Em Intro Dr Tj Herbosa

EMERGENCY MEDICINE Lesson 1 Teodoro Javier Herbosa MD FACS Past Chairman, Dept. of Emergency Medicine Associate Professor, Div. of Trauma, Dept. of Surgery College of Medicine-Philippine General Hospital University of the Philippines

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Objectives ● Define

EM & selected terms used in Emergency

Medicine. ● State

the principles of the organization and

management of an Emergency Department. ● List

logistic of requirements for emergencies

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Definitions Emergency is any situation that requires immediate action. WHO Medical Disaster is an occurrence “when the destructive effects of natural or manmade forces overwhelm the ability of a given area or community to meet the demand for health care”. ACEP

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Definitions Emergency Medicine (EM) - A branch of medicine that deals with the appropriate management of all forms of acute illness or injury. ● Specialization in EM will lessen unwanted morbidity or mortality due to a sudden illness or injury. ● In the British System this is known as Accident and Emergency (A&E). ●

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Definitions Emergency Department (ED) or Emergency Room (ER) - A unit of the hospital composed of staff and organized to address management of acute illness or injury. ● The older terminology "Emergency Room" is abandoned because the word room is misleading when compared to the complex processes and organization of such a hospital department. ●

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The Emergency Department The current trend in Emergency Medicine is to establish the ED as a separate and distinct department within the hospital, complete with its own management and staff.

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EMS System Emergency Medical Services System (EMSS) – The total system intended to care for a casualty from the site of incident to definitive care.

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What are the components of EMSS?

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EMS System includes ● Triage ● On-site

care ● Initial resuscitation and treatment ● Medical transport ● Definitive care or Trauma Center Department of Emergency Medicine

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EMS System Components ● Transport ● Personnel ● Communications ● Medical

System

Control ● Equipment and Supplies ● Legislation and advocacy Department of Emergency Medicine

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Early Access By calling first, you join a team of Emergency Service dispatchers and responders. Each member has a vital role.

The Bystander

The Dispatcher The EMS Responders

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EMS System COMPONENTS ●

Transport - system of ambulances which may vary from (BLS) to (MICU) or (ALS) vehicles. Also connotes air transport either through fixed wing aircraft or rotary wing type air transports.

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Personnel - Medical First Responders (MFR),

Emergency Medical Technicians (EMT's), Paramedics, Ambulance Nurses, and Flight Paramedics.

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PGH EMS

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EMS System COMPONENTS Communications System - connotes the ability to relay information about an emergency response and to receive information or instruction as to what further actions should be taken. Department of Emergency Medicine

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EMS System COMPONENTS Medical Control - use of on-line communications with a specialized physician or through off-line protocols of care for emergency situations. Off-line (indirect) medical control is the responsibility of the service medical director. Three components of off-line medical director are: (1) development of protocols, (2) development of medical accountability (QA) (3) development of ongoing education.

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EMS System COMPONENTS Equipment and Supplies - all the necessary tools which EMT's need Legislation and Advocacy - stipulates the regulation of the practice of pre-hospital and emergency medicine in a locality. Secures the high standards of care needed. The financial aspects of the EMS System may also be included. Department of Emergency Medicine

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Regional Trauma Care System An organized approach in the management of acute injury utilizing the components of an EMSS and trauma centers or definitive care centers, trauma specialists and other aspects of trauma care in a locality, province, region or country. Department of Emergency Medicine

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COMPARATIVE DESIGNS OF EMERGENCY RESPONSE SERVICES Funding Infrastructure National Safety stats. Vehicles, equipment's Minimum standard care provided Minimum guidelines for education & training

USA Well Funded Uniform federal Support Exists Recognition present Existing

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Asian Nations Scarce Funding Not Uniform

Does not Exist Requires recognition Not existing

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COMPARATIVE DESIGNS OF EMERGENCY RESPONSE SERVICES USA

Asian Nations Support Professional Minimal Voluntary Improvements in Organizations Organizations System Design Cost of Med. & Heightened Lack of Trauma Care awareness awareness Public Health Continued Non existent Prevention Prog. Awareness Network for Disaster Structured Partially Response structured System Flexibility Existent No System Department of Emergency Medicine

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Human Resources in the Emergency Medical Services System Medical First Responder Emergency Medical Technician - Basic EMT - Intermediate EMT – Paramedic EMS Medical Director Emergency Department Nurse Emergency Medicine Physician General Surgeon/Trauma Surgeon Emergency Manager/Emergency Department Coordinator

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Emergency Department

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Principles of Managing the Emergency Department ●Policies

and Procedures ●Equipment and Supplies ●Management Unique to the ED ●Staffing requirements unique to the ED ●Overcrowding Department of Emergency Medicine

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Principles of Managing the Emergency Department To understand how a hospital responds to a disaster, one may have to look into how the Emergency Department functions in a given hospital and how it adapts to overcrowding. Department of Emergency Medicine

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Policies and Procedures ● Emergency

Departments must have clearly written policies and procedures. ● This has to be constantly reviewed and revised. ● It must be reviewed after each major emergency.

