What is Prehospital Care?
Prehospital care was initially developed for military injuries and the concept in civilian situations is modeled on the same.
Initially used for trauma, the prehospital care has been extended to other emergencies as well.
Prehospital care in trauma is based on maintenance of the key components
Thus, the key jobs include identification of severity, establishing and securing the airway, ventilation, fluid resuscitation, and in addition, quick transport to the best-suited trauma center.
Earliest prehospital care concept can be dated back to “flying ambulances” by Napoleon’s private surgeon, Dominique-Jean Larrey, in 1792.
These ambulances were horse-drawn carriages, bringing physicians or medical supplies to the battlefield and transporting wounded soldiers away from the front line.
Modern prehospital care still follows the dictum
Bring the physician to the patient or bring the patient to the physician.
How Does Prehospital Care Work?
Most emergency management services take a multi-tier approach.
- First, the basic medical providers rush to the patient.
- This is followed by more skilled and trained personnel arriving shortly thereafter.
The emphasis is focused on rapid transport to the hospital, after the basic rescue techniques, such as airway management and fluid resuscitation, are performed at the scene.
Loss of airway or breathing is the most rapid cause of death in trauma and demands to be secured as soon as possible.
Different devices like laryngoscopes, oral and nasal airway, Eschmann elastic bougie, and even more recently, supraglottic devices have been introduced to basic providers.
In wake of blood loss, external or internal, there is a need to administer fluids and medication. This requires access to the circulatory system. Peripheral intravenous access is the gold standard but may not be possible in hypovolemic patients, intravenous drug abusers, burn patients, and children.
Intraosseous access with intraosseous devices can be established in such cases. Some settings use central venous access but are associated with higher complications.
Recent military conflicts in Iraq and Afghanistan have emphasized the use of tourniquet which once had fallen out of repute.
Accurate tourniquet use may control bleeding, preserve some length in case of amputation, etc.
Bleeding control also includes hemostatic dressing.
Apart from routine vital signs, the patient is continuously monitored for end-tidal CO2 which indicates not only effective ventilation but also better cardiac output.
Transcutaneous measurement of tissue hemoglobin oxygenation is another recent aid in monitoring.
Prehospital trauma care is an important component of all trauma care systems and definite care of trauma patients needs to be started early in the field. Various scoring systems have been devised to aid in the care of trauma patients.
Different Models of Prehospital Care
Prehospital care is structured around the world according to a variety of models. There are two main types where fire and rescue services are integrated with ambulances or ambulances are kept separate from rescue services.
There is also a difference in physician involvement in prehospital care.
The United States and Canada
The prehospital care systems are basically incorporated into the emergency response system. When a call for help is found, emergency resources are dispatched. The initial responder varies in different settings. Thus it can vary from just volunteers in rural areas & remote regions to multitiered responders in urban settings.
The fire rescue generally equipped with extrication tools and basic life support equipment are the first to respond. An ambulance for transporting the patient and providing additional medical assistance is also sent almost simultaneously.
Many regions have a greater number of staffed first responder units than ambulances who typically arrive earlier and initiate patient care until the arrival of the ambulance.
Depending on the training of first responders, they are capable of giving basic life support [mostly] and advanced life support.
Air transport facility is available in many regions where the staff personnel sometimes includes a physician too. Air transport is common in areas of
- Prolonged transport
- Difficult extrication
- Limited ground resources
These regions are sparsely populated or difficult terrains.
A physician may be present on the scene for oversight or may run the event through telecommunication with the latter model being more commonly employed via radio or cell phone system.
The ambulance service is separated from the rescue teams. Ambulance teams exist as separate entities that are subcontracted and operated by hospitals or by the national or local health systems.
These ambulances, are often dispatched from the hospital with an “on-board” physician as one of the responding members, providing a high level of emergency care to the patient before they arrive at the hospital.
It has been found that with in-field physician evaluation, patients are triaged earlier and admission to hospital care is smoother.
The German system integrates rescue teams, ambulance services, and hospital care, especially at level-I trauma centers.
Scandinavian countries have partial coverage of physician-staffed ambulances and helicopters. UK has sporadic coverage by prehospital physicians.
Anesthesiologists, emergency physicians, internists and trauma surgeons, general practitioners with specialized training participate in this model.
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