Emergency Medical Services. Группа авторов
or a newly formed rescue squad. Additionally, in both urban and rural areas, a few profit‐making providers delivered transport services and occasionally contracted with local government to provide emergency prehospital services and transport. Before 1966, very little legislation and regulation applicable to ambulance services existed, limiting consistency among services. Ambulance attendants had relatively little formal training, and physician involvement at all levels was minimal.
A number of factors combined in the mid‐1960s to stimulate a revolution in prehospital care. Advances in medical treatments led to a perception that decreases in mortality and morbidity were possible. Closed‐chest cardiopulmonary resuscitation (CPR), reported as successful in 1960 by W.B. Kouwenhoven and Peter Safar, was eventually adopted as the medical standard for cardiac arrest in the prehospital and hospital settings [12, 13]. New evidence that CPR, pharmaceuticals, and defibrillation could save lives immediately created a demand for physician providers of those interventions in both the hospital and prehospital environments. Throughout the 1960s, fundamental understanding of the pathophysiology of potentially fatal dysrhythmias expanded significantly. The use of rescue breathing and defibrillation was refined by Peter Safar, Leonard Cobb, Herbert Loon, and Eugene Nagel [14]. Safar persuaded many others that defibrillation and resuscitation were viable areas of medical research and clinical intervention.
In 1966, Pantridge and Geddes pioneered and documented the use of a mobile coronary care ambulance for prehospital resuscitation of patients in Belfast, Northern Ireland. Their treatment protocols, originally developed for the treatment of myocardial infarction in intensive care units, were moved into the field [15]. Because the physician‐led medical team was often with the patient at the time of cardiac arrest, the resuscitation rate was a remarkable 20%. Their “flying squads” added a dimension of heroic excitement to the job of being an ambulance attendant, and their performance data helped convince American city health officials and physicians that a more medically sophisticated prehospital advanced life support (ALS) system was possible.
1966: Accidental Death and Disability: The Neglected Disease of Modern Society
The modern era of prehospital care in the United States began in 1966. In that year, recognition of an urgent need for improved care, the crucial element necessary for development of prehospital systems nationwide, was heralded by a report from the National Academy of Sciences National Research Council (NAS‐NRC), a non‐profit organization chartered by Congress to provide scientific advice to the nation. Accidental Death and Disability: The Neglected Disease of Modern Society (commonly referred to as the “white paper”) documented the enormous failure of the U. S. health care system to provide even minimal care for the emergency patient in both the prehospital and hospital settings. The NAS‐NRC report identified key issues and problems facing the United States in providing emergency care (Box 1.1). Its summary report listed recommendations that would serve as a blueprint for EMS and emergency medicine development, including such things as first aid training for the lay public, state‐level regulation of ambulance services, emergency department improvements, development of trauma registries, single nationwide phone number access for emergencies, and disaster planning [16]. This document established a benchmark against which to measure subsequent progress and change in emergency care.
The 1966 NAS‐NRC document described the care provided by both prehospital services and hospital emergency departments as being woefully inadequate. In the prehospital arena, treatment protocols, trained medical personnel, rapid transportation, and modern communications concepts such as two‐way radios and emergency call numbers, were all identified as necessities that were simply not available to civilians. Although there were more than 7,000 accredited hospitals in the country at the time, very few were prepared to meet the increased demand for volume and clinical care that developed between 1945 and 1965. From 1958 to 1970, the annual number of emergency department visits increased from 18 million to more than 49 million [16]. In addition, emergency departments were staffed by the least experienced personnel, who had little education in the treatment of multiple injuries or critical medical emergencies. Early efforts of the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS) to improve emergency care were largely unsuccessful because interest and support from the medical community were essentially non‐existent [17–20].
Box 1.1 Key findings of the 1966 NAS‐NRC report
Inadequacies of Prehospital Care in 1966
1 The general public is insensitive to the magnitude of the problem of accidental death and injury.
2 Millions lack instruction in basic first aid.
3 Few are adequately trained in the advanced techniques of cardiopulmonary resuscitation, childbirth, or other life‐saving measures, yet every ambulance and rescue squad attendant, policeman, firefighter, paramedical worker, and worker in high‐risk industry should be trained.
4 Local political authorities have neglected their responsibility to provide optimum emergency medical services.
5 Research on trauma has not been supported or identified at the National Institutes of Health on a level consistent with its importance as the fourth leading cause of death and a primary cause of disability.
6 The potentials of the U.S. Public Health Service Program in accident prevention and emergency medical services have not been fully exploited.
7 Data are lacking on how to determine the number of individuals whose lives are lost through injuries compounded by misguided attempts at rescue and first aid, absence of physicians at the scene of the injury, unsuitable ambulances with inadequate equipment and untrained attendants, lack of traffic control, or the lack of voice communication facilities.
8 Helicopter ambulances have not been adapted to civilian peacetime needs.
9 Emergency departments of hospitals are overcrowded, some are archaic, and there are no systematic surveys on which to base requirements for space, equipment, or staffing for present, let alone future, needs.
10 Fundamental research on shock and trauma is inadequately supported; medical and health related organizations have failed to join forces to apply knowledge already available to advanced treatment of trauma, or educate the public and inform Congress.
Source: Adapted from Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences, 1966.
The 1966 NAS‐NRC document was the first to recommend that emergency facilities be categorized. It also emphasized aggressive clinical management of trauma, suggesting that local trauma systems develop databases, and that studies be instituted to designate select injuries to be incorporated in the epidemiological reports of the U.S. Public Health Service. Changes were also recommended concerning legal problems, autopsies, and disaster response reviews. Trauma research was especially emphasized, with the ultimate goal of establishing a National Institute of Trauma [16]. Another problem identified in the report was the broad gap between existing knowledge and operational activity. This white paper contains very good conceptual discussions that remain relevant for EMS physicians today.
In addition to the NAS‐NRC white paper, other reports raised many similar issues. The President’s Commission on Highway Safety had previously published a report entitled Health, Medical Care, and Transportation of Injured, which recommended a national program to reduce deaths and injuries caused by highway crashes. Its findings were complemented by and consistent with the NAS‐NRC report [21]. The recommendations in both documents were used when the Highway Safety Act of 1966 was drafted. This law established the cabinet‐level Department of Transportation (DOT) and gave it legislative and financial authority to improve EMS. Specific emphasis was placed on developing a highway safety program, including standards and activities for improving both ambulance service and attendant training, with particular focus on motor vehicle crashes [22]. This focus led to improvements in both transportation capabilities and clinical care.
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