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Emergency Medicine, Trauma Surgery and Disaster Medicine aim to:

Prevent unnecessary mortality and morbidity from disasters and emergencies

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What are the roles of hospitals in emergencies? Department of Emergency Medicine

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Hospital roles in an Emergency Provision of Disaster Medical Teams ● Acting as the receiving hospital for casualties from a disaster ● Triage in multiple/mass casualty incidents ● Receiving hospital for patients transferred from other disaster affected health-care facilities ●

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Hospital Emergency Plans must consider many casualties may arrive quickly.

But if a hospital is unable to handle day to day emergencies in the ED, it will not be able to cope with demands of multiple casualty incidents The Key is Preparedness Department of Emergency Medicine

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Hospital Emergency Planning Developing and implementing plans, procedures and training to ensure that the hospital’s capacity to respond to disaster is maximized.

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Emergency or Disaster Plan Contains elements such as: Who needs to be prioritized for definitive care? ● triage criteria Who is in charge? What are the functions of each and every member of the emergency team? ● incident command system (ICS)

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Emergency or Disaster Plan The goals: ●

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To control the large number of patients and problems with the best possible care. Enhance the capacities for admission and treatment. Treat patients based on the rules of good medical practice despite great numbers of victims.

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Emergency or Disaster Plan The goals: ●

Ensure an ongoing proper treatment for all

patients who are already in the hospital. ●

A smooth handling of all additional tasks

caused by large number of patients in an ED. ●

To support the damaged area by means of

medical consultation, medicaments, infusions, dressing material and any other necessary medical equipment. Hershe, B. and O.C. Wenker. Principles of Hospital Disaster Planning. The Internet Journal of Rescue and Disaster Medicine 2000 vol 1N2 (http://www.icaap.org/86.1.2.19)

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Mass Casualty Incident (MCI) An incident wherein the trauma care system is stressed due to a large number of acutely injured needing definitive care. Connotes a decrease in the resources available to the ideal management of the injured victims. Any event resulting in a number of victims large enough to disrupt the normal course of emergency health care services. –

Establishing a Mass Casualty Management System (PAHO-OPS, 1995, 58 p.) –

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Bombing

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Contingency Planning is the key to the proper response to a multiple casualty incident or disaster.

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Observation and Holding Area Temporary patient care areas ● Lobby ● Conference rooms ● Corridors ● Parking ● Prayer areas Department of Emergency Medicine

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Referral and Transfer ● Human

resources, logistics or holding areas are not available transfer to other hospitals ● Prearranged mutual aid agreement between hospitals Department of Emergency Medicine

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Staffing Requirements of the ED ED Nurses - training in triage, injury care and disaster management. - must be able to work with the emergency medicine physicians and the trauma surgeons treating injured patients. - ensures that resuscitation equipment and drugs are available help triage patients

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Staffing Requirements of the ED

Emergency Medicine Physicians (EMP) ● great help in improving the health care during MCI’s. ● help triage and institute initial management of injured patients while the surgeons deliver definitive care. ● this specialist may be those certified in other fields of specialization like general surgery, orthopedics, internal medicine, or family medicine. Department of Emergency Medicine

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Staffing Requirements of the ED Trauma Team (Surgeons, Anesthesiologists, Trauma Nurses) ● Different specialties mitigate effects of MCI ● Experience with day to day trauma cases ● Can work readily in MCI ● Minimize preventable mortalities ● Each country - different composition of their Trauma Team ● Trauma Systems also vary

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Operating Theater Access to functioning operating theaters ● Early definitive care ● Minimizes unwanted morbidity or preventable mortality. ● Lack of these in the hospital -- system of transport and referral is a must. ●

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Overcrowding ●

Overcrowding in the ED - in most Asian & African countries, state-funded hospitals have crowded ED’s.

