| Organization Of The Emergency Medical Assistance |
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Emergency medical assistance is the first aid that is given to victims of Accident s (casualties) or of the acute effects of Disease s. The basis of emergency medical assistance is the "chain of rescue": this system are based on the collaboration of different actors. The most advanced cares can only be performed by Physician s and Surgeon s with the appropriate environment ( Medical Imaging , Biochemistry analysis laboratory, Emergency Room , Operating Room ), but the acute event often happens outside the Hospital (prehospital cares): at home, in the street, at work, in a public building… The other actors involved are:
ORGANIZATION OF THE EMERGENCY MEDICAL ASSISTANCE: THE RESPONSIBILITY OF THE NATIONAL STATE In the countries which signed the '''' says:
The responsibility of the State was first introduced in the French law in 1789 , with the '' Declaration Of The Rights Of Man And Of The Citizen '':
PREREQUISITES The emergency medical assistance can be provided only when the non-emergency situations are already treated. This means that the country must have
When these conditions are fullfilled, then the country must provide:
LEVELS OF CARE AND PROGRESSIVE RESPONSE Not all situation require the same level of care. Basically, the situations can be sorted in three categories:
These categories are not so clearly separated, and depend not only on the medical condition of the casualty, but also on the organization of the health system and on social situation. For example, a Deceased Person is not a medical emergency (there is no care to perform), but in some societies, it is a social emergency (the people would not understand nothing is being done) especially in case of a children death; and it is not obvious to decide whether the person is dead or can be saved through advanced care (e.g. case of Cardiac Arrest and of Cardiopulmonary Resuscitation ). The Pain is usually not lifethreating situation, but the situation is often unbearable from the point of view of the casualty. Two things must thus be considered:
The distinction requires assessment; assessment by the witness who calls (importance of First Aid education) and remote assessment by the Dispatch ( Medical Regulation ). The confidence in the emergency assistance system warrants the efficiency of the system; otherwise, the probable reaction would be to drive the casualty to the closest hospital, making the patients flow impossible to manage (emergency rooms overcrowded with non-urgent cases, patients in inadequate hospitals), and possibly worsening the health of the casualty (transportation wthout care). This confidence can be reached only by giving an answer to all situations, even the non-urgent ones. It is thus necessary to provide a progressive response, according to the situation:
A rescue team can be sent in parallel to the ambulance. According to the countries, some of the levels can be missing. Considering the efficiency:
It is important to have enough paramedics and/or prehospital emergency physicians, but not too much, not only because of the cost (they are logically more paid than the first responders), but also to keep them efficient: according to '' USA Today '' ''Paramedics not always the saviors of cardiac-arrest patients'', Robert Davis, USA Today, March 1 , 2005 {Link without Title} , the efficiency decreases when the number of paramedic increases. This is probably due to two phenomena:
the paramedics thus lack of training and everyday practice. PREHOSPITAL CARE STRATEGIES The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, where the "stay and play" is exemplified by the French SMUR Emergency Mobile Resuscitation Unit . Scoop and run (Scoop and shoot) The strategy developed for prehospital care in North America is called Scoop And Run . It is based on the Golden Hour theory, i.e., that a victim's best chance for survival is in an Operating Room , with the goal of having the patient in surgery within an hour of the traumatic event. This is appers to be true in cases of internal Bleeding , especially penetrating truama such as gunshot or stab wounds. Thus, the minimal prehospital care is performed (ABCs, i.e. ensure airway, breathing and circulation; external bleeding control; spine immobilization; Endotracheal Intubation ) and the victim is transported as fast as possible to a Trauma Center . This philosophy is aptly summarized by the following quotation from "The Rules of EMS" : "Trauma is treated with diesel first." The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival; hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. It should be noted the "Scoop and Run" is a method developed to deal with Trauma , rather than strictly medical situations (e.g. cardiac or respiratory emergencies). Stay and play The stay and play strategy was designed in France with the SMUR (''Service Mobile d'Urgence de Réanimation,'' emergency mobile resuscitation unit) and SAMU (''Service d'Aide Médicale d'Urgence''), as it was noted that an unacceptable number of patients were dying during transport. The French thus developed a strategy based on maximum care before transportation. Prehospital medical care is provided by a medical doctor MD , a Nurse and an ambulance technician, with almost all the equipment and drugs that can be found in an Emergency Department . The priority here is the stabilization of the patient prior to transport, including Intravenous Drip to raise the blood pressure (one of the causes of death during transportation is the drop in pressure, which decreases perfusion of the brain and heart; see Shock ). The German EMS is very similar to the French system. In case of a severe Myocardial Infarction (or heart attack), all care is performed onsite (including the possibility of thrombolysis), and the victim is transported only if the heart starts again or the patient is declared dead. Defibrilation is performed by a Firefighter rescue team with an Automated External Defibrillator if they arrive before the medical team. Note that this example is one of the only "real" ''stay and play'' approaches performed in France; in most cases, the treatment by the physician is fast and the patient is transported to the hospital within the golden hour. Play and run Both the scoop and run and the stay and play strategies have their advantages and drawbacks. The synthesis of these two opposite strategies has led recently to a new concept: the play and run. The time that cannot be reduced (e.g. while extracting a victim trapped in a car) is used to perform medical care. The treatment aim is no longer to recover a "normal" blood pressure, but a minimal blood pressure, using not only intravenous drip but also vasocompressing drugs and Antishock Pants (to compress the legs and push the blood into the rest of the body). The aim is to reduce the risk of death due to transportation trauma while respecting the golden hour. The problem with ''play and run'' lies in the difficulty of getting a good IV stick in a moving vehicle and controlling the volume of IV fluids given to the patient. Too little fluid will cause inadequate circulation and Heart Failure , while too much fluid will cause excessive loss of oxygen-bearing blood. ORGANIZATION IN DIFFERENT COUNTRIES In France ; Emergency Telephone Number
; Dispatch and Medical Regulation : Samu ; Rescue : firefighters ''( Sapeurs-pompiers )'' ; First Responder level
; Paramedic level : firefighter nurses (''infirmiers sapeurs-pompiers'', ISP), since 1997 , still rare in 2006 (aim: 1 ISP for 150 professional firefighters or 1,000 volunteer firefighters) : see '' Paramedics In France '' ; Prehospital medical level
; Emergency Room
: see '' Emergency Rooms In France '' In the United States Of America ; Emergency Telephone Number : 911 ; Dispatch and Medical Regulation : Emergency Medical Service (EMS) ; Rescue : Firefighter s ; First Responder level : Emergency Medical Technician -basic (EMT-B) ; Paramedic level : Emergency Medical Technician -intermediate (EMT-I) and emergency medical technician- Paramedic (EMT-P) ; Prehospital medical level : None ; Emergency Room : Trauma Center s
SEE ALSO Notes See also
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