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OCR for page 12
EMERGENCY FIRST AID AND MEDICAL CARE
Successive steps in total emergency care involve local authorities
and lay citizens for initial care and transportation, and medical
and paramedical personnel under medical supervision for definitive
treatment. With few exceptions, the role of the physician in the
care of victims of accidental injury begins at the emergency
department of the hospital. Only rarely is he available at the scene
~ . ~
or injury.
One of the serious problems today in both the lay and the
professional areas of responsibility for total care is the broad
gap between knowledge and its application. Expert consultants
returning from both Korea and Vietnam have publicly asserted
that, if seriously wounded, their chances of survival would be
better in the zone of combat than on the average city street.
Excellence of initial first aid, efficiency of transportation, and
energetic treatment of military casualties have proved to be major
factors in the progressive decrease in death rates of battle casual-
ties reaching medical facilities, from 8 percent in World War I, to
4.5 percent in World War II, to 2.5 percent in Korea, and to less
than 2 percent in Vietman.7
Reduction of the time lag from receipt of injury to initiation of
medical care is one of the important elements in prevention of
death and permanent disability in the combat zone. Probably no
American community can lay claim to maintenance of a model
of first aid, sorting, communication, and transportation comparable
to that of the Armed Services.
First Aid
Beyond the fifth grade of elementary school, every American
citizen should be trained in basic first aid. Since initiation of the
American National Red Cross first aid training program in 1909,
over 28,000,000 students have been certified by qualified instruc-
tors (who currently number over 73,0001.8 This course should be,
but is not, universally required as a prerequisite to the more
advanced training of lifeguards, rescue squad personnel, ambulance
attendants, policemen, firemen, personnel in public health and
industrial clinics, and attendants at sports events. The Medical
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Self-Help Program of the U. S. Public Health Service, designed
to ensure care in a national emergency when the services of a
psysician are not available, also provide basic first aid training.
Only in the American National Red Cross training program and
in the Medical Self-Help Program are nationally acceptable text-
books and standardized courses of instruction provided. There is
need for equally acceptable textbooks and courses of instruction
to meet the special requirements of rescue squad personnel and of
ambulance attendants. A manual recently published by the Com-
mittee on Trauma of the American College of Surgeons provides
guidance for uniformity in such training courses.9
RECOMMENDATIONS
1. Extension of basic and advanced first aid training to greater numbers
of the lay population.
2. Preparation of nationally acceptable texts, training aids, and courses
of instruction for rescue squad personnel, policemen, firemen, and
ambulance attendants.
Ambulance Services
A review of ambulance services in the United States indicates a
paucity of information and a limited framework for the collection
of data on and the evaluation of current ambulance services.
Research aimed at improvement of these services is equally
limited. The available information shows a diversity of standards,
which are often low, frequent use of unnecessarily expensive and
usually ill-designed equipment and generally inadequate supplies.
Adequate ambulance services are as much a municipal responsi-
bility as Refighting and police services. If the community does not
provide ambulance services directly, the quality of these services
should be controlled by licensing procedures and by adequate
surveillance of volunteer and commercial ambulance companies.
Ambulance services should not only be adequate for local needs,
but should also be integrated within cities and among neighboring
communities to ensure efficient utilization in natural disasters or
national emergencies.
Very few communities provide sufficient financial support for
adequate ambulance services. Where they are provided, they are
usually maintained by the fire or police department. Many volun-
teer, nonprofit rescue squads and local ambulance groups provide
commendable service and in many small communities this system
would seem to meet basic, but usually only minimal needs.
Approximately 50 percent of the country's ambulance services
are provided by 12,000 morticians, mainly because their vehicles
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can accommodate transportation on litters. But in most instances,
as in the case of many privately owned ambulances, the vehicles
are unsuitable for active care during transportation, equipment and
supplies are incomplete, and the attendants are not properly
trained.
First class ambulance service exists in few cities. Some, such as
Baltimore, employ highly trained full-time ambulance attendants
with up-to-date vehicles and equipment as a separate mission of
the fire department. Central screening and dispatching ensure open
traffic lanes, communication en route, and distribution of casualties
to assigned hospitals. In some cities, ambulance services are pro-
vided by the police department, some with ambulances and some
with modified patrol station wagons.
