Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
EMERGENCY FIRST AID AND MEDICAL CARE Successive steps in total emergency care involve local authorities and lay citizens for initial care and transportation, and medical and paramedical personnel under medical supervision for definitive treatment. With few exceptions, the role of the physician in the care of victims of accidental injury begins at the emergency department of the hospital. Only rarely is he available at the scene ~ . ~ or injury. One of the serious problems today in both the lay and the professional areas of responsibility for total care is the broad gap between knowledge and its application. Expert consultants returning from both Korea and Vietnam have publicly asserted that, if seriously wounded, their chances of survival would be better in the zone of combat than on the average city street. Excellence of initial first aid, efficiency of transportation, and energetic treatment of military casualties have proved to be major factors in the progressive decrease in death rates of battle casual- ties reaching medical facilities, from 8 percent in World War I, to 4.5 percent in World War II, to 2.5 percent in Korea, and to less than 2 percent in Vietman.7 Reduction of the time lag from receipt of injury to initiation of medical care is one of the important elements in prevention of death and permanent disability in the combat zone. Probably no American community can lay claim to maintenance of a model of first aid, sorting, communication, and transportation comparable to that of the Armed Services. First Aid Beyond the fifth grade of elementary school, every American citizen should be trained in basic first aid. Since initiation of the American National Red Cross first aid training program in 1909, over 28,000,000 students have been certified by qualified instruc- tors (who currently number over 73,0001.8 This course should be, but is not, universally required as a prerequisite to the more advanced training of lifeguards, rescue squad personnel, ambulance attendants, policemen, firemen, personnel in public health and industrial clinics, and attendants at sports events. The Medical 12
Self-Help Program of the U. S. Public Health Service, designed to ensure care in a national emergency when the services of a psysician are not available, also provide basic first aid training. Only in the American National Red Cross training program and in the Medical Self-Help Program are nationally acceptable text- books and standardized courses of instruction provided. There is need for equally acceptable textbooks and courses of instruction to meet the special requirements of rescue squad personnel and of ambulance attendants. A manual recently published by the Com- mittee on Trauma of the American College of Surgeons provides guidance for uniformity in such training courses.9 RECOMMENDATIONS 1. Extension of basic and advanced first aid training to greater numbers of the lay population. 2. Preparation of nationally acceptable texts, training aids, and courses of instruction for rescue squad personnel, policemen, firemen, and ambulance attendants. Ambulance Services A review of ambulance services in the United States indicates a paucity of information and a limited framework for the collection of data on and the evaluation of current ambulance services. Research aimed at improvement of these services is equally limited. The available information shows a diversity of standards, which are often low, frequent use of unnecessarily expensive and usually ill-designed equipment and generally inadequate supplies. Adequate ambulance services are as much a municipal responsi- bility as Refighting and police services. If the community does not provide ambulance services directly, the quality of these services should be controlled by licensing procedures and by adequate surveillance of volunteer and commercial ambulance companies. Ambulance services should not only be adequate for local needs, but should also be integrated within cities and among neighboring communities to ensure efficient utilization in natural disasters or national emergencies. Very few communities provide sufficient financial support for adequate ambulance services. Where they are provided, they are usually maintained by the fire or police department. Many volun- teer, nonprofit rescue squads and local ambulance groups provide commendable service and in many small communities this system would seem to meet basic, but usually only minimal needs. Approximately 50 percent of the country's ambulance services are provided by 12,000 morticians, mainly because their vehicles 13
