This edition first published 2018
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Library of Congress Cataloging-in-Publication Data
Names: Seligman, William, 1990- author. | Ganatra, Sameer, author. | Parker,
Timothy, 1989- author. | Masud, Syed, 1972- author.
Title: Pre-hospital emergency medicine at a glance / William Seligman, Sameer
Ganatra, Timothy Parker, Syed Masud.
Other titles: At a glance series (Oxford, England).
Description: Hoboken, NJ : John Wiley & Sons Ltd, 2018. | Series: At a glance
series | Includes index.
Identifiers: LCCN 2017000447 (print) | LCCN 2017001693 (ebook) | ISBN
9781118829929 (pbk.) | ISBN 9781118829950 (Adobe PDF) | ISBN 9781118829967
(ePub)
Subjects: | MESH: Emergency Medical Services—methods | Emergency
Treatment—methods | Emergencies | Critical Care—methods | Handbooks
Classification: LCC RC86.8 (print) | LCC RC86.8 (ebook) | NLM WB 39 | DDC
616.02/5—dc23
LC record available at https://lccn.loc.gov/2017000447
Cover image: Courtesy of Syed Masud
Pre-hospital Emergency Medicine is an innovative and exciting new sub-specialty that is saving lives and has great potential to change the way medicine is practised. The sub-specialty has grown exponentially since its inception and has enormous potential to answer research questions that will benefit patients both outside and within the hospital.
Although it has a short history, we must remember that the sub-specialty emerged not only from the ambulance service but also from doctors who decided to travel to patients on the roadside with limited equipment, in order to deliver whatever care they could. It is from these humble beginnings that the sub-specialty has developed into the incredibly influential model of care seen today in modern pre-hospital emergency units.
With great admiration and respect, I would like to thank those that developed the concepts that made Pre-hospital Emergency Medicine the force for good that is today.
We must never forget that the practice of Pre-hospital Emergency Medicine is a sacrifice not only for those who deliver care but also for their loved ones who, in turn, care for them. Without family and friends, we would be unable to deliver the quality of care that is expected in the challenging pre-hospital environment. We are too quick to forget the partners who wait in the middle of the night for their loved ones to return from road traffic accidents or other serious incidents to deliver comforting words and understanding. Without them, we couldn’t do what we do.
This book is dedicated to both those who deliver what I like to believe is the ‘bungee jumping’ of medicine, and to those who silently support them in the background.
Dr Syed Masud
Consultant in Emergency Medicine & Pre-hospital
Emergency Medicine, Oxford University Hospitals NHS
Foundation Trust;
Clinical Governance Lead, Thames Valley Air Ambulance;
Senior Lecturer in Trauma and Pre-Hospital Emergency
Medicine, University of Oxford
Dr Adam Fendius
Consultant in Trauma Anaesthesia
Oxford University Hospitals NHS Foundation Trust
Dr Edward Horwell
Core Surgical Trainee
Wessex Deanery
Dr Anna Barrow
Specialty Trainee in Anaesthesia and Intensive Care;
National Grid Trainee in Paediatric Intensive Care
Oxford Deanery
Dr Matt Edwards
Specialty Registrar in Emergency Medicine, London School of Emergency Medicine;
Faculty, Expedition and Wilderness Medicine courses; Ex British Antarctic Medical Officer
Mr Mark Cutler
Medical Operations Manager,
The Football Association
Lt Col Jon Walker
Lt Col, RAMC
Consultant in Emergency Medicine
Oxford University Hospitals NHS Foundation Trust
Mrs Joanna Jefferies
Paramedic
Thames Valley Air Ambulance
| AF | atrial fibrillation |
| AIM | acute internal medicine |
| ALS | advanced life support |
| APS | approved practice settings |
| AVPU | alert, responsive to voice/pain, unresponsive |
