Dr. James Manos (MD)
August 7, 2018
Emergency medicine system: suggestions for improvement worldwide
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Does a perfect health system exist worldwide?
No, I am not aware of any perfect system. In the US, the current populist president threatens to revoke the ''Obamacare'' in which the system becomes less dependent on insurance companies while the state funds the uninsured patients previously dumped from the hospitals! Even in the UK, the NHS (national health system) has many problems, with the most significant related to its funding. But a considerable problem is that many posts, covered mostly by international doctors, are service instead of training. Hence, they are not educational, approved by the Dean, but we have a service type of doctor.
Additionally, the fact that the aging population in Western countries is becoming greater means that there is less working-age population to pay for their healthcare and pension, as well as that of the existing pensioners! Consequently, healthcare has less money to work efficiently. The expensive immunotherapy drugs deteriorated the national health system funding problem, as each injection cost is estimated at least $500. Gene therapy costs more than 1 - 2$ million per dose!
Should doctors be assessed with an appraisal and revalidation system?
Should complaints against doctors be made easier by clicking an option on the General Medical Council's webpage?
This system has efficiently worked in the UK and should be an example for all countries. But the way that anyone can make a complaint by merely clicking the option on the General Medical Council may have as a consequence a doctor to incline to' 'defensive medicine'' with an additional cost of unnecessary lab or imaging exams and interventions!
Should emergency medicine doctors in the emergency room (ER) and ambulance paramedics be assessed?
Yes, they should, as they should be controlled and assessed if they perform their job correctly, as guidelines, algorithms, and protocols say. Surveillance and body cameras (like the ones the American police officers carry) could be used for this assessment, but most will not agree with this. Doctors are already assessed in some countries, such as the UK. However, paramedics are usually not.
Paramedics may not always follow the protocol. For instance, you may watch the shocking, raw footage on https://www.youtube.com/watch?v=24PAhUhnACo and https://www.youtube.com/watch?v=z0j-7L094d0 showing a black man in New York who collapses after a police officer restricts him with a chokehold. Although the black man is in cardiac arrest (that caused his death), the video does not show any immediate on-scene resuscitation such as CPR and, if shockable rhythm, defibrillation by the paramedics, while the priority of the police officers was to pass handcuffs to the man who is already in cardiac arrest rather than performing chest compressions!
A similar shocking video in Minneapolis shows a police officer choking a black man with his knee to death. Although the man was in cardiac arrest, the paramedics did not mind performing any resuscitation on the scene. On the contrary, they let the officers turn the victim on the stretcher like a sandbag without any cervical spine protection! You may watch the shocking video at https://www.youtube.com/watch?v=zaGmz4DPlJw&bpctr=1590888005 and
Emergency medicine
The paramedics (ambulance rescuers)
We need to change the concept of emergency medicine. In the US, ambulances are equipped with all the appropriate medications and medical devices, and the ‘paramedics’ (ambulance rescuers) are trained and skilled to deal with emergencies such as advanced resuscitation, immobilization, trauma (injury) resuscitation, intubation, and defibrillation ('shock') in cardiac arrest, etc. They are not doctors (that is why we do not call them ‘medics’ but ‘paramedics’).
Paramedics in the US can perform advanced medical procedures such as intravenous (IV) line placement, intubation, advanced resuscitation, trauma (injury) resuscitation (correct immobilization, resuscitation, and transport), etc.
However, there are also ''simple'' ambulances with fewer trained rescuers in advanced resuscitation in the US. This, of course, does not affect the treatment and recovery of the patient since they are used for incidents that are not potentially life-threatening.
The emergency medicine system (EMS; ambulance system)
All ambulances should be equipped with all the necessary medical equipment and devices like the ambulance system of the US, which is satisfactory regarding its services in emergencies. The ambulances need to have all the medicines of emergency medicine such as dextrose (glucose), adrenaline (called epinephrine or ''epi'' in the US), atropine, lidocaine (also called xylocaine), amiodarone, morphine, midazolam, hydrocortisone, diazepam (useful in epilepsy, but also for sedation), ketamine, etc.
The ambulance should also be equipped with IV (intravenous) lines for serum fluids administrations (crystalloids or colloids) and with all the necessary equipment and devices such as a blood pressure monitor, glucose meter (device for monitoring blood glucose levels), pulse oximeter (for oxygen saturation), portable (nowadays, biphasic) defibrillator (preferably with a monitor), splints and stretcher with tapes for immobilizing injured patients (such as in a car accident where the paramedics need to immobilize the neck and spine on a board), etc.
Regarding the crew, doctors in ambulances are unnecessary in daily routine cases unrelated to massive destruction. Having a doctor in every ambulance is costly. Importantly, doctors are required in hospitals' ERs (emergency rooms) rather than ambulances. Instead, skilled emergency medical rescuers, like paramedics in the US, can do most things that a doctor does in an emergency.
Of course, some exceptions exist, such as cricothyroidotomy for choking from a foreign object that cannot be removed with the Heimlich maneuver or the Magill forceps. In this case, a skilled paramedic, under online guidance by an ER doctor, may use a special kit, such as ‘’Mini-Trach (R),’’ for cricothyroidotomy. An easier way is to perform a needle cricothyroidotomy by placing a high gauge IV catheter (on an adult a 14 – 16 G) at the cricothyroid membrane. Central IV lines are usually unnecessary to be placed in an out-hospital, non-sterilized environment. However, a skilled medic may use the femoral artery if the upper extremities are difficult to access. In recent years, if venous access is not feasible in a brief time in an emergency such as a cardiac arrest, then intraosseous access is preferred as a second option for fluid and drug administration.
The most important in emergencies is the fast transfer of the patient to the ED (emergency department) of the nearest appropriate hospital. Unnecessary advanced medical procedures in the field may consume valuable time. Instead, basic resuscitation is often adequate, and advanced life support (ALS) is usually performed at the hospital.
The scattering of the ambulance services and the system of patrolling ambulances as in New York
An adequate number of ambulances should be available at any time. For instance, many countries have a shortage of ambulances during the nights, weekends, and holidays. Ambulances need to be scattered in neighborhoods of the cities and at key points in the province instead of departing from hospitals as occurs in some countries. The system in New York City is remarkably interesting. There, the ambulances patrol all over the city, and in case of an emergency call, the nearest available ambulance responds quickly.
