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The shift in location of hospital-based helicopter programs (HEMS) to university hospitals
experienced by sufferers of these conditions have been recognized to have c o m m o n elements. These are being studied as the field of victimology. Several legal precedents have heightened the alertness of emergency physicians to these problems. Failure to recognize child abuse and to take action to protect the child is considered malpractice. No longer is the sexually assaulted female transported across town to the public hospital to be treated indifferently by fragmented staff. The American College of Emergency Physicians even developed a film and methodology for managing sexual assault cases. The recognition and early m a n a g e m e n t of these severe psychological traumatic conditions have become the domain of emergency medicine. A unique component of this responsibility is an interface with law enforcement and the judicial system. Emergency medicine has become the expert for these institutions about the medical, as well as psychological, implications of these conditions.
2
Medical Care at the Detroit Grand Prix: An Emergency Medical System in Microcosm
RL Krome, RE Jackson, B Laubscher / From the Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan; and the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit, Michigan T h e planning and development of an emergency medical syst e m for a major international motor racing event is not unlike p l a n n i n g an emergency medical s y s t e m for a c o m m u n i t y . The purpose of this study was to report how by using and incorporating essential e l e m e n t s of an emergency medical system, the emergency medical care for a large, complex international event can be planned and executed. The scope of medical care provided in this event included a system for care of the drivers during the race in the event of an accident, as well as general medical care for the spectators. For each event, 30 physicians were involved in various aspects of medical care, with another 70 nurses, and advanced and basic emergency medical technicians involved. There were two distinct medical terms involved, one for only on-track incidents and the other for spectators. Three first aid stations were staffed during the three-day event. A separate trailer served as the m a i n field hospital, medical control, and c o m m u n i c a t i o n s center. There were eight roving medical teams, three in golf carts w i t h an additional five on foot, placed strategically in areas of high spectator volume. A helicopter was available and stationed at trackside. Water rescue u n i t s also were stationed at points where the track and the Detroit river flow side-by-side. Over a three-year period, 7 drivers were treated after incidents, with 2 transferred to a hospital for definitive care. The n u m b e r of spectator patients treated was 1029, w i t h 36 transferred to the hospital for further workup and treatment. The unique knowledge and experience of emergency physicians enables t h e m to plan and execute such a prehospital system.
3
The Shift in Location of Hospital.Based Helicopter Programs (HEMS) to University Hospitals
JR Mackenzie, RE Burney, M Strozeski, K LaGreca / Section of Emergency Services, Department of Surgery, University of Michigan, Ann Arbor, Michigan One hundred eight hospital-based helicopter programs (HEMS) have been started in t h e U n i t e d States or Canada since 1971. Fifty-three of 94 programs surveyed (56%) were started by hospitals with more t h a n 500 beds, that is, hospitals w i t h tertiary care capabilities. Since 1982 the university hospitals w i t h more t h a n 200 beds have increased their programs exponentially, and in 1984, this group represented 55% of all new program starts (and 85% of all new program starts) as shown below. 15:4 April 1986
TABLE. HEMS Implementation by Year
Hospital Type U1 U2 U3 UA1 UA2 UA3 NU1 NU2 NU3 Total 71-77 78
2 0
1 0
0 0
4 0
0 1
1 0
0 0
0 1
1 0
re 79 2
0
0
6
2
0
0
2
0
9 4 12
'~ 80 2 m 81 1 ~- 82 3 83 2 84 11
0 1 2 0 1
0 0 0 0 0
1 5 1 4 5
2 8 5 1 1
0 0 1 2 0
0 0 1 0 1
0 0 1 4 1
0 1 1 0 0
5 16 15 13 20
We concluded from this survey and other historical, theoretical, and financial evidence t h a t future new HEMS programs starts will be located at university hospitals w i t h more than 500 beds; that some programs will develop at university-affiliated hospitals if they are not located in the same service area as the parent university hospital; and that HEMS programs presently located in hospitals w i t h fewer than 500 beds probably will fail if they are located in the same service areas as university-affiliated programs.
