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Dr Ismail Mohd Saiboon
Emergency Department HUKM
Introduction to emergency
PRE-HOSPITAL & in-hospital care
Assoc Prof Dr Ismail Mohd SaiboonEmergency Department UKMMC
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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
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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.
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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
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• gambar
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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
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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.
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The practice of Pre-Hospital Care
• Uncomfortable• Less ideal • Any weather- bad weather• ?Safety – depends on working
together effectively
with other emergency
service agencies.
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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)
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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
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Why do we need PHC?
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Medical emergencies
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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 dayEpidemiology of injury in M’sia, Dec 1997Epidemiology of injury in M’sia, Dec 1997
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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 %
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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 %
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“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 Ridzuan Isa. A study on inter hospital ambulance transportation of critically ill patients to GHKL, May 2003 transportation of critically ill patients to GHKL, May 2003
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TIME TO CARE VS SURVIVAL
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TRAUMA CHAIN OF SURVIVAL
Rapid Access
Pre-hospital
CareED
ResuscitationDefinitive
care
Rehabilitation
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The practice
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Malaysian ‘EMS’ Available service MOH hospitals University hospitals St. John Ambulance of Malaysia Malaysian Red Crescent Society JPA 3 Private ambulance services
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Malaysian PHC Providers Assistant Medical Officer EMTs JPAM NGOs- First Aider (SJAM, PBSM)
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~ Deciding the best option for ~ Deciding the best option for the patient on the field requires the patient on the field requires knowledge of the potential knowledge of the potential detriments and the means to detriments and the means to correct the situation in the right correct the situation in the right time frame ~time frame ~
PRINCIPLE OF PRE PRINCIPLE OF PRE HOSPITAL TRAUMA CAREHOSPITAL TRAUMA CARE
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Key element in administering a PHC system
1) Lead by a national agency (MOH, MOT) - govern the system - legislative & regulatory oversight - organization - financing2) Regional or local support – member of community3) Local administration4) Medical direction –education, training, quality
improvement5) Political support
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System of PHC
• National systems
• Local or regional systems
• Private systems
• Hospital based systems
• Volunteer system
• Hybrid system
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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
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Key aspects in PHC systems
• Personnel
• Training
• Communication systems
• Transportation
• Receiving facilities
• Documentation of care
• Legislation & regulation
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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
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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
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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
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Transportation
• Air ambulance – helicopter, fixed wing• Ground ambulance- type 1, 2, 3• Sea ambulance
Simple transport vehicle Sophisticated-specialized-efficient mobile
patient care unit
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Able to provide lifesaving maneuvers
Design: Ambulance personnel must be able to provide airway & ventilatory support while transporting
BLS- equipped
ALS- equipped
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gambar
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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
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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
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Public safety agencies
• Need strong ties with them
Police
Fire & Rescue
JPA3
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Consumer participation
• Lay person
• Political
• Consumer association
• Need their support and corporation in order to have successful PHC service
manpower/ financial/ legislative
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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.
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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.
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EMERGENCY INTERVENTION
• Airway maintenance/Cervical Spine Control
• Breathing and ventilation
• Circulation with hemorrhage control
• I mmobilization
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CARING FOR THE PATIENT WHILE EN ROUTE TO THE HOSPITAL
1. Continue to provide emergency care2. Continue monitoring vital signs3. Communicate with ED personnel using two way radio 4. Give a description of what happened5. Describe patient age, sex and his condition6. What type of injury suspected7. Patient vital signs8. Emergency care that has been provided9. Estimated time of arrival
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DEFINITIVE MANAGEMENT
Trauma center??Trauma center??Trauma team??Trauma team??
Trauma surgeon??Trauma surgeon??
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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
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Disaster Preparedness
• Any PHC system is an integral part to disaster response effort.
• Need to be involve in planning & practice drill
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In-hospital emergency care
• Receive patients
• Triage
• Resuscitation and stabilization
• Registration
• Investigation
• Treatment – definitive care, observation
• Disposal
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Bystanderinterventions
Emergency ServiceDispatch
On sceneinterventions
Early DefinitiveCare/Trauma Center/ED
Transportation
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Thank you