Year of issue: 2007
Genre: Therapy
Format: PDF
Quality: Scanned pages
Description: The need for this publication "Guide to Emergency medical care" is due to the fact that most of the available publications are devoted to the issues of emergency treatment of acute and critical conditions as such, regardless of the conditions of assistance. They do not focus on the tactics of managing patients specifically at the prehospital stage, “on call.” National leadership emergency medical care has a number of features.
1. Versatility and practical orientation: the book is a practical guide for both the doctor and the EMS paramedic; it supports making informed clinical decisions when providing emergency care.
2. Focus on the real conditions of providing emergency medical care at the prehospital stage.
3. Applicability of the recommendation in real practice. At the same time, the recommendations provided serve as a standard of care, the implementation of which ensures the highest quality medical care.
4. Recommendations for the selection of diagnostic and therapeutic interventions are based on modern clinical guidelines and benign clinical studies (in other words, based on evidence-based medicine).
5. Ease of use; simplicity, clarity and clarity in the construction and presentation of material, the presence of diagnostic and treatment algorithms.
Many Russian specialists from Moscow, St. Petersburg, Samara, Nizhny Novgorod. Experts from Moscow, Vladimir and Khabarovsk acted as reviewers. The preparation of the manual was coordinated by specialized research institutions: Institute of Emergency Medicine named after. N.V. Sklifosovsky (Moscow) and the Institute of Emergency Medicine named after. I.I. Dzhanelidze (St. Petersburg), whose employees are also represented in the team of authors and editors. The publication was prepared under the auspices of the National Scientific and Practical Society of Emergency Care and the Russian Society of Emergency Medical Care, as well as the Association of Medical Societies for Quality - a professional public organization aimed at improving the quality of medical care and medical education. Thus, the national leadership reflects the united position of leading domestic experts on diagnostics and treatment emergency conditions.
Organization and current state Emergency medical services in the Russian Federation
Primary cardiopulmonary resuscitation
Emergency conditions for diseases of cardio-vascular system
Sudden cardiac death
Chest pain
Angina pectoris
Acute coronary syndrome
Acute heart failure
Cardiogenic shock
Violations heart rate and conductivity
Hypertensive crisis
Acute venous thrombosis
Pulmonary embolism
Dissection and rupture of aortic aneurysm
Emergency conditions for respiratory diseases
Acute respiratory failure
Pneumonia
Bronchial asthma
Pneumothorax
Hemoptysis
Emergency conditions for diseases of the nervous system
Acute cerebrovascular accidents
Coma
Epileptic seizure, status epilepticus
Headache
Vertebrogenic pain syndrome
Fainting
Vegetative crises
Meningitis
Encephalitis and meningoencephalitis
Emergency conditions for diseases of the abdominal organs
Acute abdominal pain
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Gastrointestinal bleeding
Perforated ulcer of the stomach and duodenum
Acute intestinal obstruction
Strangulated hernia
Emergency conditions for diseases of the urinary system
Acute pyelonephritis
Acute urinary retention
Anuria
Renal colic
Hematuria
Emergency conditions in ophthalmology
Acute diseases of the organ of vision
Acute diseases of the eyelids
"Red eye" (without pain)
"Red eye" (with pain syndrome)
Acute attack of glaucoma
Damage to the organ of vision
Eye burns
Electroophthalmia
Sudden loss of vision
Emergency conditions in otorhinolaryngology
Nose bleed
Emergency conditions in dentistry
Acute toothache
Bleeding from a tooth socket
Emergency conditions for infectious diseases
Fever
Acute diarrhea
Nausea and vomiting
Jaundice
Acute allergic diseases
Allergic rhinitis, allergic conjunctivitis, urticaria, Quincke's edema
Anaphylactic shock
Traumatology
Traumatic brain injury
Spine and spinal cord injury
Traumatic shock
Hemorrhagic shock
Damage to the musculoskeletal system
Chest injury
Chest wounds
Abdominal injuries
Combined, multiple and combined injuries
Burns
Cold injury
Electrical injury
Drowning
Foreign bodies in the respiratory tract
Traumatic asphyxia
Strangulation asphyxia
Emergency conditions in psychiatry and narcology
General principles of emergency care
Acute psychotic states
Psychomotor agitation and aggressiveness
States of altered consciousness
Delirium
Twilight consciousness disorder
Amentia
Oneiroid
Suicidal behavior
Refusal to eat and drink
Inability to perform self-care skills
Alcohol intoxication
Alcohol withdrawal syndrome
Alcoholic psychoses
Alcohol delirium
Opioid withdrawal syndrome
Heavy side effects psychopharmacotherapy
Poisoning
Diagnosis and principles of care for acute poisoning at the prehospital stage
Clinical picture and treatment acute poisoning at the prehospital stage
Emergency conditions in obstetrics and gynecology
Dysfunctional uterine bleeding
Bleeding from injuries and malignant tumors genitals
Obstetric bleeding
Acute abdomen in gynecology
Toxicosis and gestosis in pregnant women
Childbirth
Emergency conditions in children
Principles of providing emergency medical care to children
Features of tactics when providing emergency medical care to children
Diagnosis of emergency conditions
Routes of drug administration
Infusion therapy in children at the prehospital stage
Basics of primary resuscitation care
Cardiopulmonary resuscitation in children over 14 years of age
Features of cardiopulmonary resuscitation in children under 14 years of age
Syndrome sudden death children
Emergency care for major pathological conditions in pediatrics
Fainting
Collapse
Shock
Pulmonary edema
Attack of paroxysmal tachycardia
Acute stenosing laryngotracheitis
Convulsive syndrome
Brain edema
Comatose states in children
Headache in children
Migraine in children
Tension headache
Infectious fever
Pneumonia in children
Otitis media
Bronchial asthma in children
Exicosis
Regurgitation and vomiting in children
Emergency conditions for diabetes mellitus
Diabetic ketonemic coma
Diabetic hyperosmolar coma
Hyperlactic acidemic diabetic coma
Hypoglycemic conditions
Emergency assistance for infectious diseases in children
Acute intestinal infections in children
Meningococcal infection
Infectious-toxic shock
Edema-swelling of the brain
Diphtheria
Acute respiratory diseases
Acute respiratory viral infection and influenza
Sinusitis
Acute tonsillitis
Bronchitis
Simple bronchitis
Obstructive bronchitis/bronchiolitis
Acute (surgical) diseases of the abdominal cavity
Acute appendicitis
Acute intussusception
Acute pancreatitis
Acute gastrointestinal bleeding
Emergency measures for extreme conditions in children
Traumatic brain injury
Burn injury
Accidents
Drowning
Hypothermia
Heatstroke (sunstroke)
Overheating in children under 1 year of age
Foreign bodies in the respiratory tract
Poisoning in childhood
Child Abuse Syndrome
Medicines
Subject index
Contents of the CD
Regulatory support
Emergency Medical Services Standards
Medicines
International Classification of Diseases X Revision
Glossary of ambulance service terms
Necessary minimum of modern equipment for mobile ambulance teams
List of necessary medications and equipment for emergency medical services th help for children
LITERATURE
http://www.bestmedbook.com/
Organization and condition of the emergency medical service
HISTORY AND CURRENT STATE OF EMS SERVICE IN RUSSIA
For thousands of years, humanity has accumulated experience in providing urgent help people who suddenly fell ill or suffered from accidents at home, at work, in countless wars and disasters, before realizing the need to organize emergency medical care in its modern forms.