4
Cardiopulmonary Bypass in the Treatment of Prolonged Cardiopulmonary Arrest
GB Martin, RM Nowak, DL Carden, R Eisiminger, MC Tomlanovich / Department of Emergency Medicine, and Division of Thoracic Surgery, Henry Ford Hospital, Detroit, Michigan Although in vitro studies have demonstrated functional recovery of neurons after prolonged ischemia, in vivo experience with patients resuscitated from cardiopulmonary arrest demonstrates a markedly decreased cerebral resistance to global ischemia. The degree of reperfusion attained during resuscitation from cardiopulmonary arrest may play a critical role in determining the degree of functional recovery attained after global ischemic insults. The purpose of this investigation was to study the effectiveness of veno-arterial cardiopulmonary bypass (GPB) as t r e a t m e n t for prolonged cardiopulmonary arrest. Ten mongrel dogs were fibrillated electrically and left in cardiopulmonary arrest w i t h o u t any therapy for 12 minutes. Subsequently, either CPB (n = 5) or closed CPR {CC-CPR) ( n = 5) was initiated and resuscitation attempted according to a standardized protocol. If initial resuscitation was successful (ie, return of spontaneous circulation), the animal was managed in an intensive care setting w i t h invasive h e m o d y n a m i c monitoring and ventilatory support for up to 11 hours. Neurologic function was graded using a standardized scoring system at 12 hours post insult and twice daily for one week or until death. All CPB animals were successfully resuscitated and alive at 24 hours post insult as opposed to none in the CC-CPR group (P<.005). In addition, 3 of the CPB animals were neurologically normal at final grading. T h u s CPB is more effective t h a n GC-CPR in the t r e a t m e n t of prolonged cardiopulmonary arrest. The degree of reperfusion a t t a i n e d during resuscitation after prolonged global i s c h e m i c insults may play a critical role in tolerance of end organs to such insults and their resultant functional recovery.
5
Combined Application of Trendelenburg and PASG in Hemorrhagic Hypoperfusion
HL Mayo, RG Carroll, EJ Allison, TW Whitley, SS Landis / Departments of Emergency Medicine and Physiology, East Carolina University School of Medicine, Greenville, North Carolina In hemorrhagic hypoperfusion, pneumatic anti-shock garment
Annals of Emergency Medicine
494/169
2
Medical Care at the Detroit Grand Prix: An Emergency Medical System in Microcosm
RL Krome, RE Jackson, B Laubscher / From the Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan; and the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit, Michigan T h e planning and development of an emergency medical syst e m for a major international motor racing event is not unlike p l a n n i n g an emergency medical s y s t e m for a c o m m u n i t y . The purpose of this study was to report how by using and incorporating essential e l e m e n t s of an emergency medical system, the emergency medical care for a large, complex international event can be planned and executed. The scope of medical care provided in this event included a system for care of the drivers during the race in the event of an accident, as well as general medical care for the spectators. For each event, 30 physicians were involved in various aspects of medical care, with another 70 nurses, and advanced and basic emergency medical technicians involved. There were two distinct medical terms involved, one for only on-track incidents and the other for spectators. Three first aid stations were staffed during the three-day event. A separate trailer served as the m a i n field hospital, medical control, and c o m m u n i c a t i o n s center. There were eight roving medical teams, three in golf carts w i t h an additional five on foot, placed strategically in areas of high spectator volume. A helicopter was available and stationed at trackside. Water rescue u n i t s also were stationed at points where the track and the Detroit river flow side-by-side. Over a three-year period, 7 drivers were treated after incidents, with 2 transferred to a hospital for definitive care. The n u m b e r of spectator patients treated was 1029, w i t h 36 transferred to the hospital for further workup and treatment. The unique knowledge and experience of emergency physicians enables t h e m to plan and execute such a prehospital system.
