• “America’s first trained
nurse”
• Traveled to England to learn
from Florence Nightingale
who had started a school for
nurses
• On her return to the U.S
Richards pioneered the
founding of nursing training
schools across the nation.
• In 1885 she helped to
establish Japan's first
nursing training program
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Air Evacuation
• First began in Paris in 1870
when hot-air balloons were
used to evacuate 160 soldiers
• Did not become common until
the second world war
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BEGINNINGS OF EMS IN THE U.S.
LOAD AND GO
ORIGINAL AMERICAN AMBULANCE AND
ORIGIN OF THE TERM “HAUL ASS”
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American Civil War
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Civil War
• Railroads continue to be used to evacuate casualties
• Army still used ambulances much like Napoleon
• Death rate very high because germs were unknown as
the cause of infection – barns used as hospitals
• U.S. Army set up the Medical Corps
– System-wide approach with ambulances on the battlefield
transporting to system of hospitals
• Aid stations
• Field hospitals
• Rear general hospitals
– This model was used until the Vietnam war
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WORLD WAR I
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WORLD WAR I
• Poor planning (no field hospitals) caused
excessive evacuation times of 12-18 hours
– High mortality rates >20%
– Most died of hemorrhagic shock
• No antibiotics so sepsis common
• Blood transfusions just beginning to be used
• Thomas half-ring femur splint was considered
the greatest advancement in trauma care at this
time
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WORLD WAR II
• Evacuation time for
wounded decreased to
4-6 hours
• Antibiotics developed
• Plasma and blood
transfusions common
• Hospitals closer to the
front to decrease time to
surgery
• Fixed wing air transport
• Mortality rate 3.3%
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KOREAN WAR
• Evacuation time
averaged 2-4 hours
• Helicopter evacuation of
wounded introduced
• More use of electrolyte
solutions
• Better antibiotics
• Surgical hospitals closer
to front lines
• Mortality rate 2.4%
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VIETNAM WAR
• Casualties taken directly
from front lines to surgical
hospital by helicopter
• Average evacuation time
35 minutes
• Average time to surgery
1-2 hours
• Mortality 2.3%
• Civilian systems have
never matched this
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IRAQ WAR
• Rediscovered
tourniquets
• Development of
hemostatic agents
• Developed concept of
CAB for patients with
exsanguinating
hemorrhage
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Civilian Prehospital Medical
Care
• Before Vietnam War
– A few large hospitals
provided ambulance
services (transport only)
• Bellevue Hospital began
horse drawn
ambulances in 1869
– No trained providers
– Rural areas used hearses
for ambulances
• This went on until the
1970s
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ORIGINAL VOLUNTEER RESCUE
• “Good” Samaritan was
much like volunteer
rescue folks
• Considered 2nd class
citizen
• Cared deeply for his
fellowman and was
willing to go out of his
way and furnish his own
ambulance to help him
• Set a standard we all
have to live up to today
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Beginning of EMTs
• First prehospital
training course taught
to Chicago Fire
Department in 1957
• Prehospital training
did not catch on until
the late 1960s and
with few exceptions
paramedic training
did not begin until the
1970s
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PARAMEDICS WERE
INVENTED TO REPLACE
DOCTORS IN TREATING
PREHOSPITAL CARDIAC
PATIENTS
AT THAT TIME CARDIAC PATIENTS
REQUIRED CAREFUL DELIBERATE CARE
SPEED WAS NOT NEEDED
THAT PRINICPLE IS NO LONGER TRUE
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Frank Pantridge, MD
1916-2004
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Frank Pantridge, MD
• Called the grandfather of prehospital ALS
• In Belfast Ireland, in the 1950s he began
using the new CPR system for cardiac
resuscitation but realized he needed to get
the treatment into the field
• Developed the first portable defibrillator
and then the mobile intensive care
ambulance
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Peter Safar, MD
1924-2003
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Peter Safar, M.D.