IN In Russia, the first SMP stations were opened in Moscow on April 28, 1898 at the Sushchevsky and Sretensky police stations. They were equipped with one carriage containing medicines, instruments and dressings. Each carriage was staffed by a doctor, a paramedic and an orderly. The duty began at 3 o'clock in the afternoon and ended at the same time the next day. The first report on the two-month operation of two EMS stations indicated that they carried out 82 calls and 12 transports, which took 64 hours and 32 minutes.
IN May 1908, at the suggestion of Moscow University professor P.I. Dyakov, the founding meeting of the Voluntary Society of SMP was held with the involvement of private capital. The society's goal was to provide free medical care to victims of accidents. This is how the history of the development of modern EMS service in Russia began.
IN Currently, EMS in the Russian Federation is a socially significant service and one of the most widespread types of medical care. The EMS service is part primary care healthcare system and is represented by institutions (stations, departments, hospitals, institutes of emergency medical services) organized by the authorities of the constituent entities of the Russian Federation to provide emergency medical care to adults and children in case of emergency conditions at the prehospital stage by mobile emergency medical services teams, regardless of the location of the incident (disease).
It should be noted that the EMS service in Russia is focused not only on simple transportation of the patient to the hospital and maintaining vital functions, but also on comprehensive and effective provision of assistance in emergency situations at the prehospital stage.
IN In the Russian Federation, the provision of emergency medical services is carried out by 3,268 stations and emergency medical services departments and 47 emergency hospitals with a capacity of 27,915 beds. The main resources of the EMS are: 12,490 general-profile teams (30% of the total
2 ■ Chapter 1
number of brigades), 5380 specialized brigades (13%), 1873 brigades intensive care(3%) and 22,233 paramedic teams (53%).
As of mid-2006, the EMS service employs 18,000 doctors and 90,000 paramedics. The staffing of the service with doctors and paramedics is 88.3% and 96.9%, respectively.
Over the past 10 years, the number of emergency calls has increased by 30%. In 2004, about 50 million calls were made in Russia, 52.5 million citizens were served, and more than 8 million people were hospitalized.
In the structure of calls (based on materials from the Ekaterinburg EMS station), the ratio of calls for: sudden illnesses (71.6–72.9%) and accidents and injuries (9.4–9.7%) remains stable; transportation - 10.7%; calls to apartments (88.2–89.4%) and streets (4.2–5.6%); to children (11.6–12.3%). Among nosological forms, calls to patients with cardiovascular diseases (18.4%) and with acute neurological pathology (13.3%) invariably have the highest share (both within the region and in the city).
BASIC CONCEPTS
Emergency condition- suddenly arisen pathological change functions of the human body that threatens his life, health or those around him. Emergency conditions are classified as follows.
■ Life-threatening conditions are pathological conditions characterized by disruption of vital important functions(circulation and respiration).
■ Conditions that threaten health are pathological conditions with high risk development of violations of vital functions or capable of causing persistent health problems that may occur in the absence of medical care in the near future.
■ Conditions that require urgent medical intervention in the interests of others due to the patient’s behavior.
Childbirth is considered a special type of emergency. In essence, childbirth is a physiological act and can be resolved without emergency medical intervention. At the same time, due to a certain risk of complications, including life-threatening ones, it is necessary to classify childbirth as an emergency and include it in the scope of emergency medical services. It is this approach that is legislatively enshrined in the Program of State Guarantees for Providing Free Medical Care to Russian Citizens.
The main causes of medical emergencies are listed below.
■ Acute diseases.
■ Exacerbations of chronic diseases.
■ Injuries.
■ Poisoning.
■ EMS (syn. emergency medical care) as a type of medical care - a complex of services carried out without delay therapeutic, diagnostic and tactical measures aimed at eliminating a sudden pathological condition that threatens the life and health of a person (emergency condition) or those around him at all stages of treatment.
Organization and condition of the emergency medical service ■ 3
■ EMS as a system is a set of standards, structures and interaction mechanisms that ensure the provision of EMS, its scientific and methodological support and personnel training. The definition of the SMP as a system has a broader interpretation, characterizing all its components, i.e. the term “EMS system” implies both the provision of emergency medical care at all its stages, and scientific and methodological support, and training of specialists, and therefore includes, along with emergency medical services (stations, departments) and emergency hospitals, specialized research institutes (at
Research Institute of Emergency Medicine named after. N.V. Sklifosovsky and Research Institute of Emergency Medicine named after. I.I. Dzhanelidze), training centers for emergency medical services specialists and disaster medicine centers.
The EMS hospital is a hospital-type treatment and preventive institution that includes an EMS department.
