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Issue 1 Volume 1 APRIL 14,2012 Cost : Free

THE AMBULANCE TIMES The Newsletter touching every once associated with Emergency Medical Services The ambulance times

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The ambulance times

Ground Ambulance throughout History Queen Isabella of Spain was the first to use some sort of emergency medical transportation back in 1487. At the time, the Spanish Army was treated very well both on and off the battlefield. Although an ambulance staff would care for the wounded soldiers, it was not provided until after the battle was over. Because of this, many soldiers died. A major transformation of how ambulances were used in battle was instituted by Dominique Jean Larrey, Napolean Bonaparte's chief physician. After witnessing so many soldiers die on the battle field because of their wounds, Larrey set out to make it easier for the ambulances to reach and assist the wounded soldiers. He designed a two- and four-wheel wagon pulled by horses. After the soldiers Dear Member, received initial medical attention on the field, they were transported to the hospital. Larrey also adapted his ambulances to the geographical conditions of the troops' location. For example, in a campaign in We are delighted to introduce our first Egypt, ambulances were redesigned to be pulled by camel.

newsletter for all those involved in the field of Pre hospital care, Emergency Civil War In the Civil War, Union military physicians Joseph Barnes and Jonathan Letterman expanded medicine, critical care, disaster on Larrey's ideas. They designed an in-depth treatment for wounded soldiers before they arrived at the hospital, and they created specific techniques and methods to transport patients. management. Although lack of access to nonemergency medical transportation is a barrier to health care, national transportation and health care surveys have not comprehensively addressed that need and the solutions for safe hospital care services all across the Indian subcontinent.

19th Century The first known ambulance operating for a hospital was in Cincinnati, Ohio in 1865. Ohio was quickly followed by New York who strived to bring patients to the hospital faster and more comfortably. Ambulances started carrying medical supplies and drugs such as splints, stomach pumps, morphine and brandy. Physicians realized that the speed of a patient's transport often meant the difference between life and death. As such, horses were left in their harnesses while waiting for an emergency call. The first motorized ambulance weighed 1600 pounds and traveled 16 miles per hour. It was first used in Chicago in 1899 and was donated by five local businessmen. In 1900, New York began using an ambulance with an electrically powered engine that traveled 20-30 miles per hour. World War II The first gasoline-powered ambulance was used during World War II on the battlefield. The ambulance was designed to withstand enemy fire through its heavy tractor-unit case made from bullet-proofsteel sheets. It had three wheels, two in the rear and one in the front. Ambulances started carrying advanced medical equipment with a physician on board and were dispatched by radio calls. The Red Cross also played a prominent role in the introduction of gasoline-powered ambulances during the war. These ambulances quickly replaced the horse-drawn carts.

We hope you will enjoy being a part of this newsletter, the experience of contributing to the development of Emergency services in Indian subcontinent. I proudly mention this because there is lot to learn and share 1970s The ambulance evolved significantly during the 1970s. Vehicles were now able to carry more weight which allowed ambulances to carry more medical supplies. Updated medical technology like within the neighboring countries. audible and visual warnings, first aid supplies and, most importantly, a stretcher, were now carried in We shall be sharing with you in the future issues patient transfer stories , learning experiences and newer medical procedures and protocol for safe transfer of patient by ground and air ambulances . Dr. Satish Bhardwaj MD Editor in Chief

every ambulance. Ambulance drivers also began to receive medical training and CPRbegan to be used as the procedure for cardiac arrest. During this time, the ambulance began to play the role of a mobile hospital rather than simply a transport for patients. Modern Vehicle Ambulances are now custom built with highly technical medical equipment. Improvements in the vehicle's systems have dramatically improved protection to its occupants, including anti-lock brakes and improved audio and visual warning equipment. There are also more lifts, ramps and winches so crews do not have to lift and maneuver as much. These features also increase the level of comfort and speed at which a patient arrives at the hospital. Although the ambulance has come a long way, advances continue to be made because of the growing level of education and skills in the role paramedics play. Advances will continue to be made to ensure safety and comfort for the patients.