In contrast to the days when an intern accompanied every
ambulance on emergency call, the pendulum may have swung
much too far toward total dependence on ambulance personnel.
There is complete lack of information on the number who die at
the site of injury or during transportation who might have been
saved by professional attention. Calls for ambulance services
should be screened by a responsible agent under medical super-
vision so that, when medical attendance is required, a physician
can be dispatched and an ambulance properly equipped to his
reeds made available immediately. A number of foreign countries
have demonstrated that these measures save many lives.
There are no generally accepted standards for the competence
or training of ambulance attendants. Attendants range from
unschooled apprentices lacking training even in elementary first aid
to poorly paid employees, public-spirited volunteers, and specially
trained full-time personnel of fire, police, or commercial ambulance
companies. Certification or licensure of attendants is a rarity. In a
recent survey, it was found that over 48 different courses of
instruction are provided with at least a score of different books and
brochures being used as texts. There is no standard or uniformity
in these courses, though the standard and advanced Red Cross
courses are prerequisites for most. There is need for delineation of
a standard course of instruction, a more generally acceptable text,
and training aids to ensure training beyond that of the Red Cross
program in first aid.
No manufacturer produces from the assembly line a vehicle that
can be termed an ambulance. The bodies and fixed equipment of
ambulances and rescue vehicles are produced by conversion of
passenger-type vehicles or are fabricated completely to fit assembly
14
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line chassis, and are usually expensive in outward appearance, but
impractical for resuscitative care. Although the Committee on
Trauma of the American College of Surgeons has published recom-
mendations on ambulance equipment, there are no acceptable
standards for vehicle design, and most ambulances used in this
country are unsuitable, have incomplete fixed equipment, carry
inadequate supplies, and are manned by untrained attendants.
Authority now exists under the National Traffic and Motor
Safety Act of 1966 (P.L. 89-563) to set national standards for
ambulance design and construction. Authority also now exists
under the Highway Safety Act of 1966 (P.L. 89-564) for the
establishment of national standards for used motor vehicles, for
motor vehicle inspection and for emergency services.
Through the efforts of the Joint Action Program of the Ameri-
can College of Surgeons, the American Association for the Surgery
of Trauma, and the National Safety Council, a model ordinance
has been developed for regulation of ambulance services. But in a
recent survey of 16 state capitals, only seven were found to have
ambulance ordinances. While most ambulance calls involve non-
emergency cases, the justification for speeding, the use of sirens,
and violation of local traffic regulations is debatable. It is the
consensus of representatives of the Joint Action Program that
more injuries and deaths are produced by improper control of
ambulances than would be produced by delays occasioned by
compliance with regulations. Helicopters have proved so successful
as ambulances in combat theatres that they should be adopted for
selected use in this country. They have proven to be necessary to
move physicians and equipment to the accident site and to
evacuate casualties from major highways, from remote areas, or
from a community hospital to a more specialized center. Highway
safety standards should include helicopter evacuation, which calls
for landing pads at selected hospitals on a regional pattern.
RECOMMENDATIONS
1. Implementation of recent traffic safety legislation, to ensure com-
pletely adequate standards for ambulance design and construction, for
ambulance equipment and supplies, and for the qualifications and super-
vision of ambulance personnel.
2. Adoption at the state level of general policies and regulations
pertaining to ambulance services.
3. Adoption at district, county, and municipal levels of ways and
means of providing ambulance services applicable to the conditions of
the locality, control and surveillance of ambulance services, and coordi-
nation of ambulance services with health departments, hospitals, traffic
authorities, and communication services.
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4. Pilot programs to determine the efficacy of providing physician-
staffed ambulances for care at the site of injury and during transportation.
5. Initiation of pilot programs to evaluate automotive and helicopter
ambulance services in sparsely populated areas and in regions where
many communities lack hospital facilities adequate to care for seriously
InJurec persons.
Communication
Although it is possible to converse with the astronauts in outer
space, communication is seldom possible between an ambulance
and the emergency department that it is approaching.