The EMS service interacts with hospitals various types providing emergency medical care. Patients can be delivered by ambulance teams to municipal, district, regional (regional, republican) hospitals, emergency medical institutions and specialized scientific and practical institutions.
Pre-hospital stage EMS is the provision of emergency medical care outside a medical institution.
Basic principles of providing emergency medical services.
■ The urgent nature of the provision of emergency medical care, due to a violation of the vital functions of the patient (victim) or a high risk of their development due to the rapid progression of the pathological condition in the absence of adequate treatment.
■ Trouble-free provision of emergency medical services in emergency conditions. Every citizen, regardless of social, national, cultural, religious and other characteristics, who contacts the EMS service and needs urgent medical intervention has the right to receive free emergency medical care in accordance with the standards of medical care. However, the patient has the right to refuse medical care.
■ Free assistance for patients (injured) in emergency conditions.
■ State regulation presupposes the responsibility of authorities
executive power for organizing the uninterrupted provision of emergency services. The scope of emergency medical care is a set of urgent treatment and diagnostic measures aimed at eliminating the emergency condition. Depending on the conditions for providing assistance, determined by the stage of its provision, the availability of special medical equipment and personnel, according to
power can be exerted in the following volumes.
■ First aid for sick and injured people in the form of self-help and mutual assistance.
■ Medical care is assistance provided by medical professionals.
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First medical aid is assistance provided by a medical professional in the absence of conditions for the provision of qualified assistance.
Qualified medical care is sufficient medical care provided by a medical worker with basic education in the required profile, in appropriate conditions and using appropriate equipment.
Specialized medical care is comprehensive medical care provided by a doctor with additional education (in addition to basic education), in appropriate conditions and using appropriate equipment. Providing activities to provide specialized (sanitary and aviation)
Emergency medical services for medical reasons are carried out by treatment and preventive institutions of a constituent entity of the Russian Federation.
The list of minimum necessary therapeutic and diagnostic measures for each volume of emergency medical care is regulated by relevant standards (protocols). Depending on the operational situation, the scope of emergency medical services may be incomplete, which is determined by the relevant regulatory documents.
Algorithm for emergency medical care - sequence of necessarytherapeutic and diagnosticactivities in typical clinical situations, corresponding to the stage and scope of emergency medical care.
Emergency medical care tactics - means and methods used for timely and effective provision of emergency medical care at all its stages. At the prehospital stage right choice tactics allows in each individual case, taking into account the specific situation, to ensure the most accurate achievement of the goal: timeliness and efficiency of emergency medical care, safety of transportation to the hospital or continuity of observation and treatment of the patient at home. Unlike other services in health care, wherediagnostic and treatmentthe process is based on the stages of its provision (diagnosis, and then management tactics); in the conditions of providing emergency medical care, tactics acquire paramount importance. This is due to the specificity of the service, conditions where it is difficult to diagnose (disasters, criminal circumstances), and there is no opportunity to obtain clinical information about the patient and his illness (providing assistance on the street, etc.). EMS tactics should also include a preventive component - preventing possible life-threatening conditions and other critical situations, ensuring safety for both the patient and others and medical personnel.
OPERATING MODES AND ORGANIZATION OF EMS SERVICE
The EMS service operates in daily work mode and in emergency situations and performs the following main tasks.
■ During daily work.
Organization and provision of ambulance and emergency medical care to citizens in conditions requiring urgent medical intervention, both at the scene of an incident and during transport.
Organization and condition of the emergency medical service ■ 5
hospitalization in an adequate volume according to indications, in accordance with the profile of the team.
Carrying out systematic work to improve the professional knowledge and practical skills of medical personnel.
Development and improvement of organizational forms and methods of providing emergency medical services to the population, introduction of modern medical technologies, improving and monitoring the quality of work of medical personnel.
Ensuring continuity in work with the city’s medical institutions to provide emergency medical care to the population.
Carrying out measures to prepare for work in emergency situations, ensuring a constant minimum supply dressings and LS.
■ In an emergency situation (mobile teams of specialized emergency medical services, regardless of their type and profile, perform the functions of specialized teams of constant readiness).
The EMS station operates at the direction of the Territorial Center for Disaster Medicine [republican within the Russian Federation, regional, regional, district, city (Moscow and St. Petersburg)], which is guided by the documents of the headquarters (department, committee) for civil defense and emergency matters situations.
Sends mobile ambulance teams to the emergency zone in accordance with the work plan to eliminate the health consequences of emergency situations.
Conducts medical and evacuation measures for victims during emergency situations.
The entire system of organizing and providing emergency medical services consists of two interconnected stages.
■ prehospital (EMS station);
■ hospital (hospitals of various levels). There are 3 levels in the organization of EMS work.
■ Single-level (paramedic) in rural areas.
■ 2-level (mixed) in medium-sized cities (medical team and paramedic team).
■ 3-level (mixed) in large cities (medical team, specialized medical team and paramedic team).
In addition, it is necessary to separate functions between EMS stations and clinics in order not to overload EMS stations with non-core calls for non-life-threatening diseases. There are two principles for this division.
■ Based on determining the severity of the reason for calling (life-threatening, non-life-threatening disease).
■ Based on the location of the incident (street, apartment). The most common (almost universal) form of separation
functions between emergency medical services stations and outpatient clinics in serving patients in the Russian Federation is the structure of the work of these institutions on the principle of determining the severity of the occasion. Taking this into account, the organization of medical care for patients with acute and chronic, but non-life-threatening diseases is entrusted to the clinic.
6 ■ Chapter 1
There, “extended care at home” points are being created (the former outdated name “emergency care points”). This system The provision of EMS has taken root and EMS stations have been operating through it both in rural areas and in medium-sized and large cities for more than 80 years.
A more rare form of division of functions (existing, for example, in St. Petersburg) is one in which an ambulance team goes to provide assistance in case of life-threatening diseases, regardless of the location of the incident, and an emergency team from a clinic is sent to handle calls to apartments.
The EMS service can be organized according to the following principles.
■ Geographically: urban SMP stations and rural areas, SMP branches.