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Survey done of countries in Asia – lack of resources on a day to day emergency services already exist even before an actual MCI. – There was a very rudimentary form of Prehospital Care – Much of the modern principles of EMS are not existent

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Equipment and Supplies of the ED Several basic supplies are necessary in smoothly operating an efficient ED. The following groups of devices gives idea of what supplies may run short during an actual disaster

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Airway Devices oxygen tanks non-rebreather masks nasal cannula oropharyngeal airway devices of different sizes nasopharyngeal airway devices Intubation equipment like laryngoscopes endotracheal tubes LMA's (laryngeal mask airway) tracheostomy instruments tracheostomy tubes and suction machines Cervical immobilization devices

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Endotracheal Intubation EQUIPMENTS laryngoscope (F) endotracheal tube (J/M) stylet (I) additional equipment 10 ml syringe (L) Magill forceps (G) water-soluble lubricant

L

suction unit Department of Emergency Medicine

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Management of Hypovolemic Shock Devices for hemorrhage control Surgical gauze packs Elastic and rolled bandages IV access, IV cannulas of different sizes, central lines, cutdown sets, intra-osseous infusion needles. Crystalloids & colloids for fluid replacement. Access to blood bank facilities or blood retrieval. Traction splints for long bone fractures.

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IV Access Training

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Defibrillation ●

Automated external defibrillators (AED's) – Manual defibrillators

personnel are trained in ACLS and defibrillation. ● Biphasic defibrillators ● Newer generation cardiac monitors offer biphasic AED's incorporated into one machine. ●

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Defibrillator

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Monitoring Critical monitoring devices should include ● pulse oximetry ● non-invasive blood pressure readings, heart rate and cardiac rhythm ● Point of care testing devices like arterial blood gas determinations (ABG) and electrolytes are useful. ● End Tidal carbon dioxide tension (ETCO2) is also beneficial.

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Diagnostics Access to hematology and chemistry laboratories. ● These are usually overstressed during a deluge of patients during MCI’s. ● Reagents & personnel are easily depleted. ● Imaging machines like radiology and ultrasongraphy must be available for the injured patient. ●

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Emergency Drugs ● All

emergency drugs must be in ample

supply. ● WHO ● New

shows a list of critical drugs.

Essential drug list published by

the WHO for disasters.

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Scenario 75/M, Known Diabetic & hypertensive 10 mins PTC, found unconscious inside the bathroom with a 2 cm laceration on his occiput

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Scenario Young male found unconscious. Brought in by good samaritans. No informant. 17/F, cc:RLQ pain, comes in pale, weak looking, LMP: 6 weeks ago

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Emergency ●

Medical Situation wherein – Proposed intervention is deemed necessary – Delay in treatment may jeopardize life or

result in disfigurement or impaired faculties

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What is Emergency Medicine? ●

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Takes the most difficult cases from all medical specialties Multidisciplinary Defined by the demands of the Emergency Department Involves both Medical and Non-Medical Problems Includes all Medically-related incidents outside the hospital

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Emergency Medicine International Federation for Emergency Medicine, 1991 ●

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knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury all age groups spectrum of episodic undifferentiated physical and behavioral disorders encompasses pre-hospital and in-hospital emergency medical systems

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History of Emergency Care Before Emergency Medicine ●

War – 18th Century – Field Hospitals – Medics during Korean & Vietnam Wars

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Emergency Rooms (in the 1960’s) – Staffed by nurses and interns – On-call physicians from other specialties

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History of Emergency Care

Development of EM ●

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1960s – Creation of “Casualty Department” in UK & Australia 1968 – American College of Emergency Physicians founded 1969 – 1st ACEP scientific assembly held 1970 – 1st EM residency established in Univ. of Cincinnati

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Development of EM

1972 – Casualty Surgeons Association restructured as British Association for Accident & Emergency Medicine ● 1972 – Journal of ACEP published ● 1973 – Emergency Medical Services Systems Act signed into law ● 1973 – AMA establishes section on EM ● 1974 – EMRA established Department of Emergency Medicine ● 1976 – American Board of EM established ●

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Development of EM ●

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1979 – EM established as 23rd medical specialty 1981 --Australasian Society for Emergency Medicine established 1985 – EM Treatment & Labor Act (anti-dumping law) signed 1986 – 1st International Conference on EM 1989 – ABEM given primary board status