| BASICS | British Association for Immediate Care |
| BATLS | battlefield advance trauma life support |
| BVM | bag-valve-mask (ventilation) |
| C-spine | cervical spine |
| CBRN | chemical, biological, radiological, nuclear |
| CFR | community first responder |
| CICV | can’t intubate, can’t ventilate |
| CPR | cardiopulmonary resuscitation |
| CSF | cerebrospinal fluid |
| CT | computed tomography |
| DCS | damage control surgery |
| ECRU | enhanced care response unit |
| EMS | emergency medical services |
| EPHEC | enhanced pre-hospital emergency care |
| ETT | endotracheal tube |
| FAST | focused assessment with sonography in trauma (scan) |
| FFP | fresh frozen plasma |
| GCS | Glasgow Coma Scale |
| GFR | glomerular filtration rate |
| GMC | General Medical Council |
| GP | general practitioner |
| HART | hazardous area response teams |
| HEMS | helicopter emergency medical service |
| IBTPHEM | Intercollegiate Board for Training in Pre-Hospital Emergency Medicine |
| ICH | intracranial haemorrhage |
| ICM | intensive care medicine |
| ICP | intracranial pressure |
| ICS | incident command system |
| IO | intraosseus |
| IPPA | inspection, palpation, percussion, auscultation |
| JESCC | Joint Emergency Services Control Centre |
| JRCALC | Joint Royal Colleges Ambulance Liaison Committee |
| LAM | laryngeal mask airway |
| LPA | lasting power of attorney |
| MASH | Mobile Army Surgical Hospital |
| MERT | medical emergency response team |
| MILS | manual in-line stabilisation |
| MTC | major trauma centre |
| NAI | non-accidental injury |
| NPA | nasopharyngeal airways |
| OOPE | out-of-programme experience |
| OPA | oropharyngeal (Guedel) airway |
| PHEM | pre-hospital emergency medicine |
| PPE | personal protective equipment |
| PRU | physician response unit |
| RCC | rigid cervical collar |
| ROSC | return of spontaneous circulation |
| RSI | rapid sequence induction |
| RT | resuscitative thoracotomy |
| RTC | road traffic collision |
| SAD | supraglottic airway device |
| SBAR | situation, background, assessment, recommendation |
| SCI | spinal cord injuries |
| SGSA | Sports Ground Safety Authority |
| SLUDGE | salivation, lacrimation, urination, defaecation, GI distress, emesis |
| SOMA | specialist operations medical advisor |
| STEP | safety triggers for emergency personnel |
| TARN | Trauma Audit and Research Network |
| TBI | traumatic brain injury |
| TCA | traumatic cardiac arrest |
| TPx | tension pneumothorax |
| WHO | World Health Organization |
| WTE | whole-time equivalent |
Pre-hospital emergency medicine (PHEM) is one of the newest specialties in existence, but has a remarkably long history. This chapter chronicles the development of the specialty from ancient times to the modern era, and narrates the evolution of a specialty borne out of necessity, nurtured by enthusiasm, and then ratified by clinical governance.
The first insight into pre-hospital care arises from the biblical parable of the Good Samaritan: ‘He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, brought him to an inn and took care of him.’ (Luke 10:34, NIV). From 1500 BC, the invention of the chariot allowed ancient Greeks and Romans to remove injured soldiers from the battlefield, which many regard as the very origin of pre-hospital patient transfer.
‘War is the only proper school for a surgeon’. These words of Hippocrates embody the truth that war has been the impetus for medical innovation, particularly in trauma, for the past 1000 years. During the crusades, a group of knights set up a hospital for wounded pilgrims in 1023; by 1099, the Order of the Knights Hospitaller had been formed, the first organised, uniformed group providing pre-hospital care. The knights were also known as the Order of St John, and eventually, after a long decline and ensuing revival in the nineteenth century, evolved into the St John’s Ambulance we know today.