■ According to the principle of relationship with hospitals and the type of administrative management (and financing): independent emergency medical services stations and united ones (operating as part of hospitals as divisions) in cities with multidisciplinary hospitals, and in rural areas - as part of the central district hospital.
■ According to the principle of providing ambulance “at the scene of the incident” with the organization of a parallel emergency medical service at clinics (with the division, as indicated above, of functions between pre-hospital services): street - emergency medical care, apartment - emergency medical care.
■ According to the principle of providing emergency assistance according to the “severity of the occasion”, regardless of the location of the incident (without creating an emergency medical service), using the forces and means of only the emergency medical service.
■ Based on the principle of departmental affiliation and financing and (or) division into state and non-state EMS services.
Currently, the existence of the EMS service is provided in two versions (Order of the Ministry of Health and Social Development of the Russian Federation of November 1, 2004 No. 179).
■ In settlements with a population of up to 50,000 people, emergency medical services departments are organized as part of city, central district and other hospitals. This is all the more appropriate if there is one hospital in a locality and its chief physician holds the position of head of health care for this locality or rural area.
■ In other cases, independent
NSR stations.
An emergency medical service station is a state or municipal health care institution designed to provide emergency medical care at the prehospital stage by mobile teams and has the necessary forces and means for this.
The EMS station must include: an operational department (control room) (for receiving calls), a communications department (for interaction between the station and field EMS teams), a department medical statistics with an archive, an office for receiving outpatients, a room for storing medical equipment for ambulance teams and preparing for work medical styling, a room for storing drugs, equipped with fire and security alarms, rest rooms for doctors, paramedical personnel, ambulance drivers
Organization and condition of the emergency medical service ■ 7
of cars, a room for meals for staff on duty, administrative and other premises, a garage, covered parking boxes, a fenced area with a hard surface for parking, corresponding in size to the maximum number of cars operating simultaneously. An emergency medical service vehicle must be systematically subjected to disinfection treatment, and in cases where an infectious patient is transported by transport at an emergency medical service station, the vehicle is subject to mandatory disinfection in the prescribed manner. If necessary, equip helipads.
IN Depending on the size of the station, its structure is formed in accordance with local conditions, and the staffing schedule is approved by the local health authority. NSR stations are equipped with ambulance transport, communication and control equipment, seasonal uniforms and footwear and other equipment logistics in accordance with standards.
IN in cities with a population of more than 100,000 people, taking into account the length of the settlement and the terrain, SMP substations are organized (as structural subdivision stations) with calculation 20-minute transport accessibility. Substation service areas are established depending on the number, density, development features, and area saturation industrial enterprises, condition of transport routes, traffic intensity. The boundaries of the service area are conditional, since mobile substation teams can be sent, if necessary, to the areas of activity of other substations.
The structure of the NSR station may look like this.
Rice. 1-1. Approximate structure of an emergency medical service station.
8 ■ Chapter 1
In Fig. Figure 1-1 shows a diagram of a large NSR station. It is desirable to operate a territorial disaster medicine center as part of an emergency medical service station. The expediency of such a structure is due to the following circumstances.
■ When an emergency occurs, the first signal is usually sent to the EMS station.
■ The territorial center for disaster medicine has all mobile emergency medical services teams at its disposal.
■ The maneuver is optimized by mobile teams with the help of the station’s operations department.
■ Facilitates training and response planning medical consequences emergency.
■ There is no need to spend on maintaining separate visiting teams of the territorial disaster medicine center.
The most important element in managing the operation of the EMS station is the operations department.
Operations department (control room) The EMS station provides round-the-clock centralized reception of requests (calls) from the population, timely dispatch of mobile EMS teams, operational management and control over their work, organization of EMS depending on the current operational situation.
Main functions of the operations department.
Receiving calls from the public.
Submitting calls for execution.
Operational management of field teams.
Exchange of information with substations on operational issues.
Interaction with duty services of the city (rural area): police, traffic police, fire department, Ministry of Emergency Situations, etc.
Urgent information from the station management about emergency and conflict situations.
Information about emergency situations of authorities determined by state health authorities.
Providing reference information to the population.
The main elements of the structure of the operational department.
Call reception department.
Direction department.
Hospitalization department.
Information and reference department.
The size of the EMS station determines the structure of the operational department - from a single round-the-clock post of a paramedic (nurse) for receiving and transmitting calls from the population to a large operational department, the work of which during the day is headed by a senior doctor on duty and his assistant doctors. If there are several hospitals in the city, a hospitalization department is also created, which keeps track of the bed capacity and ensures uniform delivery of patients to hospitals in accordance with the availability of available beds, the profile of the hospital and the location of the patient. To ensure emergency hospitalization
Organization and condition of the emergency medical service ■ 9
A 24-hour control post is being introduced, manned by a paramedic or a doctor-evacuator (depending on the complexity of the work).
Calls are received by a paramedic. The algorithm of his actions is defined in the job description.
Basic actions of the dispatcher when receiving a call.
■ Listen to the citizen who contacted “03”.
■ Resolve the issue of receiving the call in accordance with the instructions.
■ If it is difficult to make a decision, switch the telephone line to a senior doctor.
■ If you decide to accept the call, record the following data:
address and telephone;
last name, first name and patronymic, age of the patient;
name and telephone number of the caller, relationship to the patient;
What's happened?
■ Based on the response received, formulate the reason for the call (when working manually). When an automated call processing system operates, the reason for the call is generated by a computer program.
■ Submit the data to the referral department.
The direction department carries out:
transferring calls to field teams through a substation or directly by telephone or radio;
decision on the profile of the team sent to the call;
communication between the mobile team and the doctor (paramedic) of the tow truck;
receiving reports from field teams on calls;
collecting information on the staffing and personnel of visiting teams and on the entry of vehicles onto the line;
control of the operational work of field teams.
IN Depending on the capabilities of the EMS station, call processing can be carried out manually or based on an automated system.
■ All workstations in the operations department (control room) must be
computerized, equipped with tools for recording conversations and automatic telephone number identification.