can accommodate transportation on litters. But in most instances, as in the case of many privately owned ambulances, the vehicles are unsuitable for active care during transportation, equipment and supplies are incomplete, and the attendants are not properly trained. First class ambulance service exists in few cities. Some, such as Baltimore, employ highly trained full-time ambulance attendants with up-to-date vehicles and equipment as a separate mission of the fire department. Central screening and dispatching ensure open traffic lanes, communication en route, and distribution of casualties to assigned hospitals. In some cities, ambulance services are pro- vided by the police department, some with ambulances and some with modified patrol station wagons. In contrast to the days when an intern accompanied every ambulance on emergency call, the pendulum may have swung much too far toward total dependence on ambulance personnel. There is complete lack of information on the number who die at the site of injury or during transportation who might have been saved by professional attention. Calls for ambulance services should be screened by a responsible agent under medical super- vision so that, when medical attendance is required, a physician can be dispatched and an ambulance properly equipped to his reeds made available immediately. A number of foreign countries have demonstrated that these measures save many lives. There are no generally accepted standards for the competence or training of ambulance attendants. Attendants range from unschooled apprentices lacking training even in elementary first aid to poorly paid employees, public-spirited volunteers, and specially trained full-time personnel of fire, police, or commercial ambulance companies. Certification or licensure of attendants is a rarity. In a recent survey, it was found that over 48 different courses of instruction are provided with at least a score of different books and brochures being used as texts. There is no standard or uniformity in these courses, though the standard and advanced Red Cross courses are prerequisites for most. There is need for delineation of a standard course of instruction, a more generally acceptable text, and training aids to ensure training beyond that of the Red Cross program in first aid. No manufacturer produces from the assembly line a vehicle that can be termed an ambulance. The bodies and fixed equipment of ambulances and rescue vehicles are produced by conversion of passenger-type vehicles or are fabricated completely to fit assembly 14
line chassis, and are usually expensive in outward appearance, but impractical for resuscitative care. Although the Committee on Trauma of the American College of Surgeons has published recom- mendations on ambulance equipment, there are no acceptable standards for vehicle design, and most ambulances used in this country are unsuitable, have incomplete fixed equipment, carry inadequate supplies, and are manned by untrained attendants. Authority now exists under the National Traffic and Motor Safety Act of 1966 (P.L. 89-563) to set national standards for ambulance design and construction. Authority also now exists under the Highway Safety Act of 1966 (P.L. 89-564) for the establishment of national standards for used motor vehicles, for motor vehicle inspection and for emergency services. Through the efforts of the Joint Action Program of the Ameri- can College of Surgeons, the American Association for the Surgery of Trauma, and the National Safety Council, a model ordinance has been developed for regulation of ambulance services. But in a recent survey of 16 state capitals, only seven were found to have ambulance ordinances. While most ambulance calls involve non- emergency cases, the justification for speeding, the use of sirens, and violation of local traffic regulations is debatable. It is the consensus of representatives of the Joint Action Program that more injuries and deaths are produced by improper control of ambulances than would be produced by delays occasioned by compliance with regulations. Helicopters have proved so successful as ambulances in combat theatres that they should be adopted for selected use in this country. They have proven to be necessary to move physicians and equipment to the accident site and to evacuate casualties from major highways, from remote areas, or from a community hospital to a more specialized center. Highway safety standards should include helicopter evacuation, which calls for landing pads at selected hospitals on a regional pattern. RECOMMENDATIONS 1. Implementation of recent traffic safety legislation, to ensure com- pletely adequate standards for ambulance design and construction, for ambulance equipment and supplies, and for the qualifications and super- vision of ambulance personnel. 2. Adoption at the state level of general policies and regulations pertaining to ambulance services. 3. Adoption at district, county, and municipal levels of ways and means of providing ambulance services applicable to the conditions of the locality, control and surveillance of ambulance services, and coordi- nation of ambulance services with health departments, hospitals, traffic authorities, and communication services. 15
4. Pilot programs to determine the efficacy of providing physician- staffed ambulances for care at the site of injury and during transportation. 5. Initiation of pilot programs to evaluate automotive and helicopter ambulance services in sparsely populated areas and in regions where many communities lack hospital facilities adequate to care for seriously InJurec persons. Communication Although it is possible to converse with the astronauts in outer space, communication is seldom possible between an ambulance and the emergency department that it is approaching. It is important to recognize that major accidents, including disasters, provoke community response not only of first aid workers, ambulances, and hospital emergency departments but also authorities concerned with traffic, fire, security, utilities, civil defense, and others, and that communication facilities involve functions pertinent to each responding agency. Although these facilities must be designed for specific needs, they must