Lessons Learned from a Decade of Conflict - Boekje Pienter

the patient is flown directly to the medical treatmentfacility best situated for the care required.More similar to civilian EMS was the Army’sFLATIRON Operation of the late 1950s. InFLATIRON rescues, the objective of the aerialcrash rescue service is to save human life. Itcombines fire suppression, extrication, recoveryof injured personnel, initial emergency medicaltreatment, and evacuation to an appropriatemedical treatment facility. Neely described theuse of FLATIRON rescues by Army teams forcivilian highway accident victims and developedthe concept of using helicopters for this missionin routine civilian operations for rural America.Civilian ApplicationsIn the mid-1950s, physicians began to ask whylessons learned for emergency medical treatmentand transportation during WWII and theKorean Conflict could not be applied for civilianuse. Drs. J.D. “Deke” Farrington and Sam Banksused these combat lessons to developa trauma training program forthe Chicago Fire Department. Thisprogram later developed into theEMT-Ambulance (EMT-A) course.The American Academy ofOrthopaedic Surgeons had a previouslyestablished Committee onTrauma (COT), with an interestin prehospital care of the injured.In 1967, the COT, chaired by Dr.Walter A. Hoyt and including Dr.Farrington, developed the firstEMT program for ambulance personnelthat trained them to fullyevaluate an injured patient before transportation.This resulted in the 1967 publication of“Emergency Care and Transportation of theSick and Injured,” which became the standardfor EMT training in the 1970s.During this period, cardiologists identifiedan epidemic plaguing modern society: deathfrom myocardial infarction. Before reachingmedical care in the hospital, 40–60% of heartattack victims would die. In 1967, Pantridgeand Geddes in Belfast, Ireland, published theirexperience using morphine and lignocaine(lidocaine in the United States) to treat myocardialinfarction in the field, bringing medicalcare to the patient rather than waiting forthe patient to seek medical care. When theydid this, no patient died, which represented areduction of the mortality rate from about 50%to 0% because of one intervention. 8 The ideathat intensive (cardiac) care units could becomemobile led to the creation of the mobileintensive care unit (MICU), staffed by mobileintensive care paramedics.In the 1950s and up through the 1970s, combat veterans workingwith veterans of major emergencies began to influence the systematicapproach public safety agencies (police, fire, EMS) used whenworking in hazardous or hostile environments. During this period,physicians became more involved in prehospital medical care,which resulted in a synergistic relationship between medicine, publicsafety problem solving and leadership functions.By the 1970s, the term “ambulance” no longer referred to a vehiclefor transporting the sick and injured patient or non-ambulatorypatient. The TV series Emergency! catapulted advances in life supportand prehospital care into American living rooms and inspiredan advanced prehospital care movement that spread across thecountry. Ambulances became specialized patient carriers, and otheremergency workers, such as firefighters and police officers, startedenrolling in first-aid programs to further their medical training.As the field of emergencymedicine began to emerge, thefocus shifted to medical carebefore the diagnosis. “First do noharm” began to give way to thepublic safety creed, “Duty to act;doing nothing is harmful.”Through the 1980s, EMT education merged with paramedic trainingto produce EMS professionals who treated trauma and medicalillnesses before and during transportation. Building upon heavyexperience and influence from military combat and major civilianemergencies, public safety veterans had developed a means to performunder time constraints, in austere conditions and in a hostileenvironment using what’s describedas “interactive, real-time risk assessment.”9 With these professionals, themedical community could now bringadvanced medical care into the publicsafety environment.A Different ApproachThrough the 1970s, medicine focusedon diagnosis first, then treatment,but as the field of emergencymedicine began to emerge, the focusshifted to medical care before the diagnosis.“First do no harm” began togive way to the public safety creed,“Duty to act; doing nothing is harmful.”This commonality—the need to intervene before knowing thesituation—linked physicians and nurses to ambulance and rescuesquads with a camaraderie based on response to a shared threat:knowing what to do in the uncertain situation. The collaborationhad a measurable effect. For example, spinal cord injuries changedfrom predominantly complete lesions to predominantly incompletelesions, meaning victims of trauma retained some function in theirlower body, solely because of prehospital care. Heart attacks alsochanged from the dreaded sick call, which was a patient dying frommyocardial infarction, to a routine, near-boring response.Although medical decision-making skills have advanced slowly,in the past 20 years the military has made great advances in TacticalCombat Casualty Care (TCCC); the use of cognitive function in theface of uncertainty and the unexpected; and the use of decisionmakingprocesses, such as John Boyd’s OODA Loop (Observe-Orient-Decide-Act), which provides a way to rapidly make sense ofa changing and uncertain environment. 10Such advances are centered on the decisions combat medics mustmake to stop bleeding, support the respiratory system, prevent infectionand transport the wounded as quickly as possible—decisionsthat our EMS providers routinely face as well.Elsevier Public Safety War on Trauma 13