A single telephone number, such as 112 in Europe and 911 in the US, for the police, the fire brigade, and the ambulance services is crucial. Using a single number instead of 3 different numbers for each emergency service (the police, the ambulance, and the fire brigade service) makes coordination better, for example, in case of a traffic collision or massive destruction. Additionally, the emergency phone number could give instructions for dealing with emergencies (such as cardiac arrest) until the ambulance arrives, as 911 does in the US. These instructions are simplified and do not need to be given by a doctor but by a trained, qualified paramedic or nurse. In many cases, these instructions have proved lifesaving.
Cases of mass destruction require the good organization of the available emergency services. The triage on the scene must be done by a specific doctor who should not be tempted to treat the patients but only to triage which patient needs immediate resuscitation. Separate team leaders are required for the police, the fire brigade, and the ambulance service. A specific individual should coordinate the resuscitation as a chief officer. Receiving hospitals should be informed to employ all their personnel (those in their homes should be called immediately, regardless of whether they are or are not ‘on-call’). Other hospitals should be employed if a receiving hospital’s facilities are saturated.
Automated external defibrillators (AEDs)
Automated external defibrillators (AEDs) are portable and extremely useful in an out-of-hospital setting. An ambulance may be equipped with a more sophisticated defibrillator that may be portable as well and have the benefit of ECG monitoring (and printing), the option of asynchronized defibrillation (for a cardiac arrest and specifically for pulseless ventricular tachycardia VT or ventricular fibrillation VF) or synchronized electrical cardioversion as well as the choice of the energy levels (how much Joules to use for each defibrillation or cardioversion). The synchronized (‘sync’) option is a shock synchronized with the peak of the QRS complex. It is used in non-cardiac arrest arrhythmias with a hemodynamic compromise that may easily degenerate to ventricular fibrillation, causing a cardiac arrest.
Modern defibrillators also include a temporary non-invasive pacemaker for transcutaneous pacing. It is used for treating severe, hemodynamically unstable bradyarrhythmia (when the heart rate is slow; it may also be used in some tachyarrhythmias) such as severe bradycardia (including third-degree complete heart block and Mobitz II AV block) and asystole of brief time (such as less than 10 min). Devices may additionally include a pulse oximeter for oxygen saturation.
For children, a pediatric biphasic defibrillator is preferred. However, an adult automated external defibrillator (AED) may still be used in older than one-year-old children.
Intubation and medicine administration from the ambulance rescuers
If appropriately trained, a paramedic can perform many procedures like an emergency medicine doctor. In some countries, paramedics use a supraglottic airway device that is easy to place, specifically a laryngeal mask airway (LMA). Recently, there have been laryngeal masks with gel ready for use called i-gel™. A study demonstrated that successful insertion time was significantly shorter for i-gel™. The study showed that as i-gel™ has an easy application, it is advantageous to be used during cardiopulmonary resuscitation by non-anesthetists, in which time is critical. The study concluded that i-gel™ could be an alternative to LMA-Classic™ for controlled ventilation during anesthesia as it is easier to place. (Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4296330/ )
However, LMA does not offer complete airway protection as endotracheal intubation does, which usually only doctors (or experienced paramedics in the US) perform as it requires skill and experience. Instead of an advanced airway, paramedics in many countries ventilate patients with an ‘Ambu’ type bag valve mask. This should include a reservoir that increases the levels of administrated oxygen. An oropharyngeal airway is extremely useful in keeping the airway patent during bag-mask ventilation (BMV).
BMV may distend the stomach, causing aspiration while the airway is not protected. It would be better to use a laryngeal mask. But if it is not available, then bag-mask ventilation with a reservoir attached to the bag mask can be used after the insertion of an oropharyngeal airway to open the airway. That is useful in trauma, but it needs a jaw thrust to open the mouth, and it is contraindicated in skull base fracture.
The appropriate ventilation mask should have a bag with a reservoir to administer high oxygen levels. The ventilation bag must be connected to the oxygen supply, if available, but it should be removed in case of defibrillation. Oropharyngeal airways are reserved for unconscious patients, such as in cardiac arrest. The appropriate sizes are essential for achieving the airways’ patency. The ambulances should also have a pediatric ventilation mask and pediatric sizes of oropharyngeal airways.
There may be an objection to medicine (drug) administration by the paramedics. However, these may be lifesaving, such as on the administration of epinephrine (adrenaline) on anaphylaxis (IM, Sc) or cardiac arrest (usually IV); atropine on severe bradycardia (it is no longer used in asystole), dextrose (glucose) on hypoglycemia, saline, or colloids for external or internal bleeding or severe dehydration, etc. Drug administration is not a problem when paramedics are trained and skilled in using drugs. However, special drugs such as amiodarone for severe heart arrhythmia and medications for rapid sequence induction (before intubation) should be better administered by doctors.
The participation of firefighters in the resuscitation of medical emergencies
As in the US, firefighters should also be trained to help paramedics resuscitate in emergencies. Firefighters do not fight fires 24/7! So, when they are available, they can help in medical emergencies. As in the US, each district should have a co-located fire station and ambulance service building. Firefighters, such as in the US, may help at the scene of a medical emergency such as cardiac arrest or trauma (injury) if they are available and have no other incident to deal with, such as a fire. They should not waste time evacuating people trapped inside a lift, which in many countries, including France, is managed by private lift companies and not by the fire brigade.
The emergency lanes on the road for emergency vehicles
In some countries, the traffic problem is significant. Often, the emergency lanes on the streets, motorways, or highways used exclusively for emergency vehicles (ambulances, fire trucks, and police cruisers) that should have the priority to pass are unacceptably occupied by other vehicles, while when an ambulance is passing by, then the rest cars do not pull over. The registration plate number of any vehicle that impedes the emergency vehicles must be recorded on the scene (and photographed) by the emergency vehicle or the police patrol so that the offender pays a pricey fine. Citizens should be informed by media and internet spots not to impede the emergency lanes used by emergency vehicles. Otherwise, they must anticipate a hefty penalty on the point system and a costly fine.