■ In the operational department (control room), a single personalized database of patients who applied for emergency medical services should be formed.
■ Reception of calls and their transfer to field teams is carried out by a paramedic (nurse) for receiving and transferring calls
operational department (control room) of the EMS station.
Emergency medical service stations provide verbal information when contacting the population in person or by telephone about the location of sick and injured people, and if necessary, issue certificates of any form indicating the date, time of application, diagnosis, examination performed, and medical care provided.
Main structural unit EMS stations (departments) are a mobile team that directly provides emergency medical care to the sick and injured. The work of mobile teams is provided by various divisions of the station.
20 ■ Chapter 1
A simpler and more understandable definition of ILC is when they do what is needed, when needed and how needed.
Quality management of medical care is aimed at obtaining the maximum possible, taking into account the current level of knowledge, results of activities to improve the health of the population with the minimum necessary (optimal) expenditure of resources.
The criteria for assessing the ILC are:
■ accessibility;
■ adequacy;
■ continuity;
■ effectiveness;
■ efficiency;
■ patient focus;
■ safety;
■ timeliness.
Over the past decades clinical medicine became not only a subject of medical art, but also turned into a complex production technology with many specific technological processes. In this regard, in the healthcare of developed countries over the past 20 years, a model for managing the quality of medical care used in high-tech production has been used. This model was named industrial model of medical care quality management.
The introduction of such a model in healthcare management in developed countries has made it possible to increase the life expectancy of the population, significantly reduce morbidity and mortality, improve treatment outcomes, and also control the rising cost of medical care. Russian healthcare, including the EMS service, has the opportunity to study and implement this experience in their practice.
The industrial model of medical care quality management provides that a quality product or service is ensured through quality all components of technology. These components are:
■ structure (personnel, equipment, buildings, medicines, materials and others);
■ technological processes;
■ the results obtained.
For many decades, healthcare efforts have focused on creating optimal industry structure rather than managing clinical processes.
A medical technological process is a system of interconnected therapeutic, diagnostic and other activities carried out in order to achieve planned results.
As in high-tech manufacturing, in medicine process management should include the following steps:
■ identification;
Quote by: E.I. Polubentseva, G.E. Ulumbekova, K.I. Saytkulov. Clinical guidelines and quality indicators in the medical care quality management system: Methodological recommendations. – M.: GEOTAR-Media, 2006. – 60 p.
Organization and condition of the emergency medical service ■ 21
■ planning;
■ organization of implementation;
■ performance monitoring (measurement and control);
■ identifying deviations;
■ making changes to improve the process and eliminate deviations.
Establishing control over deviations makes it possible results management.
The process of improving the quality of medical care and, accordingly, the performance of a medical institution is a continuous cycle, and here only systematic activity is effective. Simply measuring outcomes or assessing individual elements of care will not lead to improved outcomes. It is necessary to use the results of measurements and analysis to make changes and continuously improve technologies.
Indicators of quality of medical care
Quality indicators are numerical indicators used to evaluate medical care, indirectly reflecting the quality of its main components: structure, processes and results. The value of quality indicators is expressed as a percentage of threshold (target or acceptable) values. The development and implementation of quality indicators is a methodologically complex process, but their use makes it possible to identify problematic issues and technology violations at various levels: in the activities of doctors, institutions and the industry as a whole. Analysis of these indicators allows us to develop ways to improve the quality of medical care.
IN Quality indicators for the EMS service are currently being developed and the possibilities of their implementation are being studied.
IN clinical practice for organizing medical technological process and their management currently use a number of tools, among which the most famous areclinical guidelines And .
Clinical guidelines is a systematically developed document containing information on the prevention, diagnosis, treatment of specific diseases and syndromes and helping the doctor make the right clinical decisions. Systematically developed - means that CDs are created according to a certain methodology, which guarantees their modernity, reliability, generalization of the best world experience and knowledge, applicability in practice and ease of use. CDs contain information about the effectiveness of diagnostic and treatment measures. Judgment of effectiveness is based on strict scientific evidence or on the opinion of experts. Efficiency medical interventions included in the Kyrgyz Republic must be substantiated by independent sources of information.
22 ■ Chapter 1
Standards of medical care, operating in the Russian Federation and approved by healthcare authorities, determine the recommended minimum amount of medical care and treatment periods. These documents are used for economic calculations, but not as guidelines for patient management.
Based on the Kyrgyz Republic and in accordance with their personnel and material capabilities, medical institutions at various levels can create patient management plans (protocols) with an established disease. Their implementation makes it possible to reduce treatment costs due to cost optimization, increase patient safety, reduce the incidence of complications and shorten treatment time.
PROFESSIONAL SOCIETIES OF EMS SPECIALISTS
The first professional societies of emergency medical technicians were formed back in 1908. Currently, there are both territorial societies and associations, and societies operating throughout the country.
National Scientific and Practical Society of Emergency Medical Services
On September 15, 2000, doctor at the Moscow EMS station L.G. Abashkina received certificate No. 1 of the National Scientific and Practical Society of SMP (NNPOSMP, President - Prof. A.L. Vertkin), created on the initiative Russian Academy Medical Sciences (RAMS) and Moscow State Medical and Dental University. The society has set itself several main tasks.
■ Creation and dissemination of educational programs that take into account the specifics of EMS work. NNPOSMP regularly organizes on-site regional conferences and other forms of training and information exchange.
■ Organization of clinical trials of drugs (drugs) at the prehospital stage. National The Scientific and Practical Society of Emergency Medicine organized about 20 clinical studies of drugs conducted at more than 150 ambulance stations.