be suffi- ciently flexible to ensure rapid and efficient cross communication, with medical components necessary to emergency care. It would be a mistake, therefore, for those concerned with the medical aspects of the problem to plan strictly medical response systems in parallel with or in isolation from the transportation and com- munication networks upon which they should be based. Since these two basic systems are in most parts of the country just beginning to be developed, it is essential that provision for the medical components be incorporated. A need exists for prompt voice communication between emer- gency departments and those at the site of an accident or disaster, not only to plan for the reception of casualties at the hospital but also to dispatch physicians, when needed at the site of the accident. Communication facilities are essential to mobilize. rescue equip- ment, clear traffic lanes, advise ambulance attendants on the management of complications en route, notify hospitals of the number and types of patients to be expected, and distribute patients among hospitals in accordance with the adequacy of space, facili- ties, and personnel. With rare exceptions, current ambulance radio installations provide communication only between dispatcher and drivers, with no provision for direct or tie-in contact with hospital emergency departments, traffic control authorities, or civil defense agencies. Moreover, many existing communication systems are reserved for use only in case of disaster or national emergency. Voice com- 16
munication should be used for day-to-day needs; should be under medical supervision; and should provide direct communication between the accident site, ambulances, and hospitals, and access to police, traffic control, fire, and civil defense agencies. Although the Federal Communications Commission has allotted an adequate number of radiofrequency channels for the health field and industry has provided appropriate telephone and radio equipment, these facilities are rarely used to ensure voice com- munication between the site of an accident, ambulances, hospital emergency departments, fire departments, traffic control officials, and civil defense authorities. Usually a hospital is notified of a disaster through local radio or television or by telephone communi- cation from police, or by the walking wounded. Certainly, the seriously ill and the injured deserve centralized screening and dispatching communication facilities as efficient as those used by taxicabs and in the coordination of personnel and equipment in fire fighting, forestry service, or highway maintenance. At present, experience Title radio communication in emergency medical situations is inadequate to serve as a basis for guidance of communities that would install and operate such facilities. Although available standardized equipment may be suitable for most communities, the organizational needs of the local com- munity, geographic problems in radio transmission, and the size of the area to be served dictate variations of design and installation. Ready solutions to most of these problems are available through the radio industry. There is need at the national level for the preparation of a manual delineating the available radiofrequency channels, types arid costs of equipment, and modifications of installation necessitated by local conditions. This is a function which should be the responsibility of the new National Highway Safety Agency in cooperation with the Federal Communications Commission, industry, and related groups. This Agency is charged with the responsibility for establishing standards for all aspects of state highway safety programs, of which communications is an essential element. Under many circumstances, especially in remote areas or in the absence of telephones, delay and frustration are encountered in calling for an ambulance. It would seem feasible to designate a universal, easily remembered number for all dial telephones throughout the nation. Compared to European expressways, the scarcity of public telephones on our national highways represents a significant oversight in planning. 17
RECOMMENDATIONS 1. Delineation of radiofrequency channels and of equipment suitable to provide voice communication between ambulances, emergency depart- ments, and other health-related agencies at community, regional, and national levels. 2. Pilot studies across the nation for evaluation of models of radio and telephone installations to ensure effectiveness of communication faci lilies. 3. Day-to-day use of voice communication facilities by the agencies servi ng emergency med ical needs. 