Evaluation of prehospital emergency care in the field ...

Advances in Therapy®

Volume 22 No. 1 January/February 2005

Evaluation of Prehospital Emergency Care in the Field and During the Ambulance Drive to the Hospital Suna Soysal, MD Dokuz Eylül University Advanced Professional School of Health Sciences Izmir, Turkey

Ozgur Karcioglu, MD Hakan Topacoglu, MD Dokuz Eylül University Medical School Department of Emergency Medicine Izmir, Turkey

Sinan Yenal Harun Koparan Orhan Yaman Paramedics Dokuz Eylül University Medical School Advanced Professional School of Health Sciences Izmir, Turkey

ABSTRACT This study was conducted to evaluate the appropriateness of ambulance procedures and interventions in the management of patients dispatched to 2 emergency departments (EDs) of urban hospitals in Izmir. Use of trauma boards and cervical collars, airway patency, breathing, and circulation problems were recorded in both EDs. Eighty-one patients with a mean age of 47.54±2.36 years (range, 4–89) brought into the ED via ambulances were enrolled in the study. Airway maneuvers were performed in patients with airway and breathing problems. There was no significant relationship between administration of IV fluids and the presence of circulatory impairment (P=.053). A trauma board was used in 9 of 30 trauma cases (30%) and a cervical collar in 6 of 30 (20%). It was concluded that basic procedures used in the management of patients brought into the ED via ambulances were inadequate.

Keywords: prehospital emergency care; ambulance; emergency transport; emergency department; field emergency care ©

2005 Health Communications Inc Transmission and reproduction of this material in whole or part without prior written approval are prohibited.

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Address reprint requests to Address reprint requests to Suna Soysal, MD Dokuz Eylül University Medical School Emergency Department, 35340 Inciraltı, Izmir, Turkey

INTRODUCTION Prehospital care is a fairly new concept in Turkey. It began in 1994, when the Ministry of Health initiated a program called “112 Emergency Help and Rescue Services” (112 EHRS). By dialing the telephone number 112 patients can receive access to prehospital care services from general practitioners and nurses. However, no standard training program was designed for doctors and nurses who staffed 112 EHRS in Turkey up to 2004. Dokuz Eylül University began an Ambulance and Emergency Care Technician Training Program for paramedics in 1993. Paramedics have become part of ambulance crews after government approval was obtained in 2004. But prehospital care in Turkey has not been evaluated. This study therefore evaluated the appropriateness of evaluation and prehospital care of patients brought to the emergency unit by ambulance.

MATERIALS AND METHODS This study was conducted between October 10 and December 1, 2001 in the Izmir Government Hospital and Bozyaka Social Security Hospital. Prior approval was obtained from these hospitals and paramedics working in both were informed. A form was designed to record information including the following: age and gender of the patients; time from onset of the event until arrival to the emergency department (ED); medical or trauma status; use of trauma board and cervical collar; appropriate versus inappropriate use of the cervical collar; emergency staff informed or not informed by ambulance staff; emergency problems related to the airway, breathing, and circulation as well as how problems were resolved; Glasgow Coma Scale (GCS) score. The study forms were filled in by the paramedics. Data were collected via randomization method. The data were analyzed by SPSS version 10.0 for Windows. To analyze categorical data, χ2 test was used, and t test was used to compare means among groups. Kruskal-Wallis and Fisher’s exact test were used for nonparametric data.

RESULTS During the study, 81 patients were brought by the following ambulance services to both hospitals: 112 EHRS ambulance in 60 patients (74.1%); private ambulance in 14 patients (17.3%); hospital ambulance in 3 patients (3.7%); emergency rescue system in 2 patients (2.5%); and local ambulance in 2 patients (2.4%). Mean patient age was 47.54±2.36 years (range, 4–89); 43 patients (53.1%) were male and 38 (46.9%) were female. Thirty patients (37.0%) were brought to the ED due to trauma while 51 patients (63.0%) were brought because of medical reasons. Mean time from onset of event to arrival at the ED in an ambulance was 95.50±24.72 minutes (range, 10–900). The ED was notified in advance of the arrival of only 4 (4.8%) patients, 2 stabbing injuries, 1 myocardial infarction, 1 ventricular fibrillation.

Advances in Therapy® Volume 22 No. 1, January/February 2005

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According to evaluation of airway patency, 72 (88.9%) patients had no airway obstruction. Apnea was recorded in 6 (7.4%) patients and stridor in 3 (3.7%) patients. An obstructing foreign body was present in the airways in 1 apneic patients. Pneumothorax was observed in 2 patients, 1 (1.2%) of whom had a flail chest. Other respiratory problems were observed in 10 (12.3%) patients and 62 (76.5%) patients were determined to have normal respiration. Interventions included oxygen in 10 (12.3%) patients, bag-valve mask in 2 (2.5) patients, and orotracheal intubation in 4 (5.0%) patients. Four of the 6 (66.6%) patients with apnea were intubated. Respiration was assisted in 2 patients with a bag-valve mask: 1 with one-sided respiration with flail chest and 1 patient with respiratory failure. Of the 3 patients with stridor, only 1 (33.3%) was given oxygen with a mask and the other 2 (66.7%) required no intervention. Pulse was absent in 2 (2.4%) patients and weak and superficial in 20 (25.7%) patients. Cardiopulmonary resuscitation (CPR) was administered in 1 (1.2%) patient and a drip was put-up in 40 (49.7%) patients. CPR was administered to 1 of the 2 patients with an absent pulse; the other, a 47-year-old patient with traumatic respiratory arrest, was given only an oxygen mask. Average GCS score was 13.1(±3.4). A drip was put-up and intravenous (IV) fluid treatment was given to a 21-year-old patient with a GCS score of 4 following a knife injury; no other intervention was carried out to protect his airways. Oxygen was given and a drip was put-up for administration of IV fluid to a 38-year-old patient with a GCS score of 4 who had multiple trauma. A drip was also put-up and IV fluid treatment given to a 55-year-old patient with a GCS score of 4 who was brought in with the prediagnosis of intracranial bleeding; this was later confirmed as a subdural hemorrhage. No intervention was carried out in a 73-year-old patient with a GCS score of 9 who was transported by ambulance to the ED; this patient had complaints reflecting a generally poor condition. IV fluid was given via a drip to a 19year-old patient with a GCS score of 7 who had a head injury. Of 30 patients with trauma, only 1 with a tibial fracture was carried by stretcher. All trauma cases were serious except for 1 with simple facial cuts. However, of the 29 patients who required a trauma board and neck support, only 9 (31.0%) were provided with a trauma board and only 1 (3.2%) was provided with a stretcher. Of the 9 patients provided with a trauma board, only 5 (55.6%) were given a neck support. Only a neck support, without a trauma board, was provided to a patient who had been brought in due to a fall. The neck support was inappropriately used in only 1 (1.2%) patient. A statistically significant relationship was found between the notified cases due to trauma and use of the trauma board and neck support; trauma board and neck support were used only in patients with trauma. Interventions, such as providing and maintaining a clear airway, were carried out in patients with respiratory problems (P