■ Publishing and educational activities. The Society publishes the quarterly magazine “Emergency Therapy” and the monthly magazine “Emergency Doctor”, and has published textbooks for doctors and students on EMS and a manual for paramedics, recommended as teaching aids by the Ministry of Education of the Russian Federation. The Company carries out
An important result of the work of the NNPOSMP was the holding in Moscow in October 2005 I All-Russian Congress EMS doctors and the “Round Table” in the State Duma in December 2005. The final documents of these events state that “in order to ensure the quality of EMS, the Ministry of Health and social development The Russian Federation, in cooperation with relevant public organizations, will finalize and approve standards for the provision of emergency medical care, requirements for the conditions for the implementation of this type medical activities(including requirements for equipping EMS teams, vehicles, work premises), indicators of the quality of EMS provision, uniform forms of accounting documentation for stations (departments)
Organization and condition of the emergency medical service ■ 23
lines, substations) of emergency medicine, unified programs for postgraduate training of doctors and paramedical personnel of emergency medicine, with the involvement of leading departments of emergency medicine, research institutes of emergency care, and public professional organizations.” Creation of domestic standards of medical care and clinical recommendations on the management of patients at the prehospital stage was carried out in close cooperation with other scientific societies of the country, based on the experience of EMS stations, employees of leading universities in Moscow, St. Petersburg, Yekaterinburg, etc.
Society website: http://cito.medcity.ru/
Russian Society of Emergency Medical Care
In June 2004, it was established in St. Petersburg, and in April 2005 it was held state registration at the Ministry of Justice of the Russian Federation public organization- Russian Society of Emergency Medical Care (chairman - Prof. A.L. Miroshnichenko).
ROSP carries out diverse scientific, practical, pedagogical and publishing activities. At the initiative of the society, scientific research is carried out in the field of organization, diagnosis and treatment of emergency conditions at the pre-hospital stage and in the hospital emergency room.
New methods for organizing emergency care and recommendations for providing emergency care are being developed and put into practice. A number of methodological manuals and guidelines for the provision of emergency medical services have been prepared. The society's proposals are used by the Federation Council Committee on Science, Culture, Education, Health and Environment, and the Committee on Health and Sports State Duma Federal Assembly of the Russian Federation.
Scientific and practical conferences, cycles and seminars are held to train EMS service specialists, as well as workers of other services (EMERCOM, police, fire department and etc.).
New medical equipment intended for emergency medical services is being tested. The magazine "Emergency Medical Care" is published.
Website of the society: http://www.emergencyrus.ru/
IN Representatives of both professional societies of emergency medicine, the Institute of Emergency Medicine named after. N.V. Sklifosovsky (Moscow) and the Institute of Emergency Medicine named after. I.I. Janelizde (city) St. Petersburg), employees of other leading scientific and practical institutions of the country.
The common desire of all participants in the publication was to provide EMS professionals with high-quality medical information, reliable practical guidance, and ultimately - improving the quality of emergency medical care for everyone who needs it throughout the Russian Federation.
24 ■ Chapter 2
Primary cardiopulmonary resuscitation
Article “Cardiopulmonary resuscitation in children” " is located in the section " Emergency conditions in pediatrics”, article “Sudden cardiac death” - in the section “Emergency conditions in diseases of the cardiovascular system”.
The measures taken for patients with circulatory and respiratory arrest are based on the concept of the “chain of survival”. It consists of actions performed sequentially at the scene of an incident, during transportation and during medical institution. The most important and vulnerable link is the primary resuscitation complex, since within a few minutes from the moment of circulatory arrest, irreversible changes develop in the brain.
■ Both primary respiratory arrest and primary circulatory arrest are possible.
■ The cause of primary circulatory arrest may be myocardial infarction, arrhythmias, electrolyte disturbances, PE, rupture of aortic aneurysm, etc. There are three options for cessation of cardiac activity: asystole, ventricular fibrillation and electromechanical dissociation.
■ Primary respiratory arrest (foreign bodies in the airways,
electrical trauma, drowning, central nervous system damage, etc.) are detected less frequently. By the time emergency medical care begins, as a rule, ventricular fibrillation or asystole has developed.
Signs of circulatory arrest are listed below.
■ Loss of consciousness.
■ Absence of pulse in the carotid arteries.
■ Stopping breathing.
■ Dilated pupils and lack of reaction to light.
■ Change in skin color.
To confirm cardiac arrest, the presence of the first two signs is sufficient.
Primary resuscitation complex consists of the following activities (Fig. 2-1):
■ restoration of airway patency;
■ Ventilation and oxygenation;
■ indirect cardiac massage.
Primary cardiopulmonary resuscitation ■ 25
Rice. 2-1. Cardiopulmonary resuscitation algorithm.
Specialized resuscitation complex includes the following activities:
■ electrocardiography and defibrillation;
■ providing venous access and drug administration;
■ tracheal intubation.
RESTORATION OF AIRWAY PASSABILITY
Primary cardiopulmonary resuscitation ■ 27
If the airway is obstructed by a foreign body, the victim is placed on his side and given 3–5 sharp blows bottom palms in the interscapular area, then try to remove with a finger foreign body from the oropharynx. If this method is ineffective, then the Heimlich maneuver is performed: the palm of the person providing assistance is placed on the stomach between the navel and the xiphoid process, the second hand is placed on the first and a push is made from the bottom up along the midline, and they also try to remove the foreign body from the oropharynx with their finger (Fig. 2 -3).
Rice. 2-3. Technique for performing the Heimlich maneuver.
28 ■ Chapter 2
IN Due to the risk of infection of the resuscitator upon contact with the mucous membrane of the mouth and nose, as well as to increase the effectiveness of mechanical ventilation, a number of devices are used (Fig. 2-4, 2-5).
■ “Key of Life” device. ■ Oral airway.
■ Transnasal airway.
■ Pharyngotracheal airway.
■ Double-lumen esophageal-tracheal airway (combitube). ■ Laryngeal mask.
Rice. 2-4. Devices for carrying out artificial ventilation lungs.
Primary cardiopulmonary resuscitation ■ 29
Rice. 2-5. The use of additional devices for artificial ventilation of the lungs.
Management " Ambulance
» is dedicated to the algorithms of actions of paramedical personnel: ambulance paramedics and nurses clinics and emergency departments of hospitals, on whose successful actions in the first hours of the development of the disease a particular prognosis depends.