Using helicopters for emergencies
EMS (emergency medical system) needs to have its own ‘All-Weather Search and Rescue Helicopters’ (AWSRH) helicopters, such as the '’EC225 Super Puma'’, equipped with resuscitation equipment and supplies (monitors, defibrillators, medications, intubation kits, etc.). Rescue helicopters should be used in case an ambulance vehicle is expected to delay, for instance, in remote areas, or when immediate transfer to a hospital is needed, such as in case of a traffic collision or mass destruction with multiple victims. Choppers are especially important in the latter. All hospitals must have an exclusive (X) landing area for helicopters on their roof to avoid wasting valuable time transferring a patient from the airport.
A single emergency phone number (112 in Europe; 911 in the USA) that can also give medical advice
A single telephone number, such as 112 in Europe and 911 in the US, for the police, the fire brigade, and the ambulance services is crucial. Using a single number instead of different numbers for each emergency service makes coordination better, for example, by calling the police, an ambulance, and the fire brigade. Additionally, the emergency phone number could give instructions for dealing with emergencies (such as cardiac arrest) until the ambulance arrives, as 911 does in the US. These instructions are simplified and do not need to be given by a doctor but by a trained, qualified paramedic or nurse. In many cases, these instructions have proved lifesaving.
Triage of emergencies from the ambulance crew on the scene and also on arrival at the Emergency Department (ED)
The sorting of cases is called triage and ensures that the real emergency will be treated first. Triage applies to a specific protocol based on colors, even in the outpatient setting. It is especially useful in cases of multiple victims, such as mass destruction. For triaging patients, rescuers use unique tags with colors that are placed on the patients! Red-marked incidents are emergencies with a life-threatening condition that needs immediate intervention. Yellow-marked casualties require a quick response (urgent), but their treatment may be delayed up to one hour. Green-marked are the subjects to whom treatment may be delayed up to three hours (delayed). The tags of the victims who are dead or are expected to die are colored black. These are not resuscitated, as valuable time will be wasted for a patient who is expected to die soon.
Triage is not necessary to be performed by a doctor, although some hospitals use GPs or general medicine doctors for triage. At the scene of an emergency, a skilled paramedic ambulance crew can do triage effectively. At the same time, an experienced nurse, based on common sense, can perform it in the hospital or medical center.
The golden hour in trauma (injury)
The golden hour is the hour that begins from the time that the emergency (usually refers to trauma, i.e., injury) happens until entering the operating room (OR) of the hospital (if emergency surgery is needed). The Golden Hour is one hour long. That means that the ambulance must arrive at the trauma scene in a maximum of 10 minutes, resuscitate the patient in a maximum of 10 minutes, and then transfer the patient to the hospital in a maximum of 10 minutes. The patient should be resuscitated and stabilized there at a maximum time of 30 min. Finally, if required, the patient will enter the hospital's operating theater at a maximum time of one hour after the emergency incident.
The case of Lady Diana!
In a trauma (injury) emergency, a prompt transfer to the hospital after an on-scene basic resuscitation is vital to save the patient’s life. The golden hour from the accident to surgery is crucial. The case of the death of Lady Diana in a car accident in 1997 is a characteristic example of the dated French notion in the past of stabilizing and slowly transferring the patient to the hospital. The delay in transferring Diana to the nearest appropriate hospital possibly cost her life as she died from hemorrhage of the pulmonary artery that could have been treated if she had transferred fast to the appropriate hospital and promptly the operating room in which a cardiothoracic surgeon (chest surgeon) could treat her injury. This incident also shows the lack of international protocols, as the French had their school on handling emergencies that, with Diana's death, has proven to be wrong!
The golden time in case of myocardial infarction (MI; heart attack)
In case of myocardial infarction (heart attack), and specifically in a STEMI (myocardial infarction with ST-segment elevation) or a new (or presumably new) LBBB (left bundle branch block), the goal from the moment of arrival in the emergency department until the PCI (percutaneous coronary intervention) is 90 minutes. Also, the target from entry to the emergency department until emergency thrombolysis (although less preferred than PCI) is 30 minutes. Of course, these goals are rarely achieved in many countries, and one reason is the shortage of coronary units that perform emergency angioplasty.
The golden time in case of an ischemic stroke
In the case of ischemic (not hemorrhagic) stroke, thrombolysis in many countries is not performed at all since there are no available stroke units! Thrombolytic therapy in stroke has been administered in the US, but it is still controversial in many countries. It can be administered up to 3 hours after symptom onset, so the golden time is three hours.
The nearest appropriate medical center for trauma
The trauma (injury) patient should be transferred to the nearest appropriate medical center, and the transfer should not be delayed for unnecessary or additional laboratory or radiological examinations or unnecessary interventions. The receiving hospital's physician (doctor) should be informed by phone of the patient's condition by the referring doctor and the paramedics. At the same time, all the emergency lab and imaging exams should be handed to the receiving emergency doctor.
When we say that trauma patients need to be transferred to an ‘appropriate’ medical facility with the means, equipment, and personnel to deal appropriately with trauma patients. Notwithstanding, this does not mean that the receiving hospital is a specialized center for the final treatment of the victim, such as a trauma center for a trauma patient or a burn unit for a patient with burns, unless it is near!
So, in case of a car accident, the patient should be resuscitated on the scene and transferred to the nearest appropriate medical facility so that the ambulance does not waste time transferring the patient to a small medical center that cannot manage the emergency effectively. However, things are weighed individually. In case the appropriate medical facility is very far, then other options may be sought, such as asking for a helicopter or stabilizing the patient in a district medical center.
Ambulance drones!
An ambulance takes an average of 10 minutes to get to the scene of an accident. This time is too late for help in some cases, such as severe bleeding or cardiac arrest. In the Netherlands, they created ambulance drones carrying a defibrillator that can be used in case of cardiac arrest, where it arrives very fast, faster than an ambulance! You may watch the video at https://www.youtube.com/watch?v=y-rEI4bezWc Other ambulance drones resemble an ambulance called Emergency Doctor Drone (EDD). You may watch the video at https://www.youtube.com/watch?v=lhsiGmdOa5s
Incidents of mass destruction
Cases of mass destruction require the good organization of the available emergency services. The triage on the scene must be done by a specific doctor who should not be tempted to treat the patients but only to triage which patient needs immediate resuscitation. Separate team leaders are required for the police, the fire brigade, and the ambulance service. A specific individual should coordinate the resuscitation as a chief officer. Receiving hospitals should be informed to employ all their personnel (those in their homes should be called immediately, regardless if they are or are not ‘on-call’). Other hospitals should be employed if a receiving hospital’s facilities are saturated.
