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The Transformation of Prehospital Response in Rural West Texas

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The Transformation of Prehospital Response in Rural West Texas History of EMS John A. Griswold MD, FACS Chair Emeritus Dept. of Surgery TTUHSC Medical Director TJH Burn Center UMC Disclosures • No financial or relevant relationships to disclose at this time Objectives • At the completion of this presentation the attendees should understand the unique aspects involved with care of injured patients in rural west Texas • At the completion of this presentation the attendees will be able to describe the early development of prehospital/first response services in rural west Texas • At the completion of this presentation the attendees should understand the complexity and state-of-the-art capability that exists with current prehospital response services in rural west Texas. History of EMS • “War which as it’s primary aim is to destroy and maim – at the same time provides paradoxically the opportunity for rapid advances in medical knowledge” Napoleonic Wars 1803 - 1815 The birth of battle triage of injured 1487 - Vehicles for purpose of evacuation of injured first used by Spanish in the battle of Malaga 1542 – Ambroise Pare first to Develop structure for battlefield Wound treatment Used dressings to cover wounds Ligature to stop bleeding Dominique Jean Larrey – militatry physician to Napolean developed protocols for triage severity of wounded and coined the term Ambulance for organized evacuation of casualties Napoleon ambulance Crimean War – 1853 to 1856 615,000 casualties with over 500,000 deaths Almost all due to disease British/Turks/French vs. Russia History of EMS Civil War 1861 to 1865 Joseph Barres and Jonathan Letterman expand on Larrey’s work 2-wheeled and 4-wheeled horse drawn evacuation carts Civil War History of EMS Civil War 1861 - 1865 • AMEDD – Army Medical Department – 1861 • Role = prevent disease, clear battlefield of casualties, treat the sick and injured • Each regiment (300 – 500 men) had five 2-wheeled and one 4-wheeled horse-drawn wagons for evacuation of the injured • Contract civilian drivers History of EMS Civil War 1861 - 1865 • 1862 – Maj. Jonathan Letterman • Corp ambulance service – military run, own reporting structure • 4-wheeled wagons only • 1 wagon for every 300 injured • Much more efficient even with inadequate numbers – battle of Gettysburg (1863) Union army transported 14,000 union and 7,000 confederate wounded History of EMS Medical Advances 1865 - 1895 • 1865 Chloroform + Ether used for anesthesia • 1867 Lister introduces antisepsis • 1870 Pasteur and Koch establish germ theory • 1871 von Bergmann begins antiseptic surgery with heat treatment of instruments • 1882 Vaccines for cholera, anthrax and rabies • 1890 von Behring discovers antitoxins for tetanus • 1895 Roentgen detects electromagnetic radiation – X-rays • 1899 von Bausch develops sphygmomanometer Second Boer War – 1899 to 1902 Change from large soft leaden to small caliber nickel-jacketed bullets projected at high velocity by smokeless Propellant Dry desert allowed for aseptic technique to work with undisturbed dressings as long as bleeding had stopped WW I First 2 years of casualty care were disastrous Moist environment lessened aseptic success Battle zone changed with trench warfare Heavy artillery Smaller lighter rapid fire weapons Unprotected infantry Toxic gases Aircraft WW I -Shock and Resuscitation -ABO blood groups defined -Nitrous Oxide+Ether+Oxygen -Endotracheal Intubation -Machines for gas delivery -ADS to MDS to CCS -Blood pressure measurement championed by Harvey Cushing -Ambulances equipped with heaters Blood Transfusions 1902 – Alexis Carrel and George Crile perfect suturing of blood vessels (required for successful blood and fluid infusion 1913 – A.R. Kimpton and J.H. Brown develop the Kimpton-Brown Flask – glass tube coated with paraffin Infused up to 700cc at a time 1915 – Sodium citrate used as an anticoagulant Shock defined and resuscitation as a therapy developed with start of research into crystalloid vs colloid 1903 External Chest compressions describe by George Crile 1907 first ventilator