4. Active exploration of the feasibility of designating a single nation- wide telephone number to summon an ambulance. Emergency Departments For decades the `'emergency" facilities of most hospitals have consisted only of "accident rooms," poorly equipped, inadequately manned, and ordinarily used for limited numbers of seriously ill persons or for charity victims of disease or injury. Very few hospitals have met the needs imposed since World War II for the vast expansion of facilities, equipment, and personnel demanded by society, poor and rich, for routine off-hour treatment of non- emergency conditions and of the steadily increasing numbers of accidental injuries. Society now looks to the hospital emergency department as a community center for outpatient care. More than two-thirds of the 40,000,000 "emergency room" visits in 1966 cannot be classified as emergencies. Past and projected estimates of this increasing load are as follows:~° ESTIMATED TOTAL NUMBER OF HOSPITAL OUTPATIENT VISITS YEAR (in Millions) ESTIMATED EMERGENCY ROOM VISITS (in Millions) 1958 84.5 18.0 1960 91.9 23.0 1962 99.4 28.5 1968 121.6 44.1 1970 129.0 49.3 This social change has been paralleled by a decrease in the number of house calls and by more adherence to physicians' regular office hours. Although over 90 percent of the more than 7000 accredited hospitals in the United States list emergency rooms, most such services operate at a financial loss. In contrast to staff coverage of the "accident room" by a hospital attendant and perhaps by an intern, minimal demands call for around-the-clock staffing by permanently assigned physicians and paramedical personnel 18
trained in all aspects of the care of trauma. Wings need to be added to hospitals, highly specialized equipment is required, and additional personnel must be trained. Currently four national organizations are conducting "surveys" of emergency departments, with no evidence of pooling of their resources or knowledge, resulting in piecemeal approaches to problems that, if solved by concerted effort, would provide factual grounds for Hill-Burton funds for facilities and equipment. New patterns of staff coverage of emergency departments are evolving. These include contractual relationships between the hospital and a group of physicians, usually general practitioners, who undertake all emergency care and staffing requirements for the emergency department. Some hospitals require that all medical personnel, regardless of specialty, share emergency department responsibility, including night coverage. No longer can responsi- bility be assigned to the least experienced member of the medical staff or solely to specialists who by the nature of their training and experience cannot render adequate care without the support of other staff members. The number of physicians experienced in the treatment of multiple injuries is very limited. The need is now recognized for special training in immediate care and in the overall direction of emergency departments, of a calibre commensurate with that attained by only a few individuals in active military field units caring for combat casualties. Medical undergraduate and residency training programs are generally inadequate in traumatology and mass casualty care. In recent years the Committee on Trauma of the American College of Surgeons has provided recommendations on architec- tural design and equipment of emergency departments and manuals on the treatment of fractures and soft-tissue injuries, the prevention of tetanus, and the initial management of burns. These commend- able efforts of the medical profession are but a beginning. There remains a serious lag in application of the minimal standards, but of even greater importance is the dearth of basic research in resuscitation, shock, and other immediate and long-range problems in therapy. Accreditation and Categorization of Emergency Departments The current dictum that an ambulance should deliver a patient to the nearest emergency unit is no longer acceptable. It is essential that road maps and roads signs, at appropriate locations, designate 19
routes to hospitals and emergency departments. The patient must be transported to the emergency department best prepared for his particular problem. In the absence of a descriptive categorization of the level of care that might reasonably be expected at a facility, neither the patient nor the ambulance driver can judge which facility is adequate to the immediate need. It is usually taken for granted by the general public that every emergency room can render full care for injuries of all magnitudes. There is the obligation to the severely injured patient as well as to the lone physician, to the small staffs of remote hospitals, and to institutions with minimal emergency department facilities, that the public be thoroughly informed of the extent of care that can be administered at emergency departments of varying levels of competence. A categorization of emergency departments would serve to indi- cate the level of care that a patient might reasonably expect. Current check lists used by the Joint Commission on Accreditation of Hospitals are not sufficiently comprehensive for this purpose. In a givers population, whether within a large city, a small community, or a sparsely settled area, the average number of patients requiring emergency care is generally stable, except under conditions of natural disaster or national emergency. Within a given region, it is uneconomical and impractical to expect that every emergency department deal with all degrees of severity ~ . . at Injury. Hospital emergency departments should be surveyed in a number of differing geographical areas, to determine the numbers and types of emergency facilities necessary to provide optimal emer- gency treatment for the occupants of each region. Provision must be made for the expected doubling of population within a few decades. Once the required numbers and the types of treatment facilities have been determined, it may be necessary to lessen the requirements in some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in the major emergency facilities. Until patient, ambu- lance driver, and hospital staff are in accord as to what the patient might reasonably expect and what the staff of an emergency facility can logically be expected to administer, and until effective trans- portation and adequate communication are provided to deliver casualties to proper facilities, our present levels of knowledge cannot be applied to optimal care and little reduction in mortality or lasting disability can be expected. Emergency units might be categorized as follows: 20
