STAGES OF PRE-HOSPITAL CARE

The six stages of pre-hospital care as follows :

Stage 1
Survey of the scene/approach
Look, listen, think, act
Check for dangers to yourself and patients
Assess number of casualties
Is back up required
Other services present or required
Consider mechanism of injury
Establish priorities

Stage 2
Primary Survey :
Rapid assessment of the patient to identify and treat those condition that present an immediate threat to life
Airway - ensure an open airway
Breathing - ensure that the patient is breathing
Circulation - check the adequacy of the circulation
Start CPR for cardiac arrest
Control severe haemorrhage
Consider mechanism of injury, if a cervical injury is suspected, manage accordingly

Stage 3
Secondary survey :
Closer look at the scene
Gain a comprehensive history
Physical assessment
Assess and record vital signs

Stage 4
Patient management/transport :
Appropriate patient care
Wound care
Fracture management
Transport

Stage 5
Reassessment :
Ongoing re-evaluation of the patient’s condition - ask yourself :
Was my treatment successful?
Is there any more I can do?
Have I missed anything?
Is the patient condition changing?
Do I require further assisstance?
Do I need to notify the hospital?

Stage 6
Pre - allert :
Inform medical facility or treatment centre if necessary

First aid

First aid is the provision of initial care for an illness or injury. It is usually performed by a lay person to a sick or injured patient until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care past the first aid intervention. It generally consists of a series of simple and, in some cases, potentially life-saving techniques that an individual can be trained to perform with minimal equipment.

While first aid can also be performed on animals, the term generally refers to care of human patients.

The key aims of first aid can be summarised in three key points-^[4]

• Preserve life - the overriding aim of all medical care, including first aid, is to save lives
• Prevent further harm - also sometimes called preventing the condition worsening, this covers both external factors, such as moving a patient away from a cause of harm, and applying first aid techniques to prevent worsening of the condition, such as applying pressure to stop a bleed becoming dangerous.
• Promote recovery - first aid also involves trying to start the recovery process from the illness or injury, and in some cases might involve completing a treatment, such as in the case of applying a plaster to a small wound.

First aid training also involves the prevention of initial injury and responder safety, and the treatment phases.

Certain skills are considered essential to the provision of first aid and are taught ubiquitously. Particularly, the "ABC"s of first aid, which focus on critical life-saving intervention, must be rendered before treatment of less serious injuries. ABC stands for Airway, Breathing, and Circulation. The same mnemonic is used by all emergency health professionals. Attention must first be brought to the airway to ensure it is clear. Obstruction (choking) is a life-threatening emergency. Following evaluation of the airway, a first aid attendant would determine adequacy of breathing and provide rescue breathing if necessary. Assessment of circulation is now not usually carried out for patients who are not breathing, with first aiders now trained to go straight to chest compressions (and thus providing artificial circulation) but pulse checks may be done on less serious patients.

Some organizations add a fourth step of "D" for Deadly bleeding or Defibrillation, while others consider this as part of the Circulation step. Variations on techniques to evaluate and maintain the ABCs depend on the skill level of the first aider. Once the ABCs are secured, first aiders can begin additional treatments, as required. Some organizations teach the same order of priority using the "3 Bs": Breathing, Bleeding, and Bones. While the ABCs and 3Bs are taught to be performed sequentially, certain conditions may require the consideration of two steps simultaneously. This includes the provision of both artificial respiration and chest compressions to someone who is not breathing and has no pulse, and the consideration of cervical spine injuries when ensuring an open airway.

Preserving life

As the key skill to first aid is preserving life, the single most important training a first aider can receive is in the primary diagnosis and care of an unconscious or unresponsive patient.

In order to preserve life, all persons require to have an open airway - a clear passage where air can move in through the mouth or nose through the pharynx and down in to the lungs, without obstruction. Conscious people will maintain their own airway automatically, but those who are unconscious (with a GCS of less than 8) may be unable to maintain a patent airway, as the part of the brain which autonomously controls in normal situations may not be functioning.

If the patient was breathing, a first aider would normally then place them in the recovery position, with the patient leant over on their side, which also has the effect of clearing the tongue from the pharynx. It also avoids a common cause of death in unconscious patients, which is choking on regurgitated stomach contents.

