Roadside care and rescue American style

96 Injury,11,96-98 PrintedinGreatBritair~

Roadside care and rescue A m e r i c a n style Paul P. S i l v e r s t o n

Coordinator, Mid-Anglia General Practitioner Accident Service

Summary The development of an emergency services system in the USA is described, including the training of paramedical personnel. The increase in the survival rate of the severely injured appears to be impressive and it is suggested that lessons can be learned from the American system. INTRODUCTION THE emergency medical services system which the Americans are developing is extremely impressive with its well-trained ambulance crews, often supported by helicopter transport, and backed by specialists in accident surgery in purpose-built trauma hospitals. In short, traumatology in America is rapidly being established as a specialist field in its own right. In the United States over 49 000 people are killed in road accidents every year and a further 1-8 million suffer disabling injuries, 140 000 of whom will remain permanently disabled. The cost to the nation is approximately $24 billion a year in terms of hospitalization, economic manpower and rehabilitation. To counteract the effects of this carnage, the Americans have sought to update their methods of dealing with the victims of road accidents and to provide a higher standard of emergency care at the roadside. DEVELOPMENT OF EMERGENCY M E D I C A L SERVICES It was the Federal Government and especially the Departments of Transportation and Health, Education and Welfare who led the way in promoting the growth of emergency medical services in the USA. Individual units had already developed the skills and techniques learnt in wartime in Korea and, later, in Vietnam, but it was the Government who en-

couraged their adoption on a larger scale. In 1966, the Emergency Highway Safety Act threatened States with a 10 per cent cut in highway construction funds unless they upgraded their emergency medical services system. It was in 1973, however, that the Government really took the initiative with the Emergency Medical Services Systems Act which set out plans for the funding and development of emergency medical services on a national scale. Since then, nearly $200 million have been assigned to emergency medical services by the Departments of Transportation and Health, Education and Welfare. The spirit of the movement was captured in the popular television series Emergency which showed the Los Angeles Fire Department 'paramedics' at work, which set an example for other States to follow. There are now over 27 500 ambulances with over 280000 certified Emergency Medical Technicians (EMTs) of whom over 20 000 have advanced 'paramedic' training. The majority of these ambulancemen are, in fact, volunteer firemen. The reason that they are drawn from the Fire Service is due to America's private ambulance system,which made it impossible for an ambulance service, as we know it, to exist. The vast distances and the large number of small townships makes it more logical for each community to have its own volunteer fire/ ambulance crew rather than having to rely on a vehicle travelling from the nearest city many miles away. In urban areas, most of the crews are full time because of the high incidence of accidents and violence, whereas in the rural areas the opposite is the case. The author has visited a number of volunteer stations which were paid for by the local community and staffed by local volunteers.

Silverston: Roadside Rescue American Style

They were very well equipped, extremely professional and the morale and enthusiasm of the crews was most impressive. Furthermore, the future of the emergency medical services in the United States looks very good with plans to expand the number of units in action from the present 100 to 300 in 1982, funded by $500 million of government money. EFFECT OF THE P R O G R A M M E It is recognized by everyone in the field of emergency medicine that it is extremely diffficult to prove that an emergency medical services system is either effective or economical. However, it has been noted in the areas where emergency medical services have been developed that there has been a 19 per cent decrease in the number of patients who die before arriving at hospital. Furthermore, individual units like the Maryland Institute of Emergency Medicine (MIEM) claim that in five years they have increased the survival rate of seriously injured victims from 38 per cent to 84 per cent. The 16 per cent mortality rate for the unit includes those dead on arrival, according to Dr Cowley and Dr Gill of MIEM. The trauma unit itself deals only with serious injuries and many patients, in fact, come from surrounding hospitals that cannot cope with the severity or the type of injuries involved. Its annual budget is $3"6 million and around 1200 patients are seen by the trauma teams every year. Seriously injured casualties are resuscitated and their conditions stabilized at the scene by the 'paramedics' prior to being transported into the unit by police helicopter, where a trauma team is always on stand-by. Through aggressive in-the-field and emergency room treatment, 84 out of every 100 patients who enter that unit survive. The figures speak for themselves. T R A I N I N G OF PERSONNEL The emergency medical technician (EMT) training is the basic instruction given to all fire/ambulancemen and it consists of an 81-hour course in which the skills of first aid are taught. During this period, the ambulanceman learns how to take and monitor the patient's vital signs; how to clear and maintain an airway; how to carry out external cardiac massage and cardiopulmonary resuscitation techniques; how to splint, immobilize and, where applicable, place in traction, fractures. Even at this level, the training is excellent, especially in the areas of cardiopulmonary resuscitation, the use of

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oxygen and the handling and management of spinal injuries. A year after gaining the EMT certification, the ambulanceman can then take a course to become a 'paramedic'. The Department of Emergency Medical Services specifies that the minimum length of the course is to be 480 hours and that the paramedic must learn a specified number of skills. However, each State differs in the length of training it requires a paramedic to undergo and many States require the paramedic to learn extra skills. In general, the length of the course is 500 hours: 200 hours didactic (classroom), 100 hours internship (hospital training) and 200 hours supervision in the field. An indication of the level of training can be seen in the following information drawn from the San Francisco paramedic course book Paramedic Procedures and Protocol: Fundamental principle The paramedic works as an extension of the emergency department into the field.