Traditionally, the nurse and paramedic are the first to begin contact with the patient, promptly resolving the most important issues of diagnosis, obtaining the necessary additional medical information and carrying out emergency procedures. medical manipulations. This requires a detailed understanding of the essence of the emergency condition and what is happening in the body. pathological processes, prognosis, rational and logical treatment plan, recognition of age and social features patient. At the same time, it is necessary to show maximum attention to the patient and those around him, to be tactful, watch his speech, empathize - in a word, observe the principles of medical deontology, to which the authors also devoted many pages.
The book "Emergency Care" briefly outlines the basic concepts and definitions adopted in emergency medicine, the main provisions on the status of a paramedic (nurse), the main types of violations of regulations by emergency medical personnel, the rights and responsibilities of a patient seeking emergency medical care, the main types of responsibility medical workers providing emergency care.
Vertkin A.L.. Ambulance download
What associations arise when you perceive the phrase “emergency care”? Perhaps you represent victims of an accident or a patient urgently hospitalized with bleeding? But this could also be a patient with an acute vascular accident, poisoning with severe intoxication, respiratory failure due to pneumonia or a pregnant woman with a threat of miscarriage. Emergency assistance is needed in a variety of situations and does not depend on the chosen medical specialty. The main thing is to know and be able to determine priorities in providing assistance to victims, guided primarily by the nature of the underlying disease or syndrome requiring emergency medical care and an assessment of the severity of the condition. In this case, the patient must receive the required and guaranteed medical care, regardless of place of residence, social status and age. In case of mass incidents or simultaneous treatment of several patients, the health worker must be able to determine the priority of care. The tasks that a paramedic faces during a call include determining the patient’s need for emergency assistance, the need for therapeutic and diagnostic measures and determining their volume, resolving the issue of the need for hospitalization and confidentiality of information ( medical secrecy) about the patient’s state of health (disease).
Depending on the severity of the condition, there are five levels of medical care:
Level 1 - intensive care, for patients in need of urgent medical supervision. Examples include patients with acute coronary syndrome, stroke, asthmatic condition, etc.
2. level - emergency conditions in which patients need urgent examination and quick assistance, for example, with limb injuries, hyper- and hypothermia, nosebleeds, etc.
3. level - urgent conditions, for example, intoxication or respiratory disorders in a patient with pneumonia, pain syndromes for sprains, etc. In these cases, patients can wait for examination and treatment for 30 minutes.
4. level - less urgent conditions in which medical care may be delayed, such as otitis media, chronic back pain, fever, etc.
5. level - non-urgent conditions that arise when chronic diseases, for example, constipation in older people, menstrual syndrome, etc.
To differentiate these conditions, it is necessary to assess the reason that led to seeking medical help, a detailed questioning and description of the patient’s complaints, familiarization with previous medical documentation, assessment of the effectiveness of previously administered therapy, etc. Ultimately, the solution to the above issues ensures greater efficiency of the friendly work of the doctor and nursing staff. medical personnel when providing emergency medical care.
The team of authors of the book “Emergency Care” is represented by leading specialists from the Moscow State Medical and Dental University, Moscow medical academy them. THEM. Sechenov, Russian State medical university and Samara State Medical University, as well as the ambulance and emergency medical care station named after. V.F. Kapinos of the city of Yekaterinburg, who have been involved in emergency medicine for many years.
The authors will accept all comments from readers with gratitude and understanding.
General principles of work for nurses and ambulance paramedics
1. Collection of information
2. Measuring body temperature in armpit And oral cavity patient
3. Blood pressure measurement
4. Studying the patient’s pulse and recording the temperature readings
5. Performing a cleansing enema
6. Preparation for ultrasound and retrograde cystography
7. Determination of body weight
8. Use an ice pack for the purpose
9. Carrying out measures to prevent bedsores
10. Feeding a seriously ill patient
11. Artificial nutrition patient through gastrostomy
12. Cleansing the external auditory canal
13. Assisting a patient with vomiting
14. Carrying out catheterization Bladder soft catheter in women
15. What is intubation?
16. How to use the anaphylactic kit
17. Gastric lavage
18. Taking urine for general analysis
19. Performing subcutaneous injections
20. Performing intramuscular injections
21. Performing intravenous injections
22. Taking blood from a vein for research
23. Dilution of antibiotics
24. Hand treatment before and after any manipulation
Syndromes and diseases of the cardiovascular system requiring emergency care
1. Ischemic disease hearts
2. Acute coronary syndrome
3. Cardiogenic shock and pulmonary edema
4. Rupture of the papillary muscle
5. Heart rhythm disturbances
6. Pacemaker malfunction
7. Cardiac arrest
8. Tamponade
9. Hypertensive crisis
10. Occlusion of peripheral arteries
11. Ruptured aortic aneurysm
12. Heart bruise
13. Endocarditis
14. Myocarditis
Syndromes and diseases of the respiratory system requiring emergency care
1. Acute respiratory failure
2. Stopping breathing
3. Bronchial asthma
4. Asthmatic status
5. Croup
6. Pulmonary embolism
7. Pneumonia
Gastroenterological syndromes requiring emergency care
1. Nausea and vomiting
2. Acute liver failure and hepatic encephalopathy
3. Acute jaundice
4. Acute diarrhea
Neurological syndromes and neurological emergencies
1. Brain aneurysm and subarachnoid hemorrhage
2. Brain contusion
3. Concussion
4. Epidural hematoma
5. Subdural hematoma
6. Intracerebral hematoma
7. Meningitis
8. Intervertebral disc herniation
