Chapter 6: Pre-Hospital Care
Karen Piette
Before the basic components of prehospital medicine are discussed, it is important to be familiar with medical direction used in EMS systems. Medical direction comes from qualified physicians based upon state, regional and local guidelines. These guidelines are based on current research and local needs. The ems medical director in most systems defines the clinical guidelines that advanced level providers function under. As part of medical direction, they are involved in quality review of most critical calls. They are involved in the quality improvement functions within an agency, constantly looking at ways to improve the delivery of prehospital emergency care.
First Response
First responders are those medical trained providers who will arrive prior to the Ambulance of EMS responders. These responders may be public safety personnel (police, fire or off-duty healthcare workers) or industrial responders who may respond to an industrial accident. In critical situations, these first responders may reach the patient and administer lifesaving care within minutes of the incident. This critical care has demonstrated a greater chance of survival for the patient. Most providers that fall into this group are trained at the Emergency Medical Responder (EMR) level or higher.
Disease Dissection: Coronary Artery Disease
According to the Center of Disease Control, coronary artery disease (CAD) is the most common form of heart disease. CAD is caused by atherosclerotic plaque buildup in the walls within the coronary arteries. The coronary arteries are the arteries that supply the heart with blood. Chest pain or angina is the most common symptom of CAD. Once plaque builds up, the arteries narrow causing angina to occur. Angina is a sign of a heart attack or myocardial infarction (MI), which occurs when a blood vessel supplying the heart becomes blocked, leading to death of part of the heart muscle. Different from an MI, cardiac arrest occurs when the heart stops beating and pumping blood. The damage an MI causes can lead to cardiac arrest. This condition is critical and will become fatal without appropriate intervention. During cardiac arrest, the patient requires Cardiopulmonary Resuscitation (CPR) and most likely the use of an automated external defibrillator (AED). AED’s analyze the patient’s heart rhythm and, when necessary, deliver an electrical shock to help the heart re-establish an effective rhythm. Public access defibrillator AED’s are available in many areas including schools, public buildings, and shopping malls. The goal is to provide “Zero minute” response time to cardiac arrest victims.
As a future health professional, it is important to know that heart disease is the leading cause of death in the United States. As you begin your journey in healthcare you will undoubtedly encounter this disease. It is also important to recognize the signs of an MI and be prepared to act as future health professionals. While you won’t be able to act as a first responder who has been trained to care for individuals in a medical crisis, you will at minimum be able to assist in a vitally important aspect. The first crucial step in the cardiac chain of survival is the recognition of cardiac arrest and activation of the emergency response system. Recognizing the signs of an MI, such as angina, feeling weak or faint, pain or discomfort in one or both shoulders or arms, and shortness of breath is critical for early medical intervention. Although these are classic symptoms of an MI, there are also many other symptoms that can be signs of an impending cardiac arrest such as nausea, lightheadedness, and cold sweats. Symptoms may present differently between genders as well. Either way, once the symptoms are recognized, 911 should be called right away. Early intervention results in more favorable outcomes for the patient.
Basic Life Support Ambulance
Ambulances may be staffed by emergency medical technicians (EMT), paramedics or a combination of both. The basic life support ambulance provides emergency and scheduled transportation to the sick and injured, along with scheduled transportation to those who cannot be transported by other means.
Advanced Life Support Care
Advanced level care is provided by Paramedics and in some areas by Advanced Emergency Medical Technicians (AEMT). Paramedics, who are the highest level of prehospital providers, and AEMT’s perform what are considered advanced life support to patients who have suffered a medical or trauma related injury. These providers deliver advanced assessment and treatments to patients that include medication administration, airway management and cardiac rhythm interpretation.
Emergency Department
The primary destination for those patients requiring further ongoing care is the Emergency Department. Every hospital has an Emergency Department that is staffed by specially trained physicians, midlevel providers (PA’s and NP’s), respiratory therapists, and nurses. These departments are tasked with providing the care needed to treat and stabilize the patient. Patients who require further care are either admitted to the facility or transferred to a larger hospital with greater availability of specialty services. In some areas free-standing Emergency Department usually affiliated with a hospital are commonplace. Some EMS agencies may transport patients to these facilities.
Trauma Center
trauma centers are hospitals that are designated as being able to deliver the care and stabilization to patients who have experienced a serious trauma related event. There are five levels of designation of trauma centers in Washington state with Level 1 being the highest. A level 1 trauma center is usually situated in a large academic teaching hospital. Level 1 centers are prepared 24/7 to receive the most critically injured and complex trauma patients. They have trauma surgeons in-house and operating rooms and surgical staff ready at a moment’s notice. They are able to provide ongoing care for trauma patients both in the intensive care units and further through their rehabilitative care. Level 2 trauma centers provide most of the same care that is provided at a level I center, but may not have the availability of specialized subspecialty care. Level 3, 4 and 5 centers are commonly seen in more rural and suburban areas. Level 3 centers provide initial care and stabilization of the critical trauma patient prior to transport to a higher level of trauma center for continued care. Similar to Level 1 and 2, level 3 trauma centers have 24-hour emergency medicine physicians on hand. Level 4 and 5 centers tend to have a more basic emergency department and facilities. They provide evaluation, stabilization, and diagnostic testing to patients. They provide advanced trauma life support prior to transferring patients to higher level trauma centers.
Tertiary Care Center
Tertiary care centers are specialty hospitals who provide care to a specialized group of patients. For instance burn centers, pediatric hospitals and neonatal intensive care centers are examples of these centers. Most tertiary care centers are housed or affiliated with large academic teaching hospitals.
Attributions
- Figure 6.2: image released under the Pexels License
- Figure 6.3: image released under the Pexels License
- Figure 6.4: MarkhamStouffvilleHospital23.jpg by Raysonho is released under CC0
A physician who is responsible for all aspects of patient care for an EMS system.
Abbreviated CAD.
Chest pain or discomfort caused by insufficient oxygen supply to the heart muscle, typically due to narrowed or blocked coronary arteries.
Abbreviated as MI and also known as a heart attack. A serious medical condition where there is a sudden blockage of blood flow to a portion of the heart muscle, leading to tissue damage or death.
Sudden loss of cardiac activity due to an irregular rhythm.
Commonly abbreviated as AED. A portable electronic device that can diagnose cardiac arrhythmias and is able to treat them through defibrillation to re-establish a normal rhythm.
Abbreviated as EMT. A healthcare professional who provides prehospital emergency medical care and transportation for critical and emergent patients.
An allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients.
Hospitals that are designated as being able to deliver the care and stabilization to patients who have experienced a serious trauma related event.