Organization of emergency and urgent care in Ukraine. Initial activities of medical staff
in case of the patient’s emergency condition.
Emergency medical service (or service of urgent medical care) of Ukraine is a structure, that provides the first and urgent prehospital medical aid to people in case of severe acute diseases or serious injuries, at various situations that threaten one’s health or life.
Urgent medical care (UM) or emergency medical service (
5th category stations serve territory with the population less than 50 000;
4th category – from 51 000 to 200 000 habitants;
3d category – from 201 000 to 500 000 habitants;
2nd category – from 501 000 to 1 million habitants;
1st category centers serve areas with more than 1 million habitants.
The receipt of appeals after UM comes true after a telephone number 103. For a receipt and treatment of calls controller’s separation(point) functions in the structure of the station(separation). Basic mobile functionally-structural unit of the station(separation) of UM is a medical brigade that heads for a call for a grant in place of necessary medical help and realization of reanimation measures, and also urgent hospitalization of patients and victims at presence of corresponding shows. Such medicare is named urgent.
Urgent medicare on the greatest standards must be accessible for everybody after a necessity somewhere and some time. It requires the corresponding system of measures on medicare for all people, whose life suddenly found oneself under threat, conceptions of grant of prehospital, hospital and interhospital urgent medicare. In time and the well organized help reduces lethality, duration and weight of sudden diseases and traumas, diminishes suffering of patients – so one of base positions of the Manifest of European Association of Urgent medicare sounds. In fact in actual fact the characteristic feature of our present time is an incessant increase of amount of accidents, catastrophes, elemental and ecological troubles, acute diseases that is accompanied by various pathological by the states. During the last decades as a result of strengthening of the psycho-emotional loading, increase of rate and rhythm of modern life, the amount of cases of the so-called extreme pathology(to the heart attack of myocardium, violations of rhythm and conductivity, disorders of the respiratory system) increased. There is not a doubt, that the end-point of treatment of patients with such diseases or damages largely depends on a timeliness and adequacy of grant of premedical, urgent medical premedical and skilled medical prehospital and early hospital help.
Levels of medical care
Premedical help is a complex of urgent simple medical measures, that get to the victim or person that became ill suddenly, in place of event and on the period of his transporting to medical establishment. Persons that are under an obligation to render a premeical help to the man in the urgent state are: rescuers of emergency – rescue services, workers of state fire prevention, workers of organs and subdivisions of militia, pharmaceutical workers, explorers of passenger carriages, air stewards and other persons that does not have medical education, but after the official duties must own practical skills from saving and maintenance of life of man that is in urgent state.
The range of operating under the grant of premedical help subordinates in itself three basic groups of measures:
1. Immediate stopping of action of external harmful factors with the observance of the personal safety(electric current, high and subzero temperatures, clench injured heavy objects) and evacuation of victims from the above-stated unfavorable terms, in what of them got(from the damaged transport means, from water, from an apartment that burns or toxic gases accumulated in that);
3. Organization of the rapid transporting sick or injured to curative establishment.
Emergency medical care (prehospital medical care) is provided by skilled teams of emergency medical service (staff of ambulance units) with envolving special equipment and medications with or without a doctor. Typical composition of medical assistant’s team: medical assistant, nurse, driver. Typical composition of doctor’s
In the last decades in foreign countries this help is rendered mainly paramedics – persons with special short-term medical education, that operate concordantly the accepted algorithms at implementation of medicare. Paramedicine is extraordinarily widespread practically in every country of the world.
At the same time, it is known that be what medical worker must count life and health of patient higher the personal interests. In bases of legislation of Ukraine rights for are clearly set forth duties of medical worker, where in the articles 136. 139 the Criminal code it is writtenin, that be what medical worker of obliged after the first appeal to come to help to the victim: outside, in transit, public places, at home, and able correctly to render the first medical aid at accidents and sudden diseases.
Ungrant without good reasons of help to the patient by a medical worker, what have to do, according to the set rules, to render such help, if to him scienter it is known that it can have heavy consequences for a patient, punished to fifty of untaxable minimums of profits of citizens with privation of right to hold certain positions or carry on certain activity within three years, or correctional works within three years.
The same act, if it entailed death of patient, or other heavy consequences, is punished by limitation of will within four years or imprisonment within three years, with privation of right to hold certain positions or carry on certain activity within three years or without such (article 139 the Criminal code of Ukraine).
Medical (prehospital) medicare – given by medical brigades, that have in the order a necessary apparatus, tool, medications, and others like that, and provided with theoretical knowledge and practical skills from the grant of skilled urgent prehospital of medicare. Typical composition of medical brigade: doctor, medical assistant, medical sister, driver.
Early hospital the skilled is specialized specialized medicare – urgent measures, to the victims(to the patients), delivered by the coach of UM, that is conducted in the separations of the urgent states by forces of her workers.
At the same time, there is international classification in obedience to that urgent medicare is divided into next groups:
BLS( Basic life support) is base support of vital functions, namely grant of urgent medicare on the prehospital stage by not physicians(by volunteers, policemen, firemen, rescuers), or the same physicians that by chance appeared in place of event;
ILS (Immediate of life support) is urgent support of vital functions, that can come true in a policlinic, permanent establishment, in a private cabinet, and others like that, by medical workers to arrival of the specialized rescue medical brigade);
ALS (Advanced life support) – the extended is skilled medical including reanimation help, that is given by physicians and paraphysicians with bringing in of corresponding apparatus, medications, tool on prehospital and to the early hospital the stages;
ATLS (Advanced trauma life support) is a professional grant of the first medical aid at various traumas both on preclinic and on early hospital periods(mainly executed by doctors, rarer by medical sisters, paraphysicians);
ACLS (Advance cardiac life support) is a grant of professional urgent medicare at cardiovascular pathology(conducted by doctors, medical sisters, paraphysicians);
PALS (Pediatric advanced life support) is a grant of professional urgent medicare for children(comes true by doctors, medical sisters, paraphysicians).
