Prehospital Care

Alasdair K.T. Conn

Paul D. Biddinger

Since the publication of the landmark report titled, Accidental Death and Disability: The Neglected Disease of Modern Society—a report which detailed serious deficiencies in prehospital care—the prehospital management and development of established trauma systems have evolved to be recognized as one of the key links in the survival of the severely traumatized patient. This chapter will outline the levels of prehospital care and the capabilities of the prehospital provider to initiate care of the severely traumatized patient. All participants within an established trauma system should have knowledge of the capabilities and limitations of prehospital providers, so that recommendations for system change and individual quality improvement efforts can be appropriately targeted and monitored.

PREHOSPITAL PROVIDER LEVELS

Prehospital providers at all levels are certified or licensed at the individual state level. Although many states differ in exact requirements, most states have adopted the recommendations from the federal Department of Transportation (DOT) and specifically, the curricula developed by the National Highway Traffic Safety Administration (NHTSA). This federal agency, together with the Health Resources and Services Administration (HRSA), are the two agencies involved in monitoring and developing emergency medical service (EMS) systems. Prehospital providers may be classified as first responders, Emergency Medical Technician-Basic (EMT-B), Emergency Medical Technician-Intermediate (EMT-I), and Emergency Medical Technician-Paramedic (EMT-P). See Table 1 for a list of their capabilities. The exact capabilities may differ slightly from state to state, particularly at the paramedic level in terms of the medications that they are allowed to administer; some states may require that certain medications be given and procedures be performed on standing protocol and others may demand that paramedics speak with a physician by radio (online medical direction) before they institute a specific therapy on a particular patient. The development of the standardized protocols and procedures is defined as offline medical direction and trauma surgeons should have input to the protocols for the trauma patient. Many states have adopted statewide trauma treatment and trauma protocols; these can often be upgraded at the regional or local level, but only with the appropriate state oversight and local quality assurance monitoring. In most states, emergency medical technicians (EMTs) and paramedics are required to obtain a certain number of continuing education credits and often to recertify by a practical and a written examination in order to maintain their certification.

The different levels of prehospital providers may be municipal employees, employees of an ambulance service providing EMS services to a local jurisdiction under contract, or volunteers or paid personnel from a local fire company or fire service jurisdiction. In all states, paramedics are required to have a medical director who is the physician legally responsible for the paramedics’ practice. Complaints or concerns regarding an individual paramedic’s performance should initially be directed to both the individual and the medical director level. All states will have a formal mechanism for investigating inappropriate and unprofessional conduct of prehospital providers at all levels.

ALTERNATIVE PREHOSPITAL CONFIGURATIONS

In many states, helicopter transport is available; some states have adopted licensing procedures to recognize the capability of providers, which are often above the EMT-paramedic level. Some programs fly with physicians and are, therefore, subject to the appropriate state licensing board—these physicians being capable of independent
practice. More than 90% of the US flight programs have flight nurses in their configuration; and these may operate using state-mandated protocols or protocols developed by the individual hospital or trauma center that is providing the helicopter service. Although certain components of the basic EMT, EMT-I, and paramedic course are specifically directed toward the initial care of the trauma patient, additional resources such as the Prehospital Trauma Life Support (PHTLS) course developed by the American College of Surgeons (ACS) are available in all states and provide additional information and training regarding the management of the trauma patient.

TABLE 1 PREHOSPITAL RESPONDERS

Level of Provider	Skills	Comments
First responder	Bandaging, splinting, CPR, hemorrhage control. Approximately 40 hr of training	Examples: firefighters and police; they do not transport patients
Emergency Medical Technician-Basic (EMT-B)	Assess signs and symptoms; can give oxygen, immobilization skills, and triage; can often use automatic defibrillators (AEDs). Approximately 120-160 hr of training	Usually certified on a state level; in many states it is the minimal requirement to staff an ambulance; ambulances staffed by EMT-Bs are “BLS”
Emergency Medical Technician-Intermediate (EMT-I)	Trained in IV access, often in LMAs and other airway devices	Certified by state; do not usually give medications
Emergency Medical Technician-Paramedic (EMT-Paramedic)	Advanced airway management, endotracheal intubation, and ACLS protocols; can give medications; approximately. 500-2,000 hr of training	Certified by state; must have responsible medical director (MD); ambulances staffed by EMT-Ps are “ALS”
Flight nurse; flight paramedic, critical care transport nurse; critical care transport medic	Above paramedic; variable training/certification and skills	Highest level of nonMD found in prehospital phase; several states moving to Commission on Accreditation of Medical Transport Systems (CAMTS) as a state requirement
CPR, cardiopulmonary resuscitation; BLS, basic life support; LMA, laryngeal mask airway; ACLS, advanced cardiac life support.

PREHOSPITAL CARE

Triage

Of all of the prehospital decisions and interventions that are to be provided to the multiply injured patient by the EMS provider, the most critical and most under-recognized is the initial recognition and triage of the trauma patient. States that have trauma systems have developed a specific definition of “the trauma patient” and direct the particular facility that such a trauma patient should be transferred. Transfer may be direct (by bypassing local facilities or using a helicopter to transfer directly from the scene) or by secondary triage—transferring patients to a local facility for initial resuscitation with subsequent transfer to the trauma center for definitive management and critical care. There are trauma triage guidelines that have been developed by the ACS, the American College of Emergency Physicians (ACEP), and the National Association of Emergency Medical Service Physicians (NAEMSP); and most states have adopted these criteria (or a minor modification thereof) in developing their statewide trauma triage protocols. Such protocols usually involve physiologic criteria (hypotension, respiratory distress); anatomic criteria (amputations); mechanism of injury criteria (roll over, ejection from vehicle); as well as separate pediatric trauma triage criteria. These have recently been updated based upon a meeting sponsored by the CDC in 2005. Guidelines for helicopter activation to the scene have also been developed by the NAEMSP and are often adopted at the state, regional, or local level.

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