• Intensive care specialist who pioneered the
“ABCs” of CPR including mouth-to-mouth
resuscitation
• Worked with Laerdal to develop the Resusci
Anne
• Helped develop the first ALS ambulances
• In 1966 trained some of the first “paramedics” by
taking 44 unemployed African-American men
and giving them 3000 hours of training (doctors
got 3500)
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Nancy Caroline, MD
1944-2002
“THE MOTHER OF PARAMEDICS”
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Nancy Caroline, MD
• She was influenced by Dr. Safar to believe that
nonphysicians could be trained to perform
physician skills
• She worked in the field with Dr. Safar’s original
paramedics
• Was the original author of the DOT national
standard curriculum for paramedics in 1974
• There were no paramedic textbooks so in 1975
she wrote the original textbook Emergency Care
in the Streets
– Now in its 6th edition
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Milestones
• In 1968 the American
College of Emergency
Physicians was formed.
This led to the
development of
residency training
programs and eventually
to the recognition of
emergency medicine as
a specialty in 1979..
In the House of Medicine, the light that is never
turned off
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R Adams Cowley 1917-1991
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R Adams Cowley, MD
• In the 1960s Dr. R Adams Cowley, a
cardiovascular surgeon, did pioneer work in
trauma care and helped bring about special
training in trauma care for surgeons.
• Developed the concept of the “Golden Hour”
• He was responsible for the development of the
Maryland Institute for EMS Systems (MIEMSS),
the first statewide EMS system
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EMERGENCY 1972-1977
RAMPARTS
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Milestones
• 1968 – St. Vincent’s Hospital in New York City began
first mobile coronary care unit
• 1969 Miami, FL Fire Department began the nation’s first
paramedic program under Dr. Eugene Nagel
• 1972 The television show Emergency! Began
– Soon every town wanted their own “Ramparts”
– There were 12 medic units in the country at the time
– Four years later at least 50% of the population was within
10 minutes of a medic unit
• 1973 St. Anthony’s Hospital in Denver starts the nation’s
first civilian aeromedical transport service (“Flight for
Life”)
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Rocco Morando
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Rocco Morando
• Was instrumental in establishing the National
Registry of EMTs in 1970 and became its first
executive director in 1971
– He retired in 1981 and the headquarters building was
named after him
• Was also instrumental in establishing the
National Association of EMTs in 1975
• He and Dr. McSwain helped keep NAEMT afloat
during the early years when support (and funds)
was sparse
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Milestones
• 1975
– First paramedic textbook written by Nancy Caroline
– National Association of EMTs is formed
• 1978 American Heart Association begins the “Alphabet
Courses” with ACLS
• 1980 American College of Surgeons begins the ATLS
course for physicians
• 1982 Alabama Chapter of ACEP begins BTLS course
• 1983 NAEMT and ACS begin PHTLS
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James O. Page
1936-2004
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James O. Page
• Probably best known of all those mentioned so
far
• Untiring speaker who was always ready to tell
people about EMS
• A man of many parts, Fire chief, lawyer,
technical consultant for Emergency!, first EMS
director for North Carolina, prolific writer and
speaker, founder of JEMS, most recognized
spokesman for EMS until his death in 2004
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Norman McSwain, MD
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Norman McSwain, MD
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Dedicated trauma surgeon and educator
Supporter of EMS for over 30 years
Founding father of NAEMT
Founding father of PHTLS and continues
to serve as medical director
• Gentleman and scholar
– But don’t ever let him drive
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EMS PRESENT
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WE ARE AT THE END OF THE
BEGINNING IN EMS
Ray Fowler, MD
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EMS at Present
• Except for isolated instances, the whole country
is within a reasonable distance of an ALS
ambulance
• EMS systems continue to vary widely with few
states having centralized management of the
system
• Some states don’t even have a State EMS
Medical Director
• Many states do not require that their EMS
training programs be accredited
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Standardization of the
Profession
• In process of finally standardizing levels of
prehospital EMS providers
– EMT
• BLS including AED and CPAP
• Only a committee could have come up with the brilliant
idea to take a generic term (EMT) that applied to all levels
of providers and make it refer to only one level, thus
rendering all previous references confusing
– Advanced EMT
• Above + Rescue airway, + IV fluids + limited medications
– Paramedic
• Above + intubation + Monitor Defibrillator + more meds
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Have Yet to Prove to Everyone that
Paramedics Make a Difference
• “EMS is the largest hoax ever foisted on
the American people. There is no data,
not one study, which shows that anything
beyond the intermediate level – basic EMT
with a defibrillator capabilities – does
anything in the long run to change the
health care of the United States”
– Gregory Henry, MD
– Dr. Henry is an expert in risk management,
not EMS, but he strikes a nerve
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EMS
FUTURE
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WHERE DO WE GO FROM
HERE?