The airway can also become blocked through a foreign object becoming lodged in the pharynx or larynx, commonly called choking. The first aider will be taught to deal with this through a combination of ‘back slaps’ and ‘abdominal thrusts’.

Once the airway has been opened, the first aider would assess to see if the patient is breathing. If there is no breathing, or the patient is not breathing normally, such as agonal breathing, the first aider would undertake what is probably the most recognized first aid procedure - Cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually massaging the heart to promote blood flow around the body.

Promoting recovery

The first aider is also likely to be trained in dealing with injuries such as cuts, grazes or broken bones. They may be able to deal with the situation in its entirety (a small adhesive bandage on a paper cut), or may be required to maintain the condition of something like a broken bone, until the next stage of definitive care (usually an ambulance) arrives.

Much of first aid is common sense. Basic principles, such as knowing to use an adhesive bandage or applying direct pressure on a bleed, are often acquired passively through life experiences. However, to provide effective, life-saving first aid interventions requires instruction and practical training. This is especially true where it relates to potentially fatal illnesses and injuries, such as those that require cardiopulmonary resuscitation (CPR); these procedures may be invasive, and carry a risk of further injury to the patient and the provider. As with any training, it is more useful if it occurs before an actual emergency, and in many countries, emergency ambulance dispatchers may give basic first aid instructions over the phone while the ambulance is on the way.

Training is generally provided by attending a course, typically leading to certification. Due to regular changes in procedures and protocols, based on updated clinical knowledge, and to maintain skill, attendance at regular refresher courses or re-certification is often necessary. First aid training is often available through community organizations such as the Red Cross and St. John Ambulance, or through commercial providers, who will train people for a fee. This commercial training is most common for training of employees to perform first aid in their workplace. Many community organizations also provide a commercial service, which complements their community programmes.

Conditions that often requires First Aid:

• Altitude sickness, which can begin in susceptible people at altitudes as low as 5,000 feet, can cause potentially fatal swelling of the brain or lungs.
• Anaphylaxis, a life-threatening condition in which the airway can become constricted and the patient may go into shock. The reaction can be caused by a systemic allergic reaction to allergens such as insect bites or peanuts. Anaphylaxis is initially treated with injection of epinephrine.
• Battlefield First aid - This protocol refers to treating shrapnel, gunshot wounds, burns, bone fractures, etc. as seen either in the ‘traditional’ battlefield setting or in an area subject to damage by large scale weaponry, such as a bomb blast or other terrorist activity.
• Bone fracture, a break in a bone initially treated by stabilizing the fracture with a splint.
• Burns, which can result in damage to tissues and loss of body fluids through the burn site.
• Choking, blockage of the airway which can quickly result in death due to lack of oxygen if the patient’s trachea is not cleared, for example by the Heimlich Maneuver.
• Childbirth.
• Cramps in muscles due to lactic acid build up caused either by inadequate oxygenation of muscle or lack of water or salt.
• Joint dislocation.
• Diving disorders resulting from too much pressure.
• Near drowning or asphyxiation.
• Gastrointestinal bleeding.
• Gender-specific conditions, such as dysmenorrhea and testicular torsion.
• Heart attack, or inadequate blood flow to the blood vessels supplying the heart muscle.
• Heat stroke, also known as sunstroke or hyperthermia, which tends to occur during heavy exercise in high humidity, or with inadequate water, though it may occur spontaneously in some chronically ill persons. Sunstroke, especially when the victim has been unconscious, often causes major damage to body systems such as brain, kidney, liver, gastric tract. Unconsciousness for more than two hours usually leads to permanent disability. Emergency treatment involves rapid cooling of the patient.
• Heat syncope, another stage in the same process as heat stroke, occurs under similar conditions as heat stroke and is not distinguished from the latter by some authorities.
• Heavy bleeding, treated by applying pressure (manually and later with a pressure bandage) to the wound site and elevating the limb if possible.
• Hyperglycemia, or diabetic coma.
• Hypoglycemia, or insulin shock.
• Hypothermia, or Exposure, occurs when a person’s core body temperature falls below 33.7°C (92.6°F). First aid for a mildly hypothermic patient includes rewarming, but rewarming a severely hypothermic person could result in a fatal arrhythmia, an irregular heart rhythm.
• Insect and animal bites and stings.
• Muscle strain.
• Poisoning, which can occur by injection, inhalation, absorption, or ingestion.
• Seizures, or a malfunction in the electrical activity in the brain. Three types of seizures include a grand mal (which usually features convulsions as well as temporary respiratory abnormalities, change in skin complexion, etc) and petit mal (which usually features twitching, rapid blinking, and/or fidgeting as well as altered consciousness and temporary respiratory abnormalities).
• Sprain, a temporary dislocation of a joint that immediately reduces automatically but may result in ligament damage.
• Stroke, a temporary loss of blood supply to the brain.
• Sucking chest wound, a life threatening hole in the chest which can cause the chest cavity to fill with air and prevent the lung from filling, treated by covering with an occlusive dressing to let air out but not in.
• Toothache, which can result in severe pain and loss of the tooth but is rarely life threatening, unless over time the infection spreads into the bone of the jaw and starts osteomyelitis.
• Wounds and bleeding, including laceration, incision and abrasion, and avulsion.