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Ambulance-need of the Hour. Emergency Medical Services (EMS) constitute both prehospital and hospital services. Both have long been neglected in many countries of the developing world. In India , few victims receive treatment at the scene and fewer still can hope to be transported to the hospital in an ambulance Patients are instead brought to the Casualties/Emergency Departments (ED) by relatives or bystanders in private cars, taxis or any other readily available mode of transportation. Patients commuting to major cities from remote areas are most vulnerable. They often do not have any means of transportation and have to travel on foot without any first aid. Without standard pre-hospital care, people with good survival possibilities also die at the scene or en route to the hospital. Most deaths in the early hours after injury are the result of airway compromise respiratory failure or uncontrolled hemorrhage. All three of these conditions can be readily managed using basic first aid measures. The most common mode of transport to the Casualty/ED was found tobe taxi (58%) followed by private car (23%). Specific reasons for not using ambulances included a perception that the patientWas not sick enough (45%), slow response of the ambulance services (23%), not knowing how to find one (11%) and the high cost (8%). Hence, we can see that the reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.

The general understanding is that patients have better disease outcome if provided with definitive care within 60 minutes of the occurrence of injuries. Hence, pre-hospital care is most beneficial during the second phase of the conditions such as trauma. Pre-hospital care research in developing countries has, to a large extent , will be focused on trauma. Mortality from severe injury occurs in one of the following 3 phase 1) Immediate phase occurs as a result of overwhelming injury 2) Intermediate or sub-acute phase involves deaths occurring within several hours of the event and are potentially treatable. 3) Delayed phase when deaths often occur days or weeks after the initial injury. Injury accounts for 16% of the global burden of disease. As one of the leading causes of mortality and morbidity worldwide, it overwhelmingly affects low and middle income countries. Evidence has shown that deaths are prevented and disability averted for conditions such as trauma, pregnancy, myocardial infarction, stroke and sepsis by upgrading the emergency services. Besides the metropolitan city of Delhi ,Mumbai, Kolkata and Chennai ambulances in most part of our country , where they exist, have barely a comfortable gurney and arrangements for oxygen supply. As a result, the public does not perceive EMS asmedical care providers. People view it only as transportation

with sirens. Such vehicles do not reach the hospital earlier due to multiple reasons such as distance, traffic jams and poor public cooperation. Therefore many victims die a preventable death at the scene or during the first few hours following injury. Those making decisions at the critical moment on the site of the emergency are seldom aware of the factors one should keep in mind when taking affected person to a hospital. Selection of a good ambulance service has a key role in the disease outcome of the patient. However recent developments in the evolution of ambulance services have lead to introduction of quality indicators in these services in the local setting. Among the systematic and clinical quality indicators, prompt response, availability of life saving drugs and oxygen, equipment such as intravenous catheters, electrocardiogram and glucometers are important. Training and education of the ambulance personnel including continuous training in advance life support is important. Cost is one aspect which cannot be ignored. The cost of running such services is high which has to be paid by the consumer. The Challenge is to promote sustainable and affordable prehospital care Systems that provide services to everyone. To do this, each system must be defined by local needs and capacity and must be developed according to local culture and health-care capacity. CPR - Summary of main changes 2012 A cardiac arrest is the ultimate medical emergency

treatment must be given immediately if the patient is to have any chance of surviving. The interventions that contribute to a successful outcome after a cardiac arrest can be conceptualized as a chain the Chain of Survival. Adult Basic Life Support The following changes in the basic life support (BLS) guidelines have been made to reflect the importance placed on chest compression, particularly good quality compressions, and to attempt to reduce the number and duration of pauses during chest compression: ? ? When obtaining help, ask for an automated external defibrillator (AED), if one is available. ? ? Compress the chest to a depth of 5-6 cm and at a rate of 100-120 min-1. ? ? Do not stop to check the victim or discontinue CPR unless the victim starts to show signs of regaining consciousness, such as coughing, opening his eyes, speaking, or moving purposefully AND starts to breathe normally. ? ? Teach CPR to laypeople with an emphasis on chest compression, but include ventilation as the standard, particularly for those with a duty of care. LNJP doctors beaten up, go on strike New Delhi, Sun Apr 22 2012 Services were disrupted for a few hours at Central Delhi’s LNJP hospital after the resid- ent doctors went on strike late on Friday night. The doctors decided to go on strike after attendants of a 16-year-old patient allegedly beat them up while they were trying to revive the girl

