This is a picture of mass casualty accident. It involved multiple vehicles. 35 casualties with 5 deaths. Who is going to manage this type of scenario? How are we going to manage it if it occurs in KB? Do you think it is as easy as managing ICU patients or prof Jafri patients who are already on the OT table? Who is the expert here? Last year, during the fasting month, it was raining during time. There was an accident between the a car and a truck. I followed the ambulance to dispatch the victims. The area flooded by a villagers and other emergency service personnel (BOMBA/POLIS). There was also a reporter and photographer around, snapped the pictures at different angle. Nobody cares the trapped victims. The BOMBA busy cutting the roof of the car and they hold it for me and ask me to take the patient out. I did a quick triage & I found out only one survivors. The victim had respiratory distress and poor circulation. It was not easy to remove the patient. It was not easy to manage the patient at the field. I decided to practice scoop & run rather than scoop and play. Run and play… fuh!!! Don’t want to talk about it…
Most of Trauma strategy & management were started by the military/army. Their exposure & experiences managing trauma victims during war made them more concern & the needs of trauma care. They learn the through a hard way, hard time & do not imagine the prize they have to pay. This slide shows a relationship between evacuation time and mortality rate during the different type of war. Mortality rate goes down whenever the evacuation time is reduced. The reduction of time evacuation and mortality rate were bcoz the advancement of transportation at war. For ex – the usage of helicopter to bring soldier to the medical center diring the world war 11 7 orean war.
This is a chain of survival for trauma victim. It has 5 elements… All the component which represented by a ring are attach/link to the other in sequence & strongly connected to form a chain. The morbidity & mortality are depending on the strength of the chain not a single individual or ring. A strength of the chain as strong as the weakest link.
Prehospital management is not easy or simple. Everything is difference, inconvenience and non conducive. Hot. Noisy. Too many casualties. Everybody calls us for help. Everybody asking for help. At the same time we have to take care of own safety. Decision made is very difficult. Wrong decision may jeopardy patient’s life. Yet, our enemy is a time. We re fighting with the time. We are against the time. Delayed definitive management means death. Nowadays, too fast also not very good. Too fast may compromised our safety/victims’s safety – eg sept eleven, ambulance collision.
Trauma center and availability of trauma surgeon do improve the survival of trauma patients. Trauma center is just a name. We don’t have to create a trauma center if we can coordinate and communicate among ourself. It is about mobilization of resources.
This slide is to illustrated to you there was o major organization involved in management of trauma @ even medical patients. Both of them are equally important in order to save patient life.
In order patient life we required to strengthened above chain. It is a team expert not an individual expert. Everybody has a role.
Introduction to pre hospital care and in
Introduction to emergency PRE-HOSPITAL & in-hospital care Dr Ismail Mohd Saiboon Emergency Department HUKMAssoc Prof Dr Ismail Mohd SaiboonEmergency DepartmentUKMMC
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
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.
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
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 – NotraztNow, Faculty of Pre- Hospital Care, RCS Edinburgh)• Dip. IMC• FIMC
The philosophy“ appropriate intervention at appropriate time”“ short and safe, never be prolonged”Aim of treatment: produce neurologically intact survivor & reasonable quality of lifeNeed careful judgment of when to intervene and when not to.
The practice of Pre-Hospital Care• Uncomfortable• Less ideal• Any weather- bad weather• ?Safety – depends on working together effectively with other emergency service agencies.
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)
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• VolunteersUndergone basic training
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
10 Principal causes of deaths in MOH hospitals, Malaysia 20011. 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 %
10 principal causes of hospitalization in M0H hospitals, Malaysia 20011. 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 %
“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
Malaysian ‘EMS’ Available serviceC MOH hospitalsC University hospitalsC St. John Ambulance of MalaysiaC Malaysian Red Crescent SocietyC JPA 3C Private ambulance services
Malaysian PHC ProvidersC Assistant Medical OfficerC EMTsC JPAMC NGOs- First Aider (SJAM, PBSM)
PRINCIPLE OF PRE HOSPITAL TRAUMA CARE~ Deciding the best option for thepatient on the field requires knowledgeof the potential detriments and themeans to correct the situation in theright time frame ~
Key element in administering a PHC system1) Lead by a national agency (MOH, MOT) - govern the system - legislative & regulatory oversight - organization - financing6) Regional or local support – member of community7) Local administration8) Medical direction –education, training, quality improvement9) Political support
System of PHC• National systems• Local or regional systems• Private systems• Hospital based systems• Volunteer system• Hybrid system
Key aspects in PHC systems• Personnel• Training• Communication systems• Transportation• Receiving facilities• Documentation of care• Legislation & regulation
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
TrainingInterested 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• FIMCOther courses they should undergoneBLS, BTLS/BTC, ATLS (MTLS, ATRC), ACLS, MIMMS
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
Transportation• Air ambulance – helicopter, fixed wing• Ground ambulance- type 1, 2, 3• Sea ambulanceSimple transport vehicle Sophisticated- specialized-efficient mobile patient care unit
Able to provide lifesaving maneuversDesign: Ambulance personnel must be able to provide airway & ventilatory support while transportingBLS- equippedALS- equipped
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
Critical care unit• Must identify the hospital that have tertiary care facilitiesi.e. Trauma NICU High risk Obstetric Burns Spine unit Neurosurgery Cardiac careDo NOT load one hospital with everything unless there is only one
Public safety agencies• Need strong ties with them Police Fire & Rescue JPA3
Consumer participation• Lay person• Political• Consumer association• Need their support and corporation in order to have successful PHC service manpower/ financial/ legislative
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.
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.
EMERGENCY INTERVENTION• Airway maintenance/Cervical Spine Control• Breathing and ventilation• Circulation with hemorrhage control• I mmobilization
CARING FOR THE PATIENT WHILE EN ROUTE TO THE HOSPITAL3. Continue to provide emergency care4. Continue monitoring vital signs5. Communicate with ED personnel using two way radio6. Give a description of what happened7. Describe patient age, sex and his condition8. What type of injury suspected9. Patient vital signs• Emergency care that has been provided• Estimated time of arrival
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
Disaster Preparedness• Any PHC system is an integral part to disaster response effort.• Need to be involve in planning & practice drill
In-hospital emergency care• Receive patients• Triage• Resuscitation and stabilization• Registration• Investigation• Treatment – definitive care, observation• Disposal
Bystanderinterventions Early Definitive Care/Trauma Center/EDEmergency Service Dispatch Transportation On scene interventions