Perhaps more than any other specialty, emergency medicine interfaces with outside agencies and specialties; management is always based on a team approach to care. The emergency medical system interfaces with police, firefighters, news media, transportation authorities, disaster planning agencies etc. Within the emergency department, patient care is provided by a team of professionals, including nursing staff, radiographers, pharmacists, blood bank and clinical laboratory personnel, social workers etc.
The emergency doctor must rely on medical colleagues for consultation, post admission care, and post discharge follow-up care.
The overall orchestration of personnel and resources for the immediate care of acutely ill or injured patients is the responsibility of the emergency doctor, until the evaluation shows that the patient can be formally transferred to another physician or service.
PREHOSPITAL CARE
Outside of the hospital situation, there is a clear organizational hierachy
The police are in overall control of the situation.
The fire service is in control of rescue and extrication
The ambulance service is responsible for evacuation of casualties
The medical team is present at the request of the ambulance team
Entrapment of casualties is now the most common reason for paramedics to request the assistance of a medical team - either prolonged entrapment or situations where analgesia is required.
An on site medical team must be formed from experienced staff who have high visibility protective clothing, adequate equipment and insurance for this type of work. However this is not always possible in rural and other underserviced areas.
A recent concept that is believed to improve overall outcome during disasters is the Incident Command System. Such a system is based on the philosophy that various sectors (triage, communications, transportation) are under the command of a single authority that can provide adequate control. The purpose of such a system is to reduce the amount of time and precious resources wasted on patients who do not need them (minor injuries) or will not benefit from them (victims of unsurvivable injuries, given the setting).
The incident command system provides a structure that can prevent the misuse of resources (such as transporting patients before triage occurs).
Triage means "to sort". Although numerous systems exist for triaging accident victims, the basic concept identifies four groups of patients:
a) minor illness or injury (walking wounded)
b) serious but not life threatening illness or injury (such as a patient with intra abdominal injury who is currently not in shock)
c) critical or immediately life threatening illness or injury
d) dead or unsalvageable. The actual categorization is different in various types
and magnitudes of disaster. Thus a critically injured patient who might receive the benefit of a comprehensive life saving effort in a three patient incident might be deemed unsalvageable in a disaster with a thousand victims.
The quality of medical care is directly related to the experience of personnel. A disaster has been defined as "many people trying to do quickly what they do not ordinarily do in an environment with which they are familiar". No matter how experienced an individual is, the level of care, resources available, and entire framework for resource management undergo major alterations during a disaster. Thus the development of a clear plan for the management of multiple casualties is imperative to ensure optimal outcome for the victims, given the resources available. Disaster planning must not be seen in a vacuum, but rather must include relevant agencies within the community, such as police and fire departments, ambulance team, communications and hospitals. No matter how well prepared a trauma centre might be to care for multiple casualties, if the transportation of disaster victims is disrupted or misdirected, patient outcome is adversely affected.
The only measures that have been shown conclusively to save lives in the pre-hospital situation are ABC:
Airway Clearance, maintenance and protection
Breathing Oxygenation and ventilation
Circulation Chest compression and defibrillation
Extensive clinical examination and the establishment of IV infusions are of no proven benefit. However, other pre-hospital treatments may contribute greatly to the relief of pain and suffering.
Time at the scene must not be extended by anything other than essential treatment. The priority is to get the patient to the hospital as soon as possible. The basic principles of pre-hospital care are the same as those for in hospital care. Specific resuscitation courses are now available where the applied skills may be mastered. The general practitioner is sometimes called away by patients, relatives, nurses, police or others to attend to emergencies. The lay concept of what constitutes an emergency
includes not only physical problems, but also emotional and social. The general practitioner needs to understand the patient's feeling of urgency and reassurance may not always be simple, but can require great skill and understanding. Despite this, the general practitioner must be available and organized to cope with the medically defined emergency when it comes. Emergency care outside the hospital represents one of the most interesting and rewarding areas of medical practice. City doctors will have to modify their degree of availability, equipment and skills according to paramedical emergency services, while others, especially remote doctors, will need total expertise and equipment to provide optimal circumstances to save patients lives.
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