Courses in hospitals and the community on Basic life support (BLS), CPR (Cardiopulmonary resuscitation), using an AEA (automated external defibrillator) & performing the Heimlich maneuver
The ambulance service could organize courses for citizens to teach them BLS (Basic Life Support) focusing on cardiopulmonary resuscitation (CPR), the use of an automated external defibrillator (AED) in cardiac arrest, as well as dealing with choking in adults (Heimlich maneuver) and infants. In these seminars, dummies are used for practicing BLS.
AEDs (automated external defibrillators) in critical points in the community
AEDs (automated external defibrillators) should be dispersed in the community at key points such as crowded places, for instance, museums, airports, and malls. Every building should have its own defibrillator. Its cost has decreased lately and will drop further if mass production occurs. On eBay, someone may find the cheapest used AED much cheaper than the latest iPhone.
Battery-powered cardiopulmonary resuscitation devices
All hospitals should use battery-powered cardiopulmonary resuscitation devices, such as LUCAS and AutoPulse, that perform cardiac compressions. These are important, as the central issue in cardiopulmonary resuscitation is the inferior quality of chest compressions in cardiac arrest. These devices should also be in public places, along with AEDs (automated external defibrillators).
Emergency medicine courses for doctors and nurses
All medical and nursing personnel must be trained in BLS (Basic Life Support), including cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED; heart ‘shock’ device), as well as the treatment of choking in adults (Heimlich maneuver) and infants. In all hospital clinics, an automatic external defibrillator and an 'Ambu' type mask (bag mask) with a reservoir should be available in an emergency, including cardiac arrest. Health professionals (including doctors and nurses) must know how to use them. BLS & using AED courses can be organized by the ambulance system (EMS) and the hospital's anesthesiology department. The basic life support (BLS) seminar should be mandatory for all doctors and nurses and annually repeated, as all the medical and nursing staff should be familiar with CPR and the use of an automated external defibrillator (AED), to know how to deal with a cardiac arrest inside or outside the hospital.
Hospitals and health centers should organize emergency medicine seminars and courses for all medical and nursing staff, especially those dealing with emergencies. In an emergency, all clinicians should know how to use an ‘Abu’ type bag valve mask with a reservoir bag that may be connected with oxygen to give 90-100% oxygen, much more than the 30% oxygen a simple face mask gives. An oropharyngeal airway is also useful to prevent the tongue from obstructing the airway and establish the airway’s patency. The ‘Venturi-type oxygen mask is also used to administrate a specific percentage of oxygen.
Courses and seminars on emergencies are necessary for staff (doctors and nurses) working in the emergency department (ED) in hospitals and district health centers to become familiar with resuscitation equipment and medications and know all the algorithms for resuscitation.
Emergency medicine courses for emergency department (ED) doctors and nurses
The emergency department (ED) of hospitals and health centers should regularly organize seminars for resuscitation of emergencies such as endotracheal (ET) intubation, laryngeal mask placement, ventilation with bag-mask with reservoir, defibrillation in arrest, cardioversion of life-threatening tachyarrhythmias, treatment of severe bradycardia, heart attack, and stroke diagnosis, immobilization of injured, ABCDEs assessment on trauma, etc. The emergency seminars should involve adults (seminars ALS, ACLS), children (seminars APLS, EPLS), and trauma (seminars ATLS, PHTLS, and ATCN for nurses). Training may include a variety of these courses.
Which are the emergency medicine courses?
The official emergency medicine courses are:
• BLS (Basic Life Support) for all doctors and nurses. This seminar also applies to the public. It includes cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED), as well as the treatment of choking in adults (Heimlich maneuver) and infants.
• ALS (Advanced Life Support) / ACLS (Advanced Cardiac Life Support) and AMLS (Advanced Medical Life Support) for doctors dealing with emergencies (such as emergency and acute medicine doctors) and nurses involved in emergencies.
• Airway, ECG (electrocardiogram) & pharmacology (drug administration) courses are additional courses for emergencies.
• GEMS (Geriatric Education for Emergency Medical Services) for geriatric (elderly) patients (most of the patients in hospitals).
• APLS (Advanced Pediatric Life Support) / EPLS (European Pediatric Life Support), NLS (Neonatal / Newborn Life Support) for emergency medicine doctors, pediatricians, and nurses involved in emergencies on children. Notably, in many medical facilities, there are no specialized emergency rooms and specialists, emergency pediatricians, for children, but an emergency medicine doctor treats pediatric cases in addition to adults. There is also a course called ALS (Advanced Life Support) – PEPP (Pediatric Education for Pre-hospital Professionals) for prehospital professionals.
• ATLS (Advanced Trauma Life Support), ETC (European Trauma Course), and ATT (Assessment & Treatment of Trauma) for those dealing with trauma.
• ATCN (advanced trauma care for nurses) for nurses occupied with trauma.
• PHTLS (Pre-Hospital Trauma Life Support) for ambulance rescuers (paramedics).
• ALSO (Advanced Life Support in Obstetrics) for obstetricians and those involved in emergencies that may face an obstetric emergency.
As mentioned above, hospitals and health centers' ED (emergency department) should regularly organize resuscitation courses based on the above seminars.
These seminars must be repeated after at least four years (but they may be repeated earlier). However, the clinics may frequently organize lessons based on these seminars. Medical and nursing staff involved in emergencies should be familiar with emergency algorithms.
Senior doctors must regularly hold courses and seminars in emergency medicine in all hospitals and health centers in practical workshops, not only theoretical ones. These courses can be based on the seminars mentioned above (BLS, ALS / ACLS, ATLS, PHTLS, APLS, EPLS, ALSO, NLS), and various emergency scenarios with models and monitors should be taught in a practical way (intubation, defibrillation, immobilization of injured onboard, etc.) and not only theoretically. Concerning the basic life support (BLS) course, as mentioned above, it should strictly be mandatory for all the medical and nursing staff in hospitals and health centers as well as those working in the private sector (in a private surgery or a private clinic).
The specialties of emergency medicine & acute medicine
In some countries, a separate official specialty of emergency medicine does not exist. These countries must include it in the specialty training scheme. In the UK, there is officially a specialty of emergency medicine (emergency medicine doctor) that a trained emergency medicine physician needs about seven to eight years to complete as a specialist consultant. Also, in the UK, a similar specialty called acute medicine covers emergencies, but mostly general medicine cases, while emergency medicine also covers trauma (injury).