Duties I. Bandaging and wound care. 2. Control of external bleeding. 3. Application of splints and management of fractures. 4. Administration of 0 2 by mask, cannula and nasal tongs. 5. Cardiopulmonary resuscitation. 6. Establishment and maintenance of an airway and administration of pulmonary ventilation: a) bag and mask; b) mouth to mouth; c) mouth to mask; d) positive pressure. 7. Suction: nasal, oral, pharyngeal and tracheal. 8. Extrication with the use of long and short boards. 9. Recording and interpreting vital signs. ]0. Clinical examination of the patient, recognition and interpretation of his signs and symptoms and diagnosis of various injuries and illnesses. 11. Use of a defibrillator for treatment oflfiethreatening ventricular arrhythmias. 12. Initiation of preventive therapy for cardiac arrest. 13. Recognition of cardiac arrhythmJas and identification of the possibility of treating those arrhythmJas which are life-threatening. 14. Electrical recording of cardiac rate and rhythm with the use of telemetry. 15. Anticipation of the use and administration of drugs and intravenous solutions.

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Injury: the British Journal of Accident Surgery Vol. 11/No. 2

16. Communication via radio transmission with the supervising physician; use Of proper medical terminology in describing, reporting and communicating. 17. Recognition of the complications which can result from mismanagement.

must contact the base hospital before he sets up an intravenous infusion, passes a tube, administers drugs or defibrillates. In others, his task is to stabilize the patient's condition first and then contact the hospital for further advice. The former system tends to work in urban areas where the paramedics are close to the hospital and the latter in rural areas. In both systems, the emphasis is on good resuscitation and stabilization of the patient's condition and injuries before and while moving him to the hospital.

Drug list 1. Cardiac - - lignocaine, 5 per cent glucose in water, adrenaline, lsuprel, sodium bicarbonate, nitroglycerin, frusemide, dopamine, calcium chloride. 2. Dyspnoea-- adrenaline. 3. Coma - - Narcan, dextrose 50 per cent. 4. Poison-- ipecacuanha. 5. Anaphylaxis-- adrenaline. 6. Shock/burns - - Ringer's lactate plasmolyte. 7. Obstetrics-- Ringer's lactate pitocin. 8. Seizure control-- diazepam. 9. Analgesia-- morphine.

Special equipment 1. ECG monitor, transmitter and defibrillator. These are light, portable units which the paramedic carries from the ambulance to the victim in order to record the patient's cardiac condition and to transmit (telemeter) the recording to the hospital. Thus, physician and paramedic read the ECG strip at the same time. 2. Mast s u i t - - military anti-shock trousers. A pair of inflatable trousers which are applied to the exsanguinated casualty in order to squeeze 1 litre or more of the patient's own blood back into his vital organs. It is often used to increase the blood pressure in order to set up an infusion. 3. Oesophageal obturator airway. This is a cuffed, blunt-ended oesophageal tube designed to be inserted into the oesophagus without using a laryngoscope. Once the tube has been placed in the oesophagus, the cuff is inflated to secure it there and a mask is placed tightly over the face. The patient is then given oxygen. It is faster and easier to pass than an endotracheal tube, prevents vomiting and the blood gases are comparable with the two methods of intubation. (The OOA has now been superseded by the oesophageal gastric tube airway.) Protocols The paramedic always acts upon a set of instructions which define the treatment that he can administer at the scene before having to contact the 'base hospital' for permission to carry out other procedures. In some States, the paramedic

CONCLUSION In the past decade, the American government has become increasingly aware of the cost of accidental death to the community and has sought to decrease the mortality rate by encouraging the growth of an advanced emergency medical services system. Many of the skills and techniques used in the USA originated in Great Britain and yet we are rapidly falling behind them in the field of emergency medical care. Quite simply, emergency medical services in Great Britain have failed to progress because of the negative attitude of the various government departments. The American government has led the way in this field, while the British government has placed obstacles in the path of those trying to develop emergency medical service units; it has been left to organizations like the British Association of Immediate Care Schemes to promote a better standard of emergency care in this country. The British government must be shaken out of its apathy because every day over twenty people are killed and 1000 injured on our roads. In all, 23 000 people lose their lives annually as a result of some sort of violence. We can learn a great deal from the American emergency medical services system and we should make every effort to do so.

Acknowledgements I should like to thank all those who extended the warmest hospitality to me in the USA: in Los Angeles, the staff of UCLA Trauma Unit and the Beverly Hills Fire Department paramedics; in San Francisco, the staff of the Department of Emergency Medical Services and Paramedic Training; in Washington, the staff of the Trauma Hospital Centre and in Baltimore, the staff of the Maryland Institute of Emergency Medicine, the Med-Evac Helicopter crews and the volunteer paramedic firemen of Hagerstown and Middle River Stations.

Requestsfor reprints should be addressed to: Mr P. Silverston, Beaulieu House, Bottisham, Cambridgeshire, CB5 9DZ.