Type 1. The Advanced Fast Aid Facility Information now avail- able indicates that most emergency departments across the country are in this category. They do not have a full-time physician staff, and frequently not even a full-time nursing staff. Only modest first aid equipment is available and, although minor conditions and emergency resuscitation might be satisfactorily handled in this setting, it would be unfair to the patient as well as to the staff to expect or demand adequate care of the critically injured. Type 2. The Limited Emergency Facility This type is found in many hospitals whose emergency departments function 24 hours daily, chiefly as outpatient clinics or first aid facilities, but are nevertheless often confronted with the need to render major emergency care beyond their capabilities. A nurse and perhaps a physician are available at all times. Because of limitations of equipment and facilities, problems of full-time physician coverage, and limited access to specialists, complete care cannot always be provided to the critically injured. In sparsely populated areas and small communities and many urban hospitals, facilities of this type are essential, and, by proper sorting, large numbers of medical and surgical patients can be adequately handled and removed from the chain of evacuation. It is in the rural areas and the towns of fewer than 2500 people, however, that 70 percent of the traffic fatalities occur. The dedi- cated staffs of limited emergency departments recognize that the needs of the critically injured patients frequently exceed the capabilities of their facilities and personnel. To expect highly specialized care under these circumstances is unfair both to the patient and to the physician. Emphasis on resuscitation, expendi- ture of time and effort in thorough preparation before movement, and rapid and efficient transportation to major emergency facilities would lower morbidity and mortality rates. It is here that heli- copter ambulances would be most effective. There have been no extensive surveys in either rural or urban areas to establish the number of either limited or major emergency facilities required or to define models of rapid transport. Type 3. The Major Emergency Facility The need for major emergency facilities adequate to render complete care to the severely injured or the seriously ill is well recognized. Few such facilities exist. Most emergency departments of large hospitals have not yet met the space or personnel needs of outpatient and 21
nonemergency cases, and few have the funds to construct, equip, and man adequate facilities. To carry out their mission, the number and location of major emergency facilities must be in keeping with the numbers of patients to be treated from day to day, with provision for expansion in disaster. They must be so located as to serve precisely designated rural areas or districts in densely populated areas. Major emergency facilities require 24-hour staffing by highly competent medical and paramedical personnel trained in resuscitation and other lifesaving measures before transfer of the casualty to the operating room, intensive care unit, or hospital ward. Bloodbanks, complete resuscitative equipment, X-ray facilities (including those' for angiography), constantly available well-developed clinical laboratory services, and ready accessibility to operating rooms are essential. The director of a unit of this type should be experienced in the overall care, triage, and determination of priorities of treatment of victims of severe trauma. Nursing, paramedical, and administrative per- sonnel should be assigned to the emergency department perma- nently or at least for protracted periods. Specialized consultants must be available at all times. The need for ready availability of highly qualified specialists in all branches of medicine and surgery and of laboratories devoted to clinical support and research strongly supports the view that the major emergency facility should be an integral element of large hospitals and university medical centers, rather than an isolated facility devoted solely to emergency care. Such a clinic is essential to proper training in trauma. Type 4. The Emergency Facility Combined with a Trauma Research Unit This is designed to be the ultimate goal in com- bining the highest development of patient care with research facilities that permit investigation in support of therapy. These units are discussed in the section of this report on research in trauma. RECOMMENDATIONS . Initiation of surveys and pilot programs to establish patterns of and the numbers and types of emergency departments necessary for optimal care of emergency surgical and medical casualties in a selected number of cities, groups of small communities, and sparsely populated areas. 2. Development of a mechanism for inspection, categorization, and accreditation of emergency rooms on a continuing basis. 3. Federal fund support to design, construct, and, in part, operate model emergency facilities of each type. 22
