This presentation is given to our degree paramedic students as an introduction to the course

1. Introduction to emergency
PRE-HOSPITAL &
in-hospital care
Dr Ismail Mohd Saiboon
Emergency Department HUKM
Assoc Prof Dr Ismail Mohd Saiboon
Emergency Department
UKMMC

2. What is Pre-Hospital Care?
• Giving medical care to patients beyond the wall of
Hospital (emergency dpt.)
• Wide range of activities
- ground ambulance service
- battlefield medicine
- medical cover of gatherings
- sports event- motor- cross, Rallies,
F-1, soccer etc
- disaster relief efforts
- first responder/ first aider

3. Pre-hospital care
• Aim: reduce morbidity and mortality in those seriously
injured or in dangerously ill patients outside hospital
• *39% - 47%** of pre-hospital fatalities are
preventable
• Involve - rapid attendance (ambulance personnel)
- performed life-saving@ limb saving
(basic @ advance) procedures
- stabilized patients condition, prevent
deterioration, maximized chances of
good definitive care.

4. Immediate care
• Provision of skilled medial help
• At scene and
• During transport
• By doctors or paramedic that have receive
special training, use specific equipment
• Adapted to PHC situation

5. • gambar

6. How does it started?
• Evolves from warfare
• Early organized civilian PHC group
JF Pantridge – Ireland ( Ambulance Coronary Care Unit)
UK – BASIC
US- DOT (1960’s)- EMS
Germany – Notrazt
Now, Faculty of Pre- Hospital Care, RCS Edinburgh)
• Dip. IMC
• FIMC

7. The philosophy
“ appropriate intervention at appropriate time”
“ short and safe, never be prolonged”
Aim of treatment: produce neurologically intact
survivor & reasonable quality of life
Need careful judgment of when to intervene and
when not to.

8. The practice of Pre-Hospital Care
• Uncomfortable
• Less ideal
• Any weather- bad weather
• ?Safety – depends on working
together effectively
with other emergency
service agencies.

9. Pre-Hospital Care: How does it
start?
History
• During Battles of Uhud and Hunain,
Arabian Peninsula (> 14 centuries ago)
• Sir Robert Jones, Manchester-Liverpool
canal, UK (1888)
• More organised system, US & Ireland
(1960s)

10. Who is involve?
• Doctors – General Physician
-- E Ps
-- Surgeons
-- Anesthetic
• Paramedic – MAs, S/Ns
• Uniform bodies- BOMBA, JPA3, Police, Army
• NGO- PBSM, St John, Mercy others
• Volunteers
Undergone basic training

11. Why do we need PHC?

12. Medical emergencies

14. TRAUMA IN MALAYSIA
• Trauma is the 2nd cause of mortality in
Malaysia
• Road injury is a leading cause of premature
death of age group 12 – 45 (young adult:
31.2%, adolescents: 21.5%)
• Road injury causes 25 to 30 deaths per 100
000 population, 6000 deaths per annum, 15
deaths/day
• Pre Festival week: 15 to 20 deaths per day
Epidemiology of injury in M’sia, Dec 1997

15. 10 Principal causes of deaths in
MOH hospitals, Malaysia 2001
1. Heart Diseases & Diseases of
Pulmonary Circulation 15.99 %
2. Septicaemia 14.51 %
3. Malignant Neoplasm 9.16 %
4. Cerebrovascular Diseases 4.48 %
5. Accident 6.76 %
6. Conditions Originating In The Perinatal Period 5.56 %
7. Pneumonia 4.98 %
8. Diseases of the Digestive System 4.38 %
9. Nephritis, Nephrotic, Syndrome and Nephrosis 3.72 %
10.Ill-defined conditions 2.74 %

16. 10 principal causes of hospitalization in M0H
hospitals, Malaysia 2001
1. Normal Delivery 18.91
%
2. Complications of Pregnancy 11.84 %
3. Accident 9.16 %
4. Diseases of the Circulatory System 6.94 %
5. Diseases of the Respiratory System 6.61 %
6. Conditions Ori. In The Perinatal Period 5.62 %
7. Diseases of the Digestive System 4.87 %
8. Ill-defined conditions 3.57 %
9. Diseases of the Urinary System 3.49
%
10.Malignant Neoplasms 2.62 %

17. “Transportation of critically ill
patients to EDHKL does not
follow a standard guideline”
(inadequate communication, ineffective liaison,
untrained & inexperienced staff)
Ridzuan Isa. A study on inter hospital ambulance transportation of
critically ill patients to GHKL, May 2003