Evidence based practice: Chest Ultrasound is superior to X-rays for differentiation of CHF from COPD


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You shouldn’t take your chest pain to your Doctor’s office, because time is muscle. Chest pain is often an indicator of a heart attack. Even when it's not a heart attack, telling the difference will require some sophisticated equipment not readily available at a typical doctor's office. Chest pain is one of a few medical complaints that almost always needs emergency medical care, and should never be initially seen at a doctor's office. Heart attacks deprive the heart muscle of needed blood and oxygen. They are usually caused by a blood clot in an artery already clogged with cholesterol deposits. Since the blood clot blocks blood flow to the heart, muscle tissue (which can't stop beating to save energy because the heart is an essential organ) begins to starve. Eventually, the heart muscle will die. Time is Muscle The time it takes for the heart muscle to die is different for everyone. It depends on several factors, not the least of which is the size of the clogged artery and the area of the heart being deprived of oxygen. The bigger the blocked artery, the faster the damage occursatastrophic events that may happen, like cardiac arrest - a very real risk during a heart attack. Hospitals measure success by how fast heart attack patients get treatment once they walk in the door. Doctors' offices aren't generally as efficient. It takes some specialized equipment to properly assess a potential heart attack, and most doctors are not equipped to handle these true medical emergencies. Besides the technological differences, individual doctors

- especially general or family practitioners - just don't see enough heart attacks happening in front of them to always react appropriately. Even among emergency departments, those that see more patients do a better job of iemergency departments, those that see more patients do a better job of identifyiifying heart attacks.

providers - and depending on where you live, additional first responders - addressing your chest pain in less than 10 minutes. That's much better than driving to, and waiting in, the emergency department. A Head Start

In most of the United States, ambulances that respond to 911 calls are trained and equipped to handle many of the things a One thing is certain in all heart potential heart attack victim attacks: time is muscle. The needs, all before ever reaching more time wasted before the hospital. getting treated, the more heart muscle is destroyed, which is Most ambulances don't do a why emergency departments diagnostic ECG yet (although have protocols to follow for that's changing rapidly), and of p a t i e n t s w h o c o m e i n course, ambulances can't perform surgery. With those complaining of chest pain. exceptions, a paramedic on an Getting There ambulance can start IV lines; Now that we've established the give oxygen, nitroglycerin, need for treatment in an morphine, and aspirin. As well, emergency department for all a paramedic will monitor your potential heart attack victims heart on the way to the hospital (which includes anyone with and is available to treat chest pain), let's talk about how catastrophic eveart on the way to get there. to the hospital and is available Walking into a crowded to treat catastrophic events emergency department waiting thatthat may happen, like room means you have to fill out cardiac arrest - a very real risk a form and wait your turn to be during a heart attack. evaluated. There will be a nurse Start at the Beginning - Not in the waiting room to do an the Middle assessment, and that nurse will almost certainly recognize the As emergency medicine signs and symptoms of a heart evolves, so does the team that attack once he or she gets to performs it. Systems and you, but until then, you'll wait Protocols are developed to on a first-come, first-served Address specific, common b a s i s . emergencies like heart attacks. These protocols have definite Time is muscle. entry points where patients get On the other hand, calling 911 the best outcome.Entering the will get you an ambulance. chest pain protocol at the C u r r e n t l y, t h e n a t i o n a l beginning, in your house with standard for ambulance ambulance By calling 911, response times in metropolitan you'll have at paramedics,has a areas is less than 10 better chance of success than minutes.least two emergency delaying care by going to a

