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Emergency Medical Services at the Crossroads
emergency medical services, emergency departments, and trauma centersbased on adult and pediatric service capabilities (3.1). The results of this process would be a complete inventory of emergency and trauma care assets for each community, which should be updated regularly to reflect the rapid changes in delivery systems nationwide. The development of the initial categorization system should be completed within 18 months of the release of this report.
Treatment, Triage, and Transport
Once understood, the basic classification system proposed above could be used to determine the optimal destination for patients based on their condition and location. However, more research and discussion are needed to determine the circumstances under which patients should be brought to the closest hospital for stabilization and transfer as opposed to being transported directly to the facility offering the highest level of care, even if that facility is farther away. Debate continues over whether EMS personnel should perform ALS procedures in the field, or rapid transport to definitive care is best (Wright and Klein, 2001). The answer to this question likely depends, at least in part, on the type of emergency condition. It is evident, for example, that whether a patient will survive out-of-hospital cardiac arrest depends almost entirely on actions taken at the scene, including rapid defibrillation, provision of cardiopulmonary resuscitation (CPR), and perhaps other ALS interventions. Delaying these actions until the unit reaches a hospital results in dismal rates of survival and poor neurological outcomes. Conversely, there is little that prehospital personnel can do to stop internal bleeding from major trauma. In this instance, rapid transport to definitive care in an operating room offers the victim the best odds of survival.
EMS responders who provide stabilization before the patient arrives at a critical care unit are sometimes subject to criticism because of a strongly held belief among many physicians that out-of-hospital stabilization only delays definitive treatment without adding value; however, there is little evidence that the prevailing “scoop and run” paradigm of EMS is always optimal (Orr et al., 2006). In cases of out-of-hospital cardiac arrest, properly trained and equipped EMS personnel can provide all needed interventions at the scene. In fact, research has shown that failure to reestablish a pulse on the scene virtually ensures that the patient will not survive, regardless of what is done at the hospital (Kellermann et al., 1993). On the other hand, the scoop and run approach makes sense when a critical intervention needed by the patient can be provided only at the hospital.
Decisions regarding the appropriate steps to take should be resolved using the best available evidence. Therefore, the committee recommends that the National Highway Traffic Safety Administration, in partnership