It is important to recognize that major accidents, including
disasters, provoke community response not only of first aid
workers, ambulances, and hospital emergency departments but
also authorities concerned with traffic, fire, security, utilities, civil
defense, and others, and that communication facilities involve
functions pertinent to each responding agency. Although these
facilities must be designed for specific needs, they must be suffi-
ciently flexible to ensure rapid and efficient cross communication,
with medical components necessary to emergency care. It would
be a mistake, therefore, for those concerned with the medical
aspects of the problem to plan strictly medical response systems
in parallel with or in isolation from the transportation and com-
munication networks upon which they should be based. Since these
two basic systems are in most parts of the country just beginning
to be developed, it is essential that provision for the medical
components be incorporated.
A need exists for prompt voice communication between emer-
gency departments and those at the site of an accident or disaster,
not only to plan for the reception of casualties at the hospital but
also to dispatch physicians, when needed at the site of the accident.
Communication facilities are essential to mobilize. rescue equip-
ment, clear traffic lanes, advise ambulance attendants on the
management of complications en route, notify hospitals of the
number and types of patients to be expected, and distribute patients
among hospitals in accordance with the adequacy of space, facili-
ties, and personnel.
With rare exceptions, current ambulance radio installations
provide communication only between dispatcher and drivers, with
no provision for direct or tie-in contact with hospital emergency
departments, traffic control authorities, or civil defense agencies.
Moreover, many existing communication systems are reserved for
use only in case of disaster or national emergency. Voice com-
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munication should be used for day-to-day needs; should be under
medical supervision; and should provide direct communication
between the accident site, ambulances, and hospitals, and access
to police, traffic control, fire, and civil defense agencies.
Although the Federal Communications Commission has allotted
an adequate number of radiofrequency channels for the health
field and industry has provided appropriate telephone and radio
equipment, these facilities are rarely used to ensure voice com-
munication between the site of an accident, ambulances, hospital
emergency departments, fire departments, traffic control officials,
and civil defense authorities. Usually a hospital is notified of a
disaster through local radio or television or by telephone communi-
cation from police, or by the walking wounded. Certainly, the
seriously ill and the injured deserve centralized screening and
dispatching communication facilities as efficient as those used by
taxicabs and in the coordination of personnel and equipment in
fire fighting, forestry service, or highway maintenance.
At present, experience Title radio communication in emergency
medical situations is inadequate to serve as a basis for guidance
of communities that would install and operate such facilities.
Although available standardized equipment may be suitable for
most communities, the organizational needs of the local com-
munity, geographic problems in radio transmission, and the size
of the area to be served dictate variations of design and installation.
Ready solutions to most of these problems are available through
the radio industry. There is need at the national level for the
preparation of a manual delineating the available radiofrequency
channels, types arid costs of equipment, and modifications of
installation necessitated by local conditions. This is a function
which should be the responsibility of the new National Highway
Safety Agency in cooperation with the Federal Communications
Commission, industry, and related groups. This Agency is charged
with the responsibility for establishing standards for all aspects of
state highway safety programs, of which communications is an
essential element.
Under many circumstances, especially in remote areas or in the
absence of telephones, delay and frustration are encountered in
calling for an ambulance. It would seem feasible to designate a
universal, easily remembered number for all dial telephones
throughout the nation. Compared to European expressways, the
scarcity of public telephones on our national highways represents
a significant oversight in planning.
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RECOMMENDATIONS
1. Delineation of radiofrequency channels and of equipment suitable to
provide voice communication between ambulances, emergency depart-
ments, and other health-related agencies at community, regional, and
national levels.
2. Pilot studies across the nation for evaluation of models of radio
and telephone installations to ensure effectiveness of communication
faci lilies.
3. Day-to-day use of voice communication facilities by the agencies
servi ng emergency med ical needs.
4. Active exploration of the feasibility of designating a single nation-
wide telephone number to summon an ambulance.
Emergency Departments
For decades the `'emergency" facilities of most hospitals have
consisted only of "accident rooms," poorly equipped, inadequately
manned, and ordinarily used for limited numbers of seriously ill
persons or for charity victims of disease or injury. Very few
hospitals have met the needs imposed since World War II for the
vast expansion of facilities, equipment, and personnel demanded
by society, poor and rich, for routine off-hour treatment of non-
emergency conditions and of the steadily increasing numbers of
accidental injuries. Society now looks to the hospital emergency
department as a community center for outpatient care. More than
two-thirds of the 40,000,000 "emergency room" visits in 1966
cannot be classified as emergencies. Past and projected estimates
of this increasing load are as follows:~°
ESTIMATED TOTAL NUMBER OF
HOSPITAL OUTPATIENT VISITS
YEAR (in Millions)
ESTIMATED EMERGENCY
ROOM VISITS
(in Millions)
1958 84.5 18.0
1960 91.9 23.0
1962 99.4 28.5
1968 121.6 44.1
1970 129.0 49.3
This social change has been paralleled by a decrease in the
number of house calls and by more adherence to physicians'
regular office hours.