doctor's office incapable of treating you. When treating heart attacks, speed and efficiency are essential. With no ambulance available, Indian footballer dies of cardiac arrest on pitch Bangalore, Mar 22(ANI): An Indian footballer, D Venkatesh, who plays for Bangalore Mars, has died following a cardiac arrest during a Bangalore District Football Association 'A' Division match at the Bangalore Football Stadium. According to local media reports, there was no ambulance available at the ground, and his team-mates hired a tuk-tuk (an autorickshaw) to take him to a local hospital where Venkatesh was declared brought dead.

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CPR chart

Cardio Pulmonary R escu scitation

D Ch eck for d an ger

o r o th e r h a zard s Che c k for da nge r eg el ectr ica l co rd s, p e tr o l

R Re spo ns ive

C he ck f or re s pons ivene s s If no sign s o f lif e: > U nc onsci ous > U nr esp o nsi ve > N ot bre a thing n or ma lly

S H OU T F O R H E LP !

> G e t so m eon e to dial Triple Ze ro ( 000 ) im m ed iately > DIAL A sk foYOUR r AM BULOCAL LANC E AMBULANCE SERVICE PROVIDER TEL. NO

A C lear a irw ay

> P la ce p e rso n on their b a ck > T ilt h ead b ack (n o t for in fants o r in ju re d) > R em o ve fore ig n ma tte r from m outh (a n d nose o f b aby) > P la ce o n sid e if th er e is a l ot of fo re ig n m atte r

B C heck b rea th ing

> L o ok , liste n a n d fe el fo r b re ath in g > If norm a l b re a thing is pre sent leave o r p la ce patie nt o n their si de > If norm a l b re a thing is a bs en t co m m e nce CP R 2 bre at hs t o 3 0 c om press ions a t 1 0 0 c om pre s sion s/m in – P la ce p atie n t o n th ei r b ac k – Til t h e ad back (n ot fo r infa n ts or in ju red) – L ift ja w a nd p in ch n os tr ils

C C irculation (at 100 compressions/m in)

CH IL D & ADULT: > P la ce h and s ove r th e ce n tr e o f th e ch e st (s te r num) . > Co m pr ess s te r num o n e th ird th e d e pth o f the ch es t 30 tim e s > Con tinue w ith 2 bre at hs t o 3 0 c om pre ssions > Do n ot inte rr upt co m pre ssi ons fo r m o re th a n 1 0 se co n ds INFANT: > P osi ti on 2 finge rs o n l owe r half of th e s te r num > De p ress ste rn um a ppro xim ate ly one third t he de pth o f the c he st > Con tinue w ith 2 bre at hs t o 30 c om pre ssions

D Defibrilla tion

If A u to ma te d Exte rn a l D efib ri lla tor (AED) is a va ila bl e

CO N TIN U E C PR UN TIL PAR A M EDIC S A R R IVE OR SIG N S OF LIFE R ETU R N Beware of rescuer fatigue, if help is available swap rescuers every few minutes Th is c ha rt is not a s ub stitute fo r atten ding a firs t aid co urse . L EA RN C PR NO W !

T his C PR chart is provided free of For enquiries about this c hart: his chart Kumar conforms to the Editor : TSatish Bhardwaj A us tral ian Res usc itation e and mus t not be sold. The Am bulanc e Serv ice of NSW Ownercc harg : Satish Kumar Bhardwaj Printed and Published by : Satish Kumar Bhardwaj Counc il’s guidel ines on hart is av ailable to download Lock ed Bag 105 tiv e C PR as at S eptem reproductions Pvt.ber Ltd. Printed at : Intergraphiceffec from the Am bulance webs ite at: R ozelle, NSW 2039 2011. F or more inform ation w ww.am bulanc e.nsA w.gov.au. Tel: (02) 9320 7796 v is it: w .resDelhi us.org.au-110020 11 DDA Sheds, Okhla Industrial area, Ph 1ww New

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