18. TIME TO CARE VS SURVIVAL

19. TRAUMA CHAIN OF
SURVIVAL
Rapid Access
Rehabilitation
Pre-hospital
Care ED Definitive
Resuscitation care

20. The practice

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

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

23. PRINCIPLE OF PRE
HOSPITAL TRAUMA CARE
~ Deciding the best option for the
patient on the field requires knowledge
of the potential detriments and the
means to correct the situation in the
right time frame ~

24. Key element in administering a PHC
system
1) Lead by a national agency (MOH, MOT)
- govern the system
- legislative & regulatory oversight
- organization
- financing
6) Regional or local support – member of
community
7) Local administration
8) Medical direction –education, training, quality
improvement
9) Political support

25. System of PHC
• National systems
• Local or regional systems
• Private systems
• Hospital based systems
• Volunteer system
• Hybrid system

26. Tiers in PHC provider
• 1st tier – First responder
- Basic first aider (lay people)
- Advance first aider (police/FR/ SJAM etc)
• 2nd tier – Basic PHC provider
- paramedic / nurse /EMT-B
• 3rd tier - Advance PHC provider
- doctors
- trained paramedic

27. Key aspects in PHC systems
• Personnel
• Training
• Communication systems
• Transportation
• Receiving facilities
• Documentation of care
• Legislation & regulation

28. Personnel
“Quality of a PHC is determine by the ability and
attitudes of provider couple with knowledge and
skills required”
• Come from different walks of life
• Full-time or part-time
• Paid or volunteer
• Different level of knowledge and care
• Need good coordination and understanding
• Good command and control

29. Training
Interested physician need to be involve in training
• FRLS/ FALS- Fire & Rescue, Police, ? Tow-Truck
driver
• EMT-B / Post basic - Paramedic.
• Dip. IMC
• Degree Emerg. Paramedic
• FIMC
Other courses they should undergone
BLS, BTLS/BTC, ATLS (MTLS, ATRC), ACLS, MIMMS

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

31. Transportation
• Air ambulance – helicopter, fixed wing
• Ground ambulance- type 1, 2, 3
• Sea ambulance
Simple transport vehicle  Sophisticated-
specialized-efficient mobile
patient care unit

33. Able to provide lifesaving maneuvers
Design: Ambulance personnel must be able to
provide airway & ventilatory support while
transporting
BLS- equipped
ALS- equipped

34. gambar

35. Facilities
• Transport to the closest appropriate
hospital.
• Specific dedicated hospitals for the special
conditions.
• Patient demand?? To consider or not.
• In life-threatening condition- NOT

36. Critical care unit
• Must identify the hospital that have tertiary care
facilities
i.e. Trauma
NICU
High risk Obstetric
Burns
Spine unit
Neurosurgery
Cardiac care
Do NOT load one hospital with everything unless
there is only one

37. Public safety agencies
• Need strong ties with them
Police
Fire & Rescue
JPA3

38. Consumer participation
• Lay person
• Political
• Consumer association
• Need their support and corporation in order
to have successful PHC service
manpower/ financial/ legislative

39. Access to care
• Ensure public have access to emergency care
• Must develop system that discourage public from
accessing the PHC system for wrong reason or
perceived emergency.
• Political back-up and their understanding of the
system
• Principle: all individual deserve timely access to
the emergency PHC system.

41. SCOPE OF PRE HOSPITAL
TRAUMA CARE
• Scene size up
• Triage, treatment (ABC I)
• En route management
• Patient’s Transportation
• Communication and Dispatching
• Pathway of care; sending and receiving
protocol.

42. EMERGENCY
INTERVENTION
• Airway maintenance/Cervical Spine
Control
• Breathing and ventilation
• Circulation with hemorrhage control
• I mmobilization

43. CARING FOR THE PATIENT WHILE
EN ROUTE TO THE HOSPITAL
3. Continue to provide emergency care
4. Continue monitoring vital signs
5. Communicate with ED personnel using two way radio
6. Give a description of what happened
7. Describe patient age, sex and his condition
8. What type of injury suspected
9. Patient vital signs
• Emergency care that has been provided
• Estimated time of arrival

44. DEFINITIVE MANAGEMENT
Trauma center??
Trauma team??
Trauma surgeon??

45. Public Information & Education
• Public must be informed and educate regarding
good emergency PHC system.
• Public can contribute by
- understand how a good system can benefit
them.
- Prepare to give first aid care
- Know how and when to access the system
rapidly

46. Disaster Preparedness
• Any PHC system is an integral part to disaster
response effort.
• Need to be involve in planning & practice drill

48. In-hospital emergency care
• Receive patients
• Triage
• Resuscitation and stabilization
• Registration
• Investigation
• Treatment – definitive care, observation
• Disposal

49. Bystander
interventions Early Definitive
Care/Trauma Center/ED
Emergency Service
Dispatch
Transportation
On scene
interventions

50. Thank you