The specialty of trauma surgery
The specialty ‘trauma surgeon’ is critical as this specialty deals with trauma (injury) emergencies. In many countries, this specialty does not exist or is a subspecialty of surgery or part of orthopedics.
The trauma rooms in the ED (emergency department) of the hospitals
Trauma resuscitation rooms (trauma rooms) following the US standards are needed in all emergency departments (EDs) of hospitals worldwide. In many countries, specialized trauma rooms do not exist in hospitals. So, trauma patients go to surgical emergency rooms or, in some cases, to general medicine emergency rooms!
Specialized trauma centers and burn units
A health system should have trauma centers for adults and children dealing with trauma. Their purpose is to receive and stabilize a trauma patient (if close) and for definite treatment (after the patient is stabilized). Burn units are essential for the treatment of patients with burns.
Analgesia (pain relief) is often neglected!
Regarding analgesia (pain relief), in many developed countries, a patient is not left to suffer from pain but receives appropriate analgesia. Analgesia can be administered with opiates (naloxone is an antidote to respiratory depression that may cause while an antiemetic is needed), benzodiazepines (flumazenil is the antidote), ketamine, and other anesthetics, etc. An anesthesiologist or a skilled emergency medicine doctor can also achieve it with a nerve block. There are particular analgesics for children, such as those added to lollipops. Many countries use the analgesic ENTONOX, a mixture of nitric oxide (NO) and oxygen, which is helpful in many situations and cheap. However, it has contraindications (such as pneumothorax) and limitations.
In many countries, analgesia in an emergency is neglected (even in orthopedics), usually because doctors are not skilled doctors to use it or are afraid of adverse effects such as respiratory compromise (such as from morphine) or may cover signs and symptoms such as pain in case of a patient with acute abdominal pain. However, patients should not be left in pain but need to receive appropriate analgesia with painkillers as intense pain may have severe consequences, including tachycardia and agitation that bother interventions and may even lead to cardiac arrest.
Organizing the emergency rooms (ERs) of hospitals and medical centers
Skilled emergency medicine doctors in the ERs
Junior and unskilled resident doctors should not cover, without supervision, the emergency department. After all, junior doctors do not have the skills to deal with emergencies. These need to be handled by senior doctors (registrars, consultants).
The need for family doctors/GPs to see non-emergency cases so that they do not pile up in the ED
In the community, the GPs (General Practitioners) and the family physicians (doctors) should deal with outpatient cases and relieve the emergency department (ED) from the congestion of patients who do not really need it but go there to find a doctor for free. The state should organize a family doctor system to whom people can consult for free in their residences.
Acute Medical Unit (AMU)
In the UK, hospitals have Acute Medical Units (AMUs) as separate Units related to the Emergency Department (ED) that correspond to short hospitalization and stabilization of emergencies after their resuscitation and their initial stabilization in the emergency room (ER). Unfortunately, in some countries, the acute medical units are disorganized and often are covered by unskilled junior doctors, while they are not separate units. In the emergency department in the UK, the patient expects to see a doctor soon, (supposedly) no more than an hour (I do not know if the patient sees a doctor so fast, but I think there is a fine for exceeding one hour of waiting).
The necessary medical equipment for dealing with emergencies
The emergency rooms (ER) of hospitals and health centers must be equipped with modern devices, such as the emergency ultrasound called FAST (Focused assessment with sonography for trauma) in trauma, which helps in the prompt diagnosis of internal bleeding and also helps in guide pericardiocentesis in case of cardiac tamponade. An emergency medicine doctor should be skilled in using FAST and not wait for a radiologist to come from the radiology department to do so, as life-saving time is wasted.
Ultrasound imaging is extremely helpful in case central vein access is needed with the Seldinger method, such as in the jugular vein, to avoid harming vital structures such as major arteries (such as the carotid and the subclavian) and penetrating the lung, causing pneumothorax (for this reason always an X-Ray should be performed after subclavian or jugular vein catheterization).
The ER should have portable radiology machines (for X–rays), ultrasound devices including FAST, etc. Additionally, the ER should have modern heart monitors, biphasic (the monophasic are obsolete) defibrillators capable also of transcutaneous pacing, specific kits (such as a kit for thoracotomy/thoracostomy (with chest tubes), pericardiocentesis kit, cricothyroidotomy kit, tracheostomy kit), etc.
Pagers (beepers) and loudspeakers to call doctors in an emergency
All doctors in a hospital need to have beepers (pagers) to be notified immediately in case of an emergency. For this purpose, doctors can also be called by loudspeakers (in many hospitals, there are no loudspeakers).
The emergency medical team (EMT) in the hospital and the blue code for calling them
In all hospital wards, there should be a specific alarm button called ''blue code'' to call the emergency medical team (EMT) to assemble for the resuscitation of a medical emergency. The resuscitation team is essential for immediately treating a cardiac arrest in the hospital. But their role is also preventive by resuscitating the acute exacerbation of a patient before it ends up in cardiac arrest! Most hospitals neglect their preventive role.
The emergency medical team (EMT) consists of doctors and nurses and has at least five members, and their role is designated before cardiac arrest. But during the arrest, all but the team leader may switch positions. The first rescuer is the team leader and coordinates the team; the second performs defibrillation; the third deals with intravenous (IV) access and administers medicines (usually IV); the fourth person performs heart compressions; and finally, the fifth one intubates the patient. The rescuer who intubates usually conducts endotracheal (ET) intubation. If not experienced, then you may use a laryngeal mask and give rescue breaths with a bag valve mask (with a reservoir) connected on one side with the endotracheal tube and on the other with an oxygen supply.
Ideally, the person performing the chest compressions should be changed every two minutes to achieve good quality, as they are not done correctly if the rescuer gets tired. The role of the team leader is essential. If there is no team leader, there is a mess (as in developing countries), and the resuscitation is chaotic. The resuscitation team acts, as the word says, as a group. So, teamwork is an essential skill in the EMT.
The need to recognize and treat the reversible causes of cardiac arrest!
During resuscitation of a cardiac arrest, any reversible cause should be sought. Otherwise, the patient dies from reversible causes, and it is critical to remember that this is not uncommon in the ER! Reversible causes include the six ‘T’s and the six ‘H’s.