Although over 90 percent of the more than 7000 accredited
hospitals in the United States list emergency rooms, most such
services operate at a financial loss. In contrast to staff coverage
of the "accident room" by a hospital attendant and perhaps by an
intern, minimal demands call for around-the-clock staffing by
permanently assigned physicians and paramedical personnel
18
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trained in all aspects of the care of trauma. Wings need to be
added to hospitals, highly specialized equipment is required, and
additional personnel must be trained. Currently four national
organizations are conducting "surveys" of emergency departments,
with no evidence of pooling of their resources or knowledge,
resulting in piecemeal approaches to problems that, if solved by
concerted effort, would provide factual grounds for Hill-Burton
funds for facilities and equipment.
New patterns of staff coverage of emergency departments are
evolving. These include contractual relationships between the
hospital and a group of physicians, usually general practitioners,
who undertake all emergency care and staffing requirements for
the emergency department. Some hospitals require that all medical
personnel, regardless of specialty, share emergency department
responsibility, including night coverage. No longer can responsi-
bility be assigned to the least experienced member of the medical
staff or solely to specialists who by the nature of their training and
experience cannot render adequate care without the support of
other staff members.
The number of physicians experienced in the treatment of
multiple injuries is very limited. The need is now recognized for
special training in immediate care and in the overall direction of
emergency departments, of a calibre commensurate with that
attained by only a few individuals in active military field units
caring for combat casualties. Medical undergraduate and residency
training programs are generally inadequate in traumatology and
mass casualty care.
In recent years the Committee on Trauma of the American
College of Surgeons has provided recommendations on architec-
tural design and equipment of emergency departments and manuals
on the treatment of fractures and soft-tissue injuries, the prevention
of tetanus, and the initial management of burns. These commend-
able efforts of the medical profession are but a beginning. There
remains a serious lag in application of the minimal standards, but
of even greater importance is the dearth of basic research in
resuscitation, shock, and other immediate and long-range problems
in therapy.
Accreditation and Categorization of Emergency Departments
The current dictum that an ambulance should deliver a patient to
the nearest emergency unit is no longer acceptable. It is essential
that road maps and roads signs, at appropriate locations, designate
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routes to hospitals and emergency departments. The patient must
be transported to the emergency department best prepared for his
particular problem. In the absence of a descriptive categorization
of the level of care that might reasonably be expected at a facility,
neither the patient nor the ambulance driver can judge which
facility is adequate to the immediate need. It is usually taken for
granted by the general public that every emergency room can
render full care for injuries of all magnitudes. There is the
obligation to the severely injured patient as well as to the lone
physician, to the small staffs of remote hospitals, and to institutions
with minimal emergency department facilities, that the public be
thoroughly informed of the extent of care that can be administered
at emergency departments of varying levels of competence.
A categorization of emergency departments would serve to indi-
cate the level of care that a patient might reasonably expect.
Current check lists used by the Joint Commission on Accreditation
of Hospitals are not sufficiently comprehensive for this purpose.
In a givers population, whether within a large city, a small
community, or a sparsely settled area, the average number of
patients requiring emergency care is generally stable, except under
conditions of natural disaster or national emergency. Within a
given region, it is uneconomical and impractical to expect that
every emergency department deal with all degrees of severity
~ . .
at Injury.
Hospital emergency departments should be surveyed in a number
of differing geographical areas, to determine the numbers and
types of emergency facilities necessary to provide optimal emer-
gency treatment for the occupants of each region. Provision must
be made for the expected doubling of population within a few
decades. Once the required numbers and the types of treatment
facilities have been determined, it may be necessary to lessen the
requirements in some institutions, increase them in others, and
even redistribute resources to support space, equipment, and
personnel in the major emergency facilities. Until patient, ambu-
lance driver, and hospital staff are in accord as to what the patient
might reasonably expect and what the staff of an emergency facility
can logically be expected to administer, and until effective trans-
portation and adequate communication are provided to deliver
casualties to proper facilities, our present levels of knowledge
cannot be applied to optimal care and little reduction in mortality
or lasting disability can be expected.