WE FACE SOME CHALLENGES
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Must Recruit More EMTs
• There is a critical need for competent,
professional EMTs
• Prehospital EMS is an exciting career that
should be emotionally and financially rewarding
• Somewhere we got the idea that only older
men/women should be EMTs
– “Students just out of high school are too immature to
be EMTs”
– Bill Brown, National Registry
– Tell that to the nursing profession
• We must begin recruiting students while they are
in high school
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Paramedics Must Change How
They Define Themselves
• At present too many define themselves by what
procedures they can do
– Too many dishonor the profession by being more
interested in doing invasive procedures than caring for the
patient
• The worth of a prehospital provider is not in what procedures
they do but how many people they save
• Less may be more
• Patient care must come first
• In most instances this means “Load and Go” with
most interventions done in the ambulance
– ALS is almost impossible when there is only one EMT in
the back of the ambulance
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Critical Care Systems (STEMI,
Stroke, Trauma) will allow
Paramedics to prove their worth
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Volunteers will Continue to be
Needed
• They are critical in many rural areas
• Local, state, or federal funding is not likely
to provide enough funding to replace them
• They are capable of providing the same
level of care as the best municipal or
private services
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Must Introduce Science to
Prehospital Care
• Must scientifically prove what saves lives in the
prehospital environment
– Should do only those things that are proven to help
• If there is no scientific data that a procedure helps
people, we should stop doing it
– This reflects positively not negatively on our worth
• If the data shows a procedure decreases survival it
MUST be stopped or changed to make it safer
• At present the data shows rapid transport to the
appropriate hospital is the most important role of
prehospital medicine
• Scientific studies are difficult in the prehospital arena
but must be pursued if we are to be accepted as a
profession
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Quantitative Capnography Must Become
a Requirement for Intubation
• Has been standard of care for anesthesiologists
for over 10 years
– Became standard of care because it essentially
eliminated unrecognized esophageal intubations
– If Doctors who specialize in intubating patients can’t
always recognize an esophageal intubation without
capnography, why do we think we can?
• Scientific studies show we have too many
unrecognized esophageal intubations in the field
• Quantitative CO2 devices are now under $1000
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Device that Reads Out Rate of
Ventilation and CO2 level
SOMETHING LIKE THIS MUST BE USED IF WE DO INTUBATION IN
THE FIELD (OR THE E.D.)
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CPAP WILL ELIMINATE MOST
INTUBATIONS EXCEPT FOR
TRAUMA CASES
• It is non-invasive and can be used for
many medical causes of dyspnea
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Must Better Define the Role
of Helicopter EMS
• Helicopter EMS is a critical service but is
frequently being misused
• It should be reserved for critical cases in which
the use of the helicopter will SIGNIFICANTLY
reduce the transport time
• In Alabama the average response time is 22
minutes and the average transport time is 17
minutes
– On average the patient is not delivered for one hour
after the initial call to the helicopter
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FINAL THOUGHT:
FUTURE EMS WILL BE BETTER
OR WORSE DEPENDING ON
WHAT WE DO, BUT IT IS NOT
GOING AWAY
THE AMERICAN PEOPLE LOVE
EMS, WARTS AND ALL
AND RIGHTLY SO
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