The 6 Ts are Tension pneumothorax, Cardiac Tamponade, Toxins/ poisoning/ tablets, coronary Thrombosis (myocardial infarction, i.e., heart attack), pulmonary Thrombosis (pulmonary embolism (PE))/ thromboembolism ((TE); usually related to deep vein thrombosis (DVT)) and Trauma.
The 6 ‘H’s are Hypoxia, Hydrogen ion (acidosis), Hypovolemia ((low blood pressure) including bleeding and severe dehydration), Hyperkalemia (high blood potassium; common in patients with acute/chronic kidney disease)/ hypokalemia (low blood potassium), Hypoglycemia (low blood sugar; common in diabetics taking sugar-lowering drugs), and Hypothermia ((low body temperature that needs special thermometers to be detected - usually esophageal) as well as other metabolic causes such as hypomagnesemia (and hypocalcemia (low blood calcium) that may be combined with hypomagnesemia) that may lead to Torsade’s de pointes, a severe dysrhythmia.
Notifying the EMT (emergency medical team)
In the emergency department and wards, as mentioned, there must be a particular alarm button (blue code) and a loudspeaker so that in case of an emergency (such as cardiac arrest), the resuscitation emergency medical team (EMT) is notified and assembled on the emergency scene. That is the ‘blue code.’ When the loudspeaker announces a blue code in a particular room of the chamber or the emergency department, the resuscitation team, which every day must be specific, ‘on duty,’ and immediately ready if called, should be gathered quickly at the point of the emergency. All the doctors should have pagers (beepers) to be summoned immediately for an emergency.
The preventive role of the emergency medical team (EMT)
As mentioned above, the role of the Emergency Medical Team (EMT) may also be preventive by resuscitating the acute exacerbation of a patient before this ends up in cardiac arrest.
Protective equipment for doctors & nurses
Microbe contamination may occur via body fluids,
so doctors and nurses must wear all the protective equipment in all hospital clinics, especially in the emergency (ED) department. That is especially important,
especially in trauma where medics are exposed to blood and microbe
contamination is easy to occur in unprotected staff. Notwithstanding, this
protection in many developing countries is neglected as, in many cases, the only
protection that may be used is just wearing gloves. In the UK, there may be doctors with casual clothes in the emergency department as if they were psychiatrists! The irrational tendency in the UK and Australia is to have doctors without white coats, with the excuse not to increase the patient's blood pressure. Consequently, personal protective equipment (PPE) is neglected, increasing the risk of contamination for healthcare professionals and patients.
The protective equipment should always be available and includes plastic gloves (surgical gloves are preferred in the
emergency department and when sterilization is needed), surgical face masks, a special plastic face shield/ visor, plastic cap (like the ones that surgeons
wear; some may look like pirates), disposable plastic apron, plastic shoe
covers (like the ones that surgeon wear), etc.
Waiting rooms for relatives and friends
and the appropriate announcement of the bad news
The emergency department needs to have private
waiting rooms where the resuscitated patient's relatives and friends can
stay. If the patient dies, the demise should be announced privately to the patient's relatives, not in the ward or the corridor in
front of other people, but in an isolated waiting room. However, it needs
proper training for this announcement.
Rapid sequence induction & intubation in
the hospital
Emergency intubation with induction medications
should be taught to those involved in emergencies with seminars, such as ALS
(advanced life support), that the hospital needs to organize for the health
professionals dealing with emergencies, particularly in the emergency
department. Courses are also required for the medical and nursing personnel, such as in wards where a cardiac arrest is possible, for example, the general
medicine or surgical ward (but it would be rarer, I guess, at the mental
clinic). The anesthesiology team of the hospital may organize courses on rapid
sequence induction and intubation courses for the medical and
nursing staff that handle emergencies.
Emergencies in district/ rural medical centers
All rural or district or rural medical centers,
such as in the US province, should have skilled emergency medicine doctors and trauma surgeons in their emergency department (ED). They should be covered 24 hours a day by senior doctors and an adequate number of nurses
experienced in emergency medicine. Junior or unskilled doctors, alone without
the supervision of senior doctors skilled in emergency medicine, are not
appropriate for rural medical centers, not even as a cheaper choice than
hiring experienced doctors! Of course, the ED must have all the
necessary resuscitation equipment and medications.
Intraosseous (IO) access as a way of
administrating medicine when other means of access are time-consuming or have
failed
In case of a pediatric (involving children)
emergency in the emergency department of hospitals and medical centers, when
vein access is not successful, then intraosseous (IO) access (with a special
kit or, if unavailable, with a bone marrow biopsy needle) is the next step for
providing fluids and medications inside the bone that reaches circulation.
Intraosseous access may be lifesaving in children and infants. Lately, it has
also been used in adults if fast IV access is not feasible (such as drug
addicts, those in shock with collapsed veins, etc.
Is targeted temperature management (TTM) helpful after cardiac arrest or traumatic brain injury (TBI)?
Targeted temperature management (TTM) is cooling the post-arrest (after a cardiac arrest resuscitated successfully
but with the patient in a coma) survivors with mild hypothermia. This innovative technique seems promising. It has been used mainly in children
after prolonged successful resuscitation and may prevent damage to brain
function. A study concluded that endovascular cooling and gel-adhesive pads
provide more rapid hypothermia induction and more effective temperature
maintenance than water-circulating cooling blankets. (Reference: https://www.ncbi.nlm.nih.gov/pubmed/29288014 ).
However, another study concluded that the
esophageal cooling device (ECD) seems an interesting, safe, accurate,
semi-invasive cooling method in out-of-hospital cardiac arrest (OHCA) patients
treated with 33 Celsius degrees TTM, particularly during the maintenance phase.
(Reference: https://www.resuscitationjournal.com/article/S0300-9572(17)30632-9/fulltext )
Preliminary observations in 2002 suggested that
treatment with moderate hypothermia improves outcomes in patients
with coma after resuscitation from out-of-hospital cardiac arrest.
(Reference: https://www.nejm.org/doi/full/10.1056/NEJMoa003289 ).
However, targeted temperature management (TTM) after a cardiac arrest is
controversial, as recent studies debate its efficacy. A recent systematic
review and meta-analysis concluded that TTM with therapeutic hypothermia might
not improve mortality or neurological outcomes in post-arrest survivors.