Emergency units might be categorized as follows:
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Type 1. The Advanced Fast Aid Facility Information now avail-
able indicates that most emergency departments across the country
are in this category. They do not have a full-time physician staff,
and frequently not even a full-time nursing staff. Only modest first
aid equipment is available and, although minor conditions and
emergency resuscitation might be satisfactorily handled in this
setting, it would be unfair to the patient as well as to the staff to
expect or demand adequate care of the critically injured.
Type 2. The Limited Emergency Facility This type is found in
many hospitals whose emergency departments function 24 hours
daily, chiefly as outpatient clinics or first aid facilities, but are
nevertheless often confronted with the need to render major
emergency care beyond their capabilities. A nurse and perhaps a
physician are available at all times. Because of limitations of
equipment and facilities, problems of full-time physician coverage,
and limited access to specialists, complete care cannot always be
provided to the critically injured.
In sparsely populated areas and small communities and many
urban hospitals, facilities of this type are essential, and, by proper
sorting, large numbers of medical and surgical patients can be
adequately handled and removed from the chain of evacuation.
It is in the rural areas and the towns of fewer than 2500 people,
however, that 70 percent of the traffic fatalities occur. The dedi-
cated staffs of limited emergency departments recognize that the
needs of the critically injured patients frequently exceed the
capabilities of their facilities and personnel. To expect highly
specialized care under these circumstances is unfair both to the
patient and to the physician. Emphasis on resuscitation, expendi-
ture of time and effort in thorough preparation before movement,
and rapid and efficient transportation to major emergency facilities
would lower morbidity and mortality rates. It is here that heli-
copter ambulances would be most effective. There have been no
extensive surveys in either rural or urban areas to establish the
number of either limited or major emergency facilities required
or to define models of rapid transport.
Type 3. The Major Emergency Facility The need for major
emergency facilities adequate to render complete care to the
severely injured or the seriously ill is well recognized. Few such
facilities exist. Most emergency departments of large hospitals
have not yet met the space or personnel needs of outpatient and
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nonemergency cases, and few have the funds to construct, equip,
and man adequate facilities. To carry out their mission, the
number and location of major emergency facilities must be in
keeping with the numbers of patients to be treated from day to
day, with provision for expansion in disaster. They must be so
located as to serve precisely designated rural areas or districts in
densely populated areas. Major emergency facilities require
24-hour staffing by highly competent medical and paramedical
personnel trained in resuscitation and other lifesaving measures
before transfer of the casualty to the operating room, intensive
care unit, or hospital ward. Bloodbanks, complete resuscitative
equipment, X-ray facilities (including those' for angiography),
constantly available well-developed clinical laboratory services,
and ready accessibility to operating rooms are essential. The
director of a unit of this type should be experienced in the overall
care, triage, and determination of priorities of treatment of victims
of severe trauma. Nursing, paramedical, and administrative per-
sonnel should be assigned to the emergency department perma-
nently or at least for protracted periods. Specialized consultants
must be available at all times. The need for ready availability of
highly qualified specialists in all branches of medicine and surgery
and of laboratories devoted to clinical support and research
strongly supports the view that the major emergency facility should
be an integral element of large hospitals and university medical
centers, rather than an isolated facility devoted solely to emergency
care. Such a clinic is essential to proper training in trauma.
Type 4. The Emergency Facility Combined with a Trauma
Research Unit This is designed to be the ultimate goal in com-
bining the highest development of patient care with research
facilities that permit investigation in support of therapy. These units
are discussed in the section of this report on research in trauma.
RECOMMENDATIONS
. Initiation of surveys and pilot programs to establish patterns of and
the numbers and types of emergency departments necessary for optimal
care of emergency surgical and medical casualties in a selected number
of cities, groups of small communities, and sparsely populated areas.
2. Development of a mechanism for inspection, categorization, and
accreditation of emergency rooms on a continuing basis.
3. Federal fund support to design, construct, and, in part, operate
model emergency facilities of each type.
22
Representative terms from entire chapter:
ambulance services