developed History of EMS WW I • Shock patient description – Herman Fisher “He is lying still, pupils dilated, unaware of what is going on around him, skin and mucous membranes pale and marbled, hands and lips bluish, large droplets of swear on forehead, whole body feels cold, limbs lifted fall immediately, very rapid breathing with long a deep breaths mixed with short almost invisible breaths” History of EMS WW I • RAMC – Royal Army Medical Corp • Consisted of 10 medical officers, 220 RAMC soldiers, 50 Army service corps personnel, divided into 3 units. • Each unit located just behind forward fighting lines – collected in barrier stations made up of receiving area and tent station for medical treatment History of EMS WW I • Diseases of WWI • 1918 50,000,000 die from influenze pandemic • Trench warfare led to Lice infestation and spread of Rickettsia and Bordetella purtusis • Venereal Disease rampant = Heroic era of Prostitution • Hook worm infections World War II Korean War Korea Vietnam Vietnam War History of EMS Civilian Injury - 1960 • US ambulance response run by funeral homes • No training for personel or drivers • Only communication between funeral home and ambulance driver • No organized Emergency rooms • No 24 hour ORs • No specialty training for physicians or surgeons in emergency or injury care History of EMS 1965 Injury Statistics • 50,000,000 accidental injuries • 107,000 died • 10,000,000 temporarliy disabled • 400,000 perminently disabled • $18 bil in cost of care and work time lost History of EMS National Academy of Sciences 1966 Accidental Death The Broken and Disability Circle of life History of EMS Accidental Death and Disability The Neglected Disease of Modern Society • No treatment protocols • No trained personell • Ineffective transportation • Lack of modern communication • Abdication of responsibility by politicians • Lack of quality research History of EMS 1966 NAS report – “Accidental Death and Disability – the Neglected Disease of Modern Society Department of Transportation developed Lyndon Johnson appoints David Boyd MD Chief of Division of Emergency Medial Services National Highway Safety Act passed History of EMS 1970s the Golden Years for EMS • National Highway Safety Act 1966 • Dept of Transportation developed 1967 • Division of EMS under DOT led by David Boyd • EMS Act of 1973 • Federal Communication adoption of 911 and standards set for trauma center designation - 1973 Star of life Chair 1975 - 1979 Francis C Jackson, MD, FACS TSS 1978 History of EMS SPEMS – The Beginning • 1973 – South Plains Association of Governments (SPAG) obtains one of 15 federal/state grants to begin EMS training • 1977 – SPEMS incorporated Giles McCrary 1st chairman and Francis Jackson MD 1st med dir • 1978 – David Boyd MD now head of Dept of Health, Education, and Welfare in addressing joint session of Congress uses SPEMS as single example of how regional EMS should be organized History of EMS Initial Accredited Paramedic Programs • 1880 UCLA Center of Health Services • 1980 Eastern Kentucky University • 1981 Pennsylvania College of Technology • 1982 HealthONE EMS Univ. of Colorado • 1983 UT San Antonio • 1984 University of Alabama • 1984 Texas Tech Univ. Health Sciences Ctr. JEMS 1996 History of EMS Golden Age Loses Steam • 1986 – MI patient 4X greater chance of dying in US than Europe • 1990 – Increase in scene medical care hurt injury victims • 1991 - >50% of US communities had no access to 911 – those with access only 20% with E911 • 2012 - >1/3 of services lack complex airway management, hemorrhage control, and serious confusion over prehosp. Resus. History of EMS Golden Age Loses Steam • 2010 – NAS followup report – full benefit of organized EMS not or hindered due to lack of national coordination and standards • No Registry • Training not standardized • Disjointed Medical Direction • Outcome still unacceptable • Military to civilian arena still severely hampered 2017 RAC Award History of EMS SPEMS Medical Leadership • 1977 – 1985 Francis Jackson MD • 1986 – 1996 CRF Baker MD • 1997 – 2004 Fred Hagedorn MD • 2005 – 2015 Joe Sasin MD • 2015 - Charles Addington MD Jim AeroCare 1992 2017 RAC Award Katrina 2005.
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