(Reference: https://www.ncbi.nlm.nih.gov/pubmed/29239942
Cooling may be useful in cases other than arrest, such as traumatic brain injury (TBI). A meta-analysis demonstrated that
therapeutic hypothermia was beneficial only if the cooling index (a measure of
a combination of cooling parameters) was sufficiently high and concluded that
cooling improves the outcome of severe traumatic brain injury (TBI). This beneficial effect depends on specific cooling parameters and their integrated
measure, the cooling index. (Reference: https://www.ncbi.nlm.nih.gov/pubmed/29681213 )
The cardiopulmonary bypass machine!
In the emergency department of large busy
hospitals, a cardiopulmonary bypass machine may save lives in some selected
cases. Emergency cardiopulmonary bypass (ECPB) has been investigated
experimentally and clinically as an advanced resuscitation method that may
rescue patients with refractory cardiac arrest or cardiogenic shock
unresponsive to traditional medical interventions. By diverting blood flow from
the patient to an extra-corporeal heart and lung system capable of providing a
full cardiac output, ECPB can provide blood flow and gas exchange to the
patient when there is not the capability of the patient's heart or lungs to
sustain these functions intrinsically. (Reference: https://www.criticalcare.theclinics.com/article/S0749-0704(11)00111-4/fulltext )
Cardiopulmonary bypass (CPB) and extracorporeal
membrane oxygenation (ECMO) facilitate circulatory support in
standard cardiac surgery and emergency intervention. A recent review concluded
that extracorporeal circulatory support could be used in thoracic,
renal, and tracheal surgery. These surgical procedures have involved the
management of hemodynamically unstable patients. According to the review,
patient outcomes have been encouraging with few complications.
(Reference: https://www.ncbi.nlm.nih.gov/pubmed/29753653 ).
An older study concluded that as cardiopulmonary resuscitation using a
percutaneous cardiopulmonary support system (PCPS) improves survival, it
appears that PCPS is a powerful resuscitative modality for seriously ill
patients with acute myocardial infarction (heart attack) or LV (left
ventricular) rupture. (Reference: https://link.springer.com/article/10.1007%2FBF01744596 )
DPL (diagnostic peritoneal lavage) (vs) FAST
(focused assessment with (ultra) sonography for trauma) in the Emergency
Department (ED) on trauma patient
On patients with trauma (injury), the DPL
(diagnostic peritoneal lavage) helps evaluate whether a blunt trauma on the
abdomen requires surgery. However, it is time-consuming and has limitations. The FAST (focused assessment with sonography
for trauma) ultrasound is a fast procedure that allows the emergency medicine
doctor to quickly diagnose internal bleeding in the abdomen. Additionally, it
helps diagnose cardiac tamponade, which facilitates needle
pericardiocentesis. Importantly, the M-mode may help diagnose pneumothorax! That is crucial, as there is no time for a chest x-ray (CXR) in tension pneumothorax. FAST is necessary for the emergency department (especially
for trauma patients), and its advance is that a radiologist is not needed, as
an emergency medicine doctor is (or should be) familiar with it. Moreover, it
is a quick, non-invasive method. On the contrary, DPL lately is less favored and, in
many cases, is replaced by FAST.
Coronary care units (CCUs) in the hospitals
In many countries, there is a shortage of
coronary units, hemodynamic units for emergency angioplasty (PTA, or PTCA
or PCI) on myocardial infarction (heart attack)/ acute coronary syndrome (ACS).
PCI is the most comprehensive method of treating ACS, and it is preferred over
angioplasty with contraindications and adverse effects, including bleeding.
In STEMI (myocardial infarction with ST-segment
elevation) and new or presumably new LBBB (left bundle branch block), the
golden time from the moment of arrival in the emergency department until the
PCI (percutaneous coronary intervention) is 90 minutes. Also, the golden time
from arrival at the emergency department until emergency
thrombolysis is 30 minutes. Of course, in many countries, these goals, especially angioplasty, are uncommonly achieved for many reasons, such as the
patient's delay in visiting the hospital or when the ambulance delays (for
instance, when the patient lives in remote areas where a helicopter would be a
better choice). The patient may also delay in a busy emergency department where
triage is not performed correctly or at all, or the lack of
available coronary units conducting emergency angioplasty.
Stroke units in hospitals
In the US, non-contrast computed
tomography (CT) remains the primary imaging modality for evaluating patients with suspected stroke. Conventional brain MRI studies can take up
to one hour to complete. They are not very good at detecting cytotoxic or
intracellular edema seen in the stroke's acute or less than a 24-hour phase. Standard MRI images (T1 and T2) are good at detecting vasogenic
edema in the subacute phase of stroke, 24 hours to several days after. (Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088377/ )
Strokes should ideally be treated at stroke
units where thrombolysis with the thrombolytic medication rTPA (recombinant
tissue plasminogen activator; also known as alteplase) can be administered on
ischemic (non-hemorrhagic) strokes, in selected cases, when it is not
contraindicated.
In many countries, thrombolysis in ischemic
stroke is not performed since there are no stroke units or experience with
this procedure. Thrombolytic therapy in stroke is used in the US but is
controversial in other countries. It can be administered within 4.5 hours
of stroke onset after symptom onset, which is why it is not
conducted, as often patients delay going to the hospital and ask for medical
help.
Thrombolytic therapy is proven and substantially beneficial for selecting patients with acute cerebral ischemia.
(Reference: https://emedicine.medscape.com/article/1160840-overview ).
Present guidelines recommend using alteplase within 4.5 hours of stroke onset with no upper
age limit. Data supports older patients benefiting at least as much as those
less than 80 years old, mainly if administered in the first three hours post
(after) stroke onset. Alteplase improves the overall odds of a good stroke
outcome despite the increased risk of symptomatic (including fatal)
intracranial hemorrhage (Reference: https://www.rcpe.ac.uk/sites/default/files/jrcpe_47_4_robinson.pdf )
A recent meta-analysis concluded that intravenous recombinant tissue plasminogen activator IV-tPA treatment was associated
with better functional outcomes but not mortality among patients with mild
ischemic stroke (MIS). However, there was an increased risk of symptomatic
intracranial hemorrhage (sICH). (Reference: https://svn.bmj.com/content/3/1/22 ). For
this reason, some say that a stroke unit should have a neurosurgeon to deal
with brain hemorrhage as an adverse effect of rtPA.