3
The Shift in Location of Hospital.Based Helicopter Programs (HEMS) to University Hospitals
JR Mackenzie, RE Burney, M Strozeski, K LaGreca / Section of Emergency Services, Department of Surgery, University of Michigan, Ann Arbor, Michigan One hundred eight hospital-based helicopter programs (HEMS) have been started in t h e U n i t e d States or Canada since 1971. Fifty-three of 94 programs surveyed (56%) were started by hospitals with more t h a n 500 beds, that is, hospitals w i t h tertiary care capabilities. Since 1982 the university hospitals w i t h more t h a n 200 beds have increased their programs exponentially, and in 1984, this group represented 55% of all new program starts (and 85% of all new program starts) as shown below. 15:4 April 1986
TABLE. HEMS Implementation by Year
Hospital Type U1 U2 U3 UA1 UA2 UA3 NU1 NU2 NU3 Total 71-77 78
2 0
1 0
0 0
4 0
0 1
1 0
0 0
0 1
1 0
re 79 2
0
0
6
2
0
0
2
0
9 4 12
'~ 80 2 m 81 1 ~- 82 3 83 2 84 11
0 1 2 0 1
0 0 0 0 0
1 5 1 4 5
2 8 5 1 1
0 0 1 2 0
0 0 1 0 1
0 0 1 4 1
0 1 1 0 0
5 16 15 13 20
We concluded from this survey and other historical, theoretical, and financial evidence t h a t future new HEMS programs starts will be located at university hospitals w i t h more than 500 beds; that some programs will develop at university-affiliated hospitals if they are not located in the same service area as the parent university hospital; and that HEMS programs presently located in hospitals w i t h fewer than 500 beds probably will fail if they are located in the same service areas as university-affiliated programs.
4
Cardiopulmonary Bypass in the Treatment of Prolonged Cardiopulmonary Arrest
GB Martin, RM Nowak, DL Carden, R Eisiminger, MC Tomlanovich / Department of Emergency Medicine, and Division of Thoracic Surgery, Henry Ford Hospital, Detroit, Michigan Although in vitro studies have demonstrated functional recovery of neurons after prolonged ischemia, in vivo experience with patients resuscitated from cardiopulmonary arrest demonstrates a markedly decreased cerebral resistance to global ischemia. The degree of reperfusion attained during resuscitation from cardiopulmonary arrest may play a critical role in determining the degree of functional recovery attained after global ischemic insults. The purpose of this investigation was to study the effectiveness of veno-arterial cardiopulmonary bypass (GPB) as t r e a t m e n t for prolonged cardiopulmonary arrest. Ten mongrel dogs were fibrillated electrically and left in cardiopulmonary arrest w i t h o u t any therapy for 12 minutes. Subsequently, either CPB (n = 5) or closed CPR {CC-CPR) ( n = 5) was initiated and resuscitation attempted according to a standardized protocol. If initial resuscitation was successful (ie, return of spontaneous circulation), the animal was managed in an intensive care setting w i t h invasive h e m o d y n a m i c monitoring and ventilatory support for up to 11 hours. Neurologic function was graded using a standardized scoring system at 12 hours post insult and twice daily for one week or until death. All CPB animals were successfully resuscitated and alive at 24 hours post insult as opposed to none in the CC-CPR group (P<.005). In addition, 3 of the CPB animals were neurologically normal at final grading. T h u s CPB is more effective t h a n GC-CPR in the t r e a t m e n t of prolonged cardiopulmonary arrest. The degree of reperfusion a t t a i n e d during resuscitation after prolonged global i s c h e m i c insults may play a critical role in tolerance of end organs to such insults and their resultant functional recovery.
5
Combined Application of Trendelenburg and PASG in Hemorrhagic Hypoperfusion
HL Mayo, RG Carroll, EJ Allison, TW Whitley, SS Landis / Departments of Emergency Medicine and Physiology, East Carolina University School of Medicine, Greenville, North Carolina In hemorrhagic hypoperfusion, pneumatic anti-shock garment
Annals of Emergency Medicine
494/169