Psychiatric syndromes and psychiatric emergencies
1. Anorexia nervosa
2. Bipolar disorder
3. Depression
4. Schizophrenia
Sudden illnesses And acute syndromes in hematology
1. Anticoagulant-induced coagulopathy
2. Idiopathic thrombocytopenia
3. Disseminated intravascular coagulation syndrome
4. Hemophilia
Endocrinological sudden illnesses and acute syndromes
1. Diabetic ketoacidosis
2. Hyperosmolar non-ketoacidotic state
3. Hypoglycemic state and hypoglycemic coma
Sudden diseases and acute syndromes in nephrology
1. Acute glomerulonephritis
2. Acute renal failure
Syndromes and emergencies in acute surgical diseases
1. Thrombophlebitis
2. Closed injury belly
3. Acute pain in a stomach
4. Appendicitis
5. Intestinal infarction
6. Bleeding from the upper gastrointestinal tract
7. Bleeding from esophageal varices
8. Hypovolemic shock
9. Strangulated inguinal hernia
10. Burns
Syndromes and emergencies in acute urological diseases
1. Acute pyelonephritis
2. Acute epididymitis (acute inflammation of the epididymis)
3. Kidney stone. Renal colic
4. Renal vein thrombosis
5. Bladder injury
Syndromes and emergencies in acute gynecological diseases
1. Premature abruption of a normally located placenta
2. Placenta previa
3. Toxicoses
4. Preeclampsia
5. Premature birth
6. Premature rupture of membranes
7. Ectopic pregnancy
Acute conditions due to trauma
1. Examination of trauma patients
2. Chest injury
3. Hemothorax
4. Pneumothorax
5. Compartment syndrome
6. Femoral neck fracture
7. Fracture of long bones
8. Pelvic fracture
9. Osteomyelitis
10. Septic arthritis
11. Sprain
12. Overvoltage
Syndromes and emergencies for diseases of the ear, nose and throat
1. Nosebleed
2. Maxillofacial fracture
3. Acute otitis media
4. Damage to the eardrum
Syndromes and complications in ophthalmology
1. Eye burns
2. Corneal erosion
3. Glaucoma
4. Eye injury
The most common syndromes requiring emergency care
1. Carbon monoxide poisoning
2. Poisoning
3. Septic shock
4. Anaphylactic shock
5. Respiratory acidosis
6. Hypercalcemia
7. Hypokalemia
8. Hyponatremia
9. Metabolic acidosis
10. Metabolic alkalosis
11. Caisson disease
12. Electric shock
13. Hyperthermia
14. Hypothermia
15. Insect bites
16. Animal bites
17. Drowning
18. Radiation exposure
19. Cardiopulmonary resuscitation
Medical deontology
Basic concepts and definitions in emergency medicine
Regulations on the paramedic
Regulations on the paramedic ( nurse) for receiving and transmitting calls to the station (substation, department) of the emergency service
Main types of violations of regulations by emergency medical personnel
Types of responsibility of medical workers
Reasons leading to violation of patient rights by emergency medical personnel
Priority tasks that a paramedic faces during a call
Basic medicines from the arsenal of the average medical worker[b]
Name: National Ambulance Guide
Vertkin A.L.
The year of publishing: 2012
Size: 1.97 MB
Format: pdf
Language: Russian
The practical guide “National Guide to Emergency Care,” edited by A.L. Vertkin, examines the main syndromes and symptoms of emergency conditions in the practice of an emergency physician. Described clinical manifestations cardiovascular pathology, respiratory system, cardiac arrest and other pathological events requiring immediate assistance. Questions stated cardiopulmonary resuscitation, tactics for bleeding, injuries, poisoning, allergies, comas. For medical students, practicing doctors, emergency physicians.
Name: Emergency situations in clinical practice
Frimmel M.
The year of publishing: 2018
Size: 80.66 MB
Format: pdf
Language: Russian
Description: The educational manual “Emergencies in Clinical Practice”, edited by Marcel Frimmel, examines the principles of diagnosis and treatment of emergency conditions that arise in everyday practice... Download the book for free
Name: Emergency endocrinology.
Mkrtumyan A.M., Nelaeva A.A.
The year of publishing: 2019
Size: 1.63 MB
Format: pdf
Language: Russian
Description: The book "Emergency Endocrinology" is a guide for a practicing physician, which reflects the relevance of the topic of emergency conditions in endocrinology, the book provides in detail the algorithms for treating patients in life... Download the book for free
Name: Severe combined injury
Tulupov A.N.
The year of publishing: 2015
Size: 5.29 MB
Format: pdf
Language: Russian
Description: The presented monograph “Severe combined trauma”, edited by A.N. Tulupova, examines modern and topical issues of injuries of varying severity in peaceful and war time. In the book op... Download the book for free
Name: Emergency cardiology.
Ogurtsov P.P., Dvornikov V.E.
The year of publishing: 2016
Size: 3.42 MB
Format: pdf
Language: Russian
Description: Textbook "Emergency Cardiology" edited by P.P. Ogurtsova examines in detail emergency conditions in cardiology and algorithms for cardiac emergency care. The book contains character... Download the book for free
Name: Emergency pediatrics. National leadership
Blokhin B.M.
The year of publishing: 2017
Size: 14.55 MB
Format: pdf
Language: Russian
Description: National manual "Emergency Pediatrics" edited by Blokhin B.M. is considering wide range current problems emergency and emergency pediatrics, arguing the relevance of this topic... Download the book for free
Name: Emergency conditions in children. Directory
Veltishchev Yu.E., Sharobaro V.E.
The year of publishing: 2011
Size: 20.01 MB
Format: pdf
Language: Russian
Description: The practical manual “Emergency Conditions in Children,” edited by Veltishcheva Yu.E., et al., addresses the issues of the main syndromes and symptoms of the development of emergency conditions in pediatrics. Illuminated in... Download the book for free
Name: Emergency medical care for victims of road accidents
Bagnenko S.F., Stozharov V.V., Miroshnichenko A.G.
The year of publishing: 2007
Size: 11.48 MB
Format: djvu
Language: Russian
Description: The educational manual “Emergency medical care for victims of road traffic accidents”, edited by S.F. Bagnenko, et al., examines the multifaceted aspects of road traffic injuries... Download the book for free
Name: Emergency help for shockogenic trauma and acute blood loss at the prehospital stage
Lapshin V.N., Mikhailov Yu.M.
The year of publishing: 2017
Size: 26.34 MB
Format: pdf
Language: Russian
Description: Practical guide “Emergency care for shockogenic trauma and acute blood loss at the prehospital stage,” edited by V.N. Lapshin, et al., examines the principles of providing urgent, emergency medical...