Toxicology tests
There are commercially available kits
specifically for toxicological tests involving medications. Often, poisoning is caused by paracetamol (acetaminophen) overdose, but it may also be from aspirin,
anticonvulsants, antidepressants, hypnotics and tranquilizers, blood thinners,
opiates, cannabis, stimulants/psychedelics (including 'ecstasy''), etc. In some
cases, such as acetaminophen, lithium, and digitalis, the medication's levels
in the blood are needed.
However, not all biochemistry departments can
perform them. Some biochemistry departments do not perform toxicology tests, especially in developing countries or even in developed, especially rural medical centers. Toxicology
tests for heavy metals (such as arsenic and lead) are more specialized and are
ordered if a doctor suspects heavy metal poisoning, such as in case of
unexplained neurological, blood, or kidney problems. These particular tests may
be requested in the toxicology department of the pathology/ forensic service,
although large hospitals should include them in order not to decongest the
above facilities.
Antidotes for cyanide poisoning (common in
victims who inhaled fire smoke, especially plastic)
Cyanide poisoning may be deadly in minutes. Many fire victims may not die from burns or inhaling carbon monoxide (CO) but from breathing cyanide in smoke, mainly from burning plastic materials, including plastic couches! Cyanide poisoning may also occur from the consumption of bitter almonds and an overdose of the antihypertensive medication sodium nitroprusside. Antidotes for cyanide poisoning do exist and include cobalt EDTA (it has many adverse effects), hydroxocobalamin (a form of vitamin B12; the most favorable treatment), amyl nitrite (administered with inhalation), sodium nitrite, and sodium thiosulfate (but it acts with delay).
Security guards in hospitals and medical centers
Importantly, in the emergency department (ED) of hospitals, medical centers, and hospital clinics, there should be security guards because there are huge problems with troublemakers such as relatives who do not leave the ward, gypsies (called Roma in Europe) who sometimes may be aggressive when waiting too long in the emergency department; drug addicts who are under the influence of drugs or of drug withdrawal syndrome they threaten doctors to give them sedatives and opioids (such as morphine, pethidine, fentanyl patch, and others); alcoholics; homeless who are often drunk; arrested thugs or inmates; mental ill patients such as with psychotic crisis, etc.
Security guards are also needed for cases of petty larceny in hospitals, which are relatively common since anyone can get into the hospital and steal. The security at the hospital gate should check who enters the hospital to prevent the entry of people who do not have a relative or friend to visit.
In the emergency departments, security guards are essential when shortening the cases (TRIAGE) so the real emergencies will reach the doctor fast. Triage may cause tension in patients waiting long in the emergency department to see a doctor or insist their case is severe, even though they may have something minor. So, security guards may need to enforce the order when patients become disobedient and cause trouble. If a patient or visitor is very aggressive, restriction measures may be required, and the police may be called to enforce the order.
Of course, security officials must be trained to know how to restrain a dangerous person, such as an arrested villain, a prisoner, or a person under the influence of alcohol or illicit drugs. For this purpose, security staff should carry defense weapons such as batons and electric tasers and not just stand with hands in their pockets waiting for the police. When large hospitals are on duty, they may need one or two police officers to be in the emergency department (ED) as not infrequently injured thugs at large visit a hospital for treatment. Additionally, they may be useful in handling troublemakers.
Dangerous people with stimulation and agitation, such as psychotic crisis, may need restrictions that can be physical, such as being tied with gauze on the bed, and sedation, such as with diazepam or lorazepam and haloperidol. For legal reasons, hospitals must have a restrictive protocol with physical restraint.
Legal issues related to emergencies
Many times, in the emergency department (ED), legal problems may occur, such as the refusal of a Jehovah for blood transfusion to himself/ herself or his/her child, the unwillingness for surgery in a life-threatening emergency, parents' denial to consent on a life-saving operation of their child; cases of physical and sexual abuse, etc. Doctors in the emergency department need to have directives from their medical association and the hospital's legal team on how to act in such cases.
Also, 24/7 access to the hospital's lawyer is needed. I think that an ‘on-call’ lawyer for non-business hours is important! In some dubious cases, an urgent court decision for an injunction may be needed, for example, when parents do not consent to their child's emergency surgery! In the UK, there are legal directives for similar cases, so doctors and hospital lawyers know what to do.
Cases of physical and sexual abuse visiting the Emergency Department (ED)
Cases of physical and/ or sexual abuse in adults or minors should always be referred to a senior doctor to write a report, take photos (if the lesion is visible, such as cigarette burns on the child's skin), perform imaging tests (such as radiography for rib and other fractures) and inform the social services and the police. The medical evidence will probably be used in court. Electronic medical records of patients visiting the emergency department of the area's hospitals are especially useful as they reveal frequent visits of the same patients in the emergency room of the particular or other hospitals.
In some cases, a doctor may meet a patient with the Munchhausen syndrome by proxy in which parents themselves cause symptoms in their child, for instance, by giving it a purgative (laxative) that causes diarrhea. This syndrome is also called a factitious disorder imposed on another. Studies have shown a mortality rate of between 6 percent and 10 percent, making it perhaps the most lethal form of abuse. By diagnosis, 6 percent of the affected persons died, mostly from apnea (a typical result of smothering) or starvation, and 7 percent suffered long-term or permanent injury. (Reference (Retrieved: August 7, 2018): https://en.wikipedia.org/wiki/Factitious_disorder_imposed_on_another )
Sexual abuse, including rape involving a minor or an adult, should be treated with a specific protocol. The victim should not take a shower after the rape but should be examined as soon as possible by a gynecologist, a pathologist, or a police surgeon. Vaginal samples should be handed to the police lab to detect sperm for DNA for comparison with suspects. Of course, the police should be informed immediately.
The inappropriate visit to the emergency department (ED) for insignificant problems!
As mentioned above, the institution of the family doctor/ general practitioner (GP) is necessary so that everyone can visit without any charge a district GP who will examine the patient and administer treatment. If the case is more severe or needs further investigation, the patient is referred to the hospital with a referral note for further investigation and treatment. Hence, patients with minor complaints will not pile up at the emergency room to find a doctor for free. For this reason, the family doctor (or GP in the UK) is the cornerstone of healthcare.
Thanks for reading!
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