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Ambulance Equipments

Trolley / Stretcher / Cot + Straps: stretcher to carry the patient plus safety rope, Immobiliser Kits: splint for fracture fixation, Carrying chair + straps:folding chairs to bring the patient up / down ladder + rope , Defibrillator:DC Shock for Tachycardia & ventricle ventricle Vibrilasi equipped with ECG monitors and pulse oximeter, Scoop stretcher:to move the patients with spinal injuries, Suction machine: to suction mucus / blood, Backboard:to bring patients with spinal injuries, Life Support Products (LSP): O2 small tube to the patient breathing , Kendrick Extrication Devices (KED):To move a patient with spinal injuries in a car that crashed, Entonox:contains O2 Nitrous oxide for pain relief while the patient , O2 cylinder, regulator: The main oxygen supply in key equipped ambulance, humidant+flowmeter:to moisten the air and regulate the amount of O2 given
Ventilator / Dragger:respiratory aids, Fracture Immobiliser: splint for fractures, Sharp Disposable Container:where reservoir another sharp needles used are used for patients , Trash Bucket: trash can, Head Immobiliser:buffer head and neck , Neck Collar:neck buffer , Ambubag (BVM):to provide assisted respiration , Sphygmomanometer:to check blood pressure, Stethoscope:to auscultation, Torch: flashlight to check pupils, Glucometer:to check blood sugar random, Glucostrips: to accommodate the blood drop in blood sugar checks , Blood Lancet: needle puncture to remove blood, Guedel airway (OPA):to open the airway , Adhesive tape:adhesive plaster , Ambulance dressing: for dressing wounds, Vomiting bags:patient vomit bag container, Cotton wool:cotton rolls , Gauze:gauze bandage , Crepe bandage:roll bandage , Eye pad:eye bandage, Scissors:Versatile scissors, Disposable razor:shaving razor , Syringe:syringe , Pulse oxymeter:to check oxygen saturation and pulse , Ambulance sheet: bed linen to the gurney, Disposable sheet:above the base sheet, Blankets, Pillow, Triangular bandage, Suction tube, Surgical face mask, Disposable gown, Nebuliser masks, Nasal canula, O2 masks, Disposable gloves, Triage card sets, Fire Extinguisher, Defibrilator pads, Suction catheter, Ventolin: bronkodilator, Adrenalin:emergency medicine in cardiac resuscitation , Glucagon:for patients with hypoglycemia , Atropine Sulfate:emergency medicine in cardiac resuscitation , Lignocain
: for cardiac arrhythmias, Normal saline:for infusion / clean the wound, Water gels:for burns, ECG Electrodes:ECG liaison with the patient's body , Lubrication jelly
:gel lubricant to the suction hose and hose intubation, Gliceryl Trynitrate (GTN) spray:for chest pain due to cardiac infarction / Angina with other effects of lowering blood pressure , Paramedic bags:paramedic bag containing the tools for infusion and intubation , First aid bags: contains tools for first aid

Ambulance

An ambulance is a vehicle for transporting sick or injured people,^[1] to, from or between places of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to bring medical care to patients outside of the hospital or to transport the patient to hospital for follow-up care and further testing. In some jurisdictions there is a modified form of the ambulance used, that only carries one member of ambulance crew to the scene to provide care, but is not used to transport the patient.^[2] In these cases a patient who requires transportation to hospital will require a patient-carrying ambulance to attend in addition to the fast responder.