The eighteenth and nineteenth centuries bore witness to great advances in pre-hospital care through a number of conflicts. Baron Dominique Jean Larrey, surgeon-in-chief of the Napoleonic armies, is credited with instituting the first coordinated pre-hospital care system in 1797, complete with an ambulance service and triage and field hospitals. Impressed by the speed at which the French horse-drawn ‘flying artillery’ manoeuvred across the battlefield, Larrey developed ambulances volantes (flying ambulances), adapting the artillery units and manning them with trained crews. His system of triage was the first to prioritise by clinical need, and not by rank or nationality. The first instance of true aeromedical transportation was documented during the Prussian siege of Paris of 1870 (Franco–Prussian War), in which hot air balloons were used to transport wounded soldiers.
The world wars of the twentieth century catalysed developments, particularly in trauma. The Thomas splint, named after Hugh Owen Thomas, regarded as the father of orthopaedic surgery in the UK, was developed during the First World War and reduced mortality related to compound femoral fractures from 87% to less than 8% over three years. The first blood bank was set up in the First World War and the Second World War saw blood transfusions being performed in the field. The far-reaching nature of the Second World War meant that the front line was often on the streets of London; with ambulance services stretched, the need for doctors on ambulances was questioned for the first time, and this encouraged the development of paramedical services.
In 1942, Igor Sikorsky designed the first mass-producible helicopter, and its potential for rapid evacuation of casualties from the field to treatment areas was swiftly seized upon in later conflicts, especially in Korea and Vietnam. These same wars featured the first mobile army surgical hospital (MASH) units, designed to bring expert surgeons closer to the front lines so that the wounded could be treated more quickly.
War continues to drive innovations in pre-hospital care, with advances in fluid resuscitation, blood transfusion and major haemorrhage control from recent conflicts now being applied routinely by civilian Helicopter Emergency Medical Services (HEMS).
The first civilian adoption of military innovations came in the shape of horse-drawn ambulances used in the 1832 London cholera epidemic. Run by the Metropolitan Asylums Board, requests were made by telegram. Ambulance services developed soon after the epidemic, being funded by charities in the UK (e.g. St John’s Ambulance) and run by individual hospitals in the USA. The first American ambulance ran from Bellevue Hospital in New York City in 1869. It was manned by an ambulance surgeon equipped with scalpels, saws, splints, laudanum (an opiate) and brandy!
Air ambulances followed. The first known air ambulance was built in North Carolina in 1910; it flew 400 yards before crashing. The Australians then led the world in aeromedical retrieval with the institution of the Royal Flying Doctors Service in 1928. The first air ambulance in the UK launched in Cornwall in 1987 and there are now 27 services operating.
The advent of modern PHEM was heralded by Frank Pantridge, a cardiologist from Belfast. With the ABC algorithm for basic life support having been pioneered by Peter Safar in Pittsburgh, USA, in 1956, Pantridge realised that many patients died from ventricular fibrillation before reaching hospital. As a result, he designed the first portable cardiac defibrillator and fitted it into a van; by 1965, the first mobile coronary cardiac unit was active in Belfast. Over the next few decades, the Belfast treatment system (or ‘Pantridge Plan’) was adopted by emergency medical services all over the world, and automated external defibrillators were developed for safe use by members of the public.
Pre-hospital care has evolved significantly since the time of Pantridge. It has been transformed over the last four decades from volunteer services (e.g. the British Association for Immediate Care, BASICS) into a recognised subspecialty with a dedicated Faculty and robust clinical governance systems. Volunteers still practise today in the form of community first responders, qualified general practitioners and emergency physicians who give up their time to respond to pre-hospital emergencies.
Further integration between volunteers and structured training programmes is required in the future: such collaboration is intrinsic in order to develop further this life-saving specialty in the UK. Strong governance systems and structure are pivotal for this specialty to continue growing.Most recently, smartphone applications, e.g. GoodSAM, have been developed that serve to alert trained volunteers to nearby cardiac arrests and other medical emergencies in the community.