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Development of EM ● ●

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1990 – International Federation for EM founded 1992 – ABEM and American Pediatric Society establish Subspecialty Board for Pediatric EM 1994 – 1st Subspecialty Board for Toxicology 1995 – EM recognized as medical specialty in New Zealand 1997 – Hong Kong College of EM adopted by Ministry of Health 1998 – 1st Asian Congress of EM held in Singapore. Asian Society of EM Founded

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Emergency Medicine in the Philippines 1988 –Emergency department created at Makati Medical Center ● 1989 -- Philippine Society of Emergency Care Physicians formed ● 1991 -- Emergency Rescue Unit Foundation, Cebu ●

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Emergency Medicine in the Philippines 1991 –Departmentalization of Emergency Services, Philippine General Hospital ● 1996 – Setting up of PGH Emergency Medical Services System ● 1997 – Establishment of Residency Program at DEMS, PGH ● 2001 – Department of EM established as Academic unit of UP College of Medicine ●

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Emergency Doctrine Implied Consent for patients in the ED who cannot give consent for actions to save or preserve life ● Serves to protect emergency personnel who act in good faith ● Encourages personnel to act decisively in the patient’s best interest ●

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Characteristics of the Specialty

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Triage, Stabilize, Prioritize, Refer, Observe ● ABCs ● Limited resources ●

– Time – Information – Space

Technology dependent ● Cutting-edge medicine ●

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Difference with other Specialties

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Not necessary to arrive at diagnosis ● Does not follow sequence of SOAP ●

– Assess  Action  Reassess  Action ●

Always thinks of worst-case scenario – Chest pain is MI!

AMPLE history ● Don’t believe everything you hear! ●

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Pillars of EM Chain of Survival ● ABCDs . . . ●

– BLS – RSI, ACLS – PALS / NALS – ATLS

Pain Management ● EMSS ●

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Characteristics of the Practice ●

Low overhead – No clinic to rent – No staff to hire – Minimal equipment necessary

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Flexible Work Hours – Choose your hours – Maximum 60-hours/week – Not necessary to file for leave

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Characteristics of the Practice ●

High Stress – Kinds of cases seen – Kinds of patients seen – Limited resources

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No Follow-ups – Do not admit to the hospital

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Prone to Legal & Ethical situations

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Characteristics of EM Physicians Type A personality ● Adrenaline junky ● Multi-tasker ● Able to make quick decisions ● Willing to work nights, weekends, holidays ●

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Subspecialties ● ● ●

Pediatric EM Toxicology Emergency Health – – – –

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Emergency Medical Services Disaster Medicine and Mass Gatherings International EM Emergency Public Health information

ED Administration Trauma / Pre-hospital & ED Care

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Areas of Special Interest ● ● ● ● ● ●

Cardiology / Emergency Cardiac Care Neurology: “ Brain Attack” Sports Medicine / On-site Medical Care Research Domestic Violence, Child Abuse & Women’s Issues Environmental & Occupational Health

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Emergency Medical Services System ●

System Components – – – –

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Communications Center Personnel Patient transport Receiving units

Types of Systems – – – –

Public vs. Private Single- vs Multi-Tiered Urban vs. Rural BLS vs. ALS

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Personnel First Responder ● EMT-B, EMT-D, EMT-I ● Paramedic ● MD, Medical Direction ●

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Patient Transport Star of Life ● Type I – cab & chassis ● Type II – van-type, modified height ● Type III – larger with walk-through passage ● BLS or ALS/ICU ●

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Receiving Units ● ●

Primary, Secondary, Tertiary Trauma Centers / Lead Hospitals for Trauma – PGH, EAMC, JRRMMC, DLS-UMC – VSMMC (Cebu), WVRH (Iloilo) – DMC (Davao), ZRH (Zamboanga)

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Orthopedic Hospitals Pediatric / Neonatal Centers

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Directions in EM Curricular changes for Undergraduate Medical Education ● Research and Documentation ● Training ●

– BLS, ACLS, ATLS – Emergency Nursing – Emergency Medical Technicians

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Directions in EM

Pre-Hospital & ED reimbursement ● Emergency Public Health Information Dissemination ● ED Design ● CQI ●

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Summary ● Defined

selected terms used in Trauma

Surgery, Emergency Medicine and Disaster Medicine. ● Stated

the principles of the organization

and management of an Emergency Department. ● Listed

logistic of requirements for emergencies

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Conclusion The Emergency Department is the frontline of the hospital response to a disaster. ● The ED plays a critical role in hospital emergency management system ● Preparedness is the key to maximize capacity in MCI ●

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Questions ?

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