The term ambulance comes from the Latin word ambulare, meaning to walk or move about^[3] which is a reference to early medical care where patients were moved by lifting or wheeling. The word originally meant a moving hospital which follows an army in its movements.^[4] During the American Civil War vehicles for conveying the wounded off the field of battle were called ambulance wagons.^[5] Field hospitals were still called ambulances during the Franco-Prussian War^[6] of 1870 and in the Serbo-Turkish war of 1876^[7] even though the wagons were first referred to as ambulances about 1854 during the Crimean War.^[8]

The word is most commonly associated with the land-based, emergency motor vehicles that administer emergency care to those with acute illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with flashing warning lights and sirens to facilitate their movement through traffic. It is these emergency ambulances that are most likely to display the Star of Life,^[9] which represents the six stages of prehospital medical care.

There are other types of ambulance, with the most common being the patient transport ambulance. These vehicles are not usually (although there are exceptions) equipped with life-support equipment, and are usually crewed by staff with fewer qualifications than the crew of emergency ambulances. Their purpose is simply to transport patients to, from or between places of treatment. In most countries, these are not equipped with flashing lights or sirens.

Other vehicles used as ambulances include trucks, vans, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships.

Functional types:

• Emergency ambulance – The most common type of ambulance, which provide care to patients with an acute illness or injury. These can be road-going vans, boats, helicopters, fixed-wing aircraft (known as air ambulances) or even converted vehicles such as golf carts.
• Patient transport ambulance – A vehicle which has the job of transporting patients to, from or between places of medical treatment, such as hospital or dialysis center, for non-urgent care. These can be vans, buses or other vehicles.
• Response unit – Also known as a fly-car, which is a vehicle which is used to reach an acutely ill patient quickly, and provide on scene care, but lacks the capacity to transport the patient from the scene. Response units may be backed up by an emergency ambulance which can transport the patient, or may deal with the problem on scene, with no requirement for a transport ambulance. These can be a wide variety of vehicles, from standard cars, to modified vans, motorcycles, pedal cycles, quad bikes or horses. These units can function as a vehicle for officers or supervisors (similar to a fire chief's vehicle, but for ambulance services).
• Charity ambulance – A special type of patient transport ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the United Kingdom's 'Jumbulance' project.^[10] These are usually based on a bus.

Common ambulance crew qualifications are:

1. First Responder – A person who arrives first at the scene of an incident,^[63] and whose job is to provide early critical care such as CPR or using an AED. First responders may be dispatched by the ambulance service, may be passers-by, or may be dispatched to the scene from other agencies, such as the police or fire departments.
2. Ambulance Driver – Some services employ staff with no medical qualification (or just a first aid certificate) whose job is to simply drive the patients from place to place.
3. Ambulance Care Assistant – Have varying levels of training across the world, but these staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care.^[64] Dependent on provider, they may be trained in first aid or extended stills such as use of an AED, oxygen therapy and other life saving or palliative skills. They may provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.
4. Emergency medical technician – Also known as Ambulance Technician. Technicians are usually able to perform a wide range of emergency care skills, such as defibrillation, spinal care, and oxygen therapy. Some countries split this term in to levels (such as in the US, where there is EMT-Basic and EMT-Intermediate).^[65]
5. Paramedic – This is a high level of medical training and usually involves key skills not permissible for technicians, such as cannulation (and with it the ability to administer a range of drugs such as morphine), intubation and other skills such as performing a cricothyrotomy.^[66] Dependent on jurisdiction, Paramedic can be a protected title, and use of it without the relevant qualification may result in criminal prosecution.^[67]
6. Emergency Care Practitioner – This position, sometimes called 'Super Paramedic' in the media, is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are already qualified paramedics who have undergone further training,^[68] and are trained to prescribe medicines (from a limited list) for longer term care, such as antibiotics, as well as being trained in a range of additional diagnostic techniques.
7. Registered nurse (RN) – Nurses can be involved in ambulance work, and as with doctors, this is mostly as air-medical rescuers or critical care transport providers, often in conjunction with a technician or paramedic. They may bring extra skills to the care of the patient, especially those who may be critically ill or injured in locations that do not enjoy close proximity to a high level of definitive care such as trauma, cardiac, or stroke centers.
8. Doctor – Doctors are present on ambulances – most notably air ambulances^[69][70] – will employ physicians to attend on the ambulances, bringing a full range of additional skills such as use of prescription medicines.

Types of operators / providers:

1. Government Ambulance Service – Operating separately from (although alongside) the fire and police service of the area, these ambulances are funded by local or national government. In some countries, these only tend to be found in big cities, whereas in countries such as Great Britain almost all emergency ambulances are part of a national health system.^[59]
2. Fire or Police Linked Service – In countries such as the U.S. and France ambulances can be operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. In some cases this can lead to an illness or injury being attended by a vehicle other than an ambulance, such as a fire truck.
3. Volunteer Ambulance Service – Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service across the world on a volunteer basis.^[60] (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance^[32] and the Order of Malta Ambulance Corps.^[61] These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of Australia and in Ireland.
4. Private Ambulance Service – Normal commercial companies with paid employees, but often on contract to the local or national government. Private companies may provide only the patient transport elements of ambulance care (i.e. non urgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility impaired if they have for example fallen and just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies.
5. Combined Emergency Service – these are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where size or budget does not warrant separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.
6. Hospital Based Service – Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital.
7. Charity Ambulance – This special type of ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the UK's 'Jumbulance' project.^[10]
8. Company Ambulance - Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehichles in the event of a fire or explosion.

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Emergency Medical Services (EMS)

Emergency medical services (abbreviated to the initialism "EMS" in some countries) are a branch of Emergency services dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the First responder, believes constitutes a medical emergency.^[1]

Emergency medical services may also be locally known as: First aid squad,^[2] Emergency squad,^[3] Rescue squad,^[4] Ambulance squad,^[5] Ambulance service,^[6] Ambulance corps^[7] or Life squad.^[8]

The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the malady, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital or another place where physicians are available. The term Emergency Medical Service evolved to reflect a change from a simple transportation system (ambulance service) to a system in which actual medical care occurred in addition to transportation. In some developing regions, the is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.^[9]

In most places in the world, the EMS is summoned by members of the public (or other emergency services, businesses or authority) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.^[10]

In some parts of the world, the term EMS also encompasses services developed to move patients from one medical facility to an alternative one; inferring transfer a higher level of care. In such services, the EMS is not summoned by members of the public but by clinical professionals (eg. physicians or nurses) in the referring facility. Specialized hospitals that provide higher levels of care may include services such as neonatal intensive care (NICU),^[11], pediatric intensive care (PICU), state regional burn centers,^[12] specialized care for spinal injury and/or neurosurgery,^[13] regional stroke centers,^[14] specialized cardiac care^[15][16] (cardiac catherization^[17]), and specialized/regional trauma care.^[18]

In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue.^[19] Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive the ambulance, with no medical training.^[9] In contrast, most systems have personnel that retain, at a minimum, a basic first aid certificate (Basic Life Support (BLS)), additionally many EMS systems are staffed with Advanced Life Support (ALS) personnel, including fully qualified paramedics, nurses, or, less commonly, physicians.^[20]

The purposes of EMS:

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery.

This common theme in medicine is demonstrated by the star of life. The Star of Life shown here, where each of the 'arms' to the star represent one of the 6 points. These 6 points are used to represent the six stages of high quality pre-hospital care, which are:^[31]

1. Early Detection^[31] - Members of the public, or another agency, find the incident and understand the problem
2. Early Reporting^[31] - The first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted
3. Early Response^[31] - The first professional (EMS) rescuers arrive on scene as quickly as possible, enabling care to begin
4. Good On Scene Care^[31] - The emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident
5. Care in Transit^[31] - the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
6. Transfer to Definitive Care^[31] - the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

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