Organization of urgent medical care in Ukraine.
Activity of medical first-aid of Ukraine during all, especially last years of independence, regulated by the row of normative state acts, namely: by resolution of Cabinet of Ministers of Ukraine № 1290 from 5.11.2007 “About claim of the Government programs of creation of the single system of grant of urgent medicine help on a period 2010 to by an order №24 Ministries of Guard of health of Ukraine from 17.01.2005 “About claim of protocols from the grant of medicare after speciality “Medicine of the urgent states”, by an order №120 МОЗ of Ukraine from 18.03.2005 “About organization of studies of medical and unmedical workers from the grant of medicare in urgent situations”, order № 132 МОЗ of Ukraine from 2.03.2009 “About organization of studies of separate categories of unmedical workers to skills of grant of the first urgent medical aid”, by an order №283 МОЗ of Ukraine from 28.04.2009 “About the improvement of preparation and in-plant training of medical workers from the grant of urgent and urgent medicare”, by an order №370 МОЗ of Ukraine from 01.06.2009 “About the single system of grant of urgent medicare”.
In July, 2012 was passed an act, that entered into operating under 01.01.2013 On urgent medicare.
After an entry in an action of this Law service of UM of Ukraine tested native, it is possible bravely to say, revolutionary changes. The main task of this reorganization is approaching of the quality first and urgent medical aid to the population and also rapid arrival to the patients (victims). For today in obedience to the substantive provisions of this law it is regulated доїзд to the patient within the limits of city to 10 minutes, in the settlements of rural locality – to 20 minutes.
There were created Centers of urgent medicare and medicine of catastrophes in all areas. On Ternopil Region in force of different reasons such Center was organized on the walks of life of Ukraine one of the last. In obedience to an organizational structure, all district stations, substations of UM, and also analogical structures of Ternopil, are inferior him.
In accordance with separate this law, financing of this service provisions will come true from regional and partly state budgets, in fact not secret, that municipal and district budgets are for today able to close the separate most protected articles only, namely salary, fuel, medications.
Activity of Center is envisage the coordinated actions of rescue services 101, 102 and 103 with creation of the system of call after an only number 112. of Cognation of their work important at liquidation of emergencies of natural and technogenic character with plenty of victim.
Especially it topically during liquidation of road and transportation adventures and another cases that take place on the limits of territories of districts, when finding out, from which one district the brigades of UM must drive out results in the loss of precious time. In obedience to the separate this Law provisions from the submission of central district hospitals the separations of UM hatch with creation on their base of the independent stations and substations of UM. Guidance depends all subdivisions of service upon the Territorial center of urgent medicare and medicine of catastrophes of area.
In a law clear differentiation is envisaged between urgent on by the first medical aid. Yes, all accidents, traumas, acute diseases that result in the sudden worsening of general of patient fall into the category of urgent cases and provided by the grant of medicare by the workers of UM and МC. In the sphere of activity of this service realization of departures of leading specialists-physicians enters also within the limits of area for realization of highly skilled consultative and operative help to the patients. At the same time to the patients with chronic pathology of prehospital medicare will be given by district and domestic doctors and she will be named urgent. Arrival to such category of patients can be carried out on the draught of hour.
Yet for a year to the acceptance of this law there is a working group that was headed by the chancellor of the Ternopil state medical university the name of І.Y. Gorbachevskyi, corresponding member of National Academy of Medical Sciences of Ukraine, presiding of regional soviet commissioner from a health protection maternity and childhood professor L.Y.Kovalchuk together with the leading specialists of this industry and scientists hang thoroughly learned and analysed organization and activity of service of UM of Ukraine and Ternopil, separating the row of foreground jobs that have for an object maximally to approach a “ambulance” to the patient here. Gratifying, that a few suggestions from conception of recommended by a commission, found the place in this Law. At the same time, in detail becoming familiar with the map of Ternopil Region, an initiative group were certain regions with a large remoteness from the stations(separations) of UM and made decision about opening 18 points of the temporal basing in the districts of area and 2 substations in Ternopil.
Creation of twenty-four-hour posts of controllers is pre-arranged with accepting challenge in a number of districts, where they are absent with their further transmission in an only dispatching office at the Territorial center. For the grant of adequate medicare to the population on the prehospital stage at every station of UM in districts a presence will be provided not less than one twenty-four-hour departure medical brigade, here completing positions of medical assistants of brigades of UM to the їз taking into account of two twenty-four-hour posts on every UM in all substations and points. Considerable attention is also spared to the material and technical rigging of coaches of UM. It is known that not having regard to the role of the so-called human factor(professional preparation of physicians), it is difficult to count patients on successful treatment, in particular, on the prehospital stage without the proper apparatus, tool, medications. In obedience to the order of Ministry of health of Ukraine № 500 from 29.08.2008р. the brought list over of property and medications necessary in the robot of brigade UM.
It is also planned to equip all ambulances a radio contact and systems of GPS- of navigation that will give an opportunity of permanent contact of controller with a brigade and monitoring of movement of ambulance. The coordinating actions of only controller’s service will give an opportunity at the necessity to lead from one district brigade to the patient that is in other district, the so-called territorial principle of medical service of population of area is thus leveled.
Cardinal changes are tested by professional preparation of physicians and drivers of “ambulance”, in fact topically creation
Realization of substantive provisions of Law on the single system of grant of urgent medicare in our area on condition of rational organization, management and financing of network of the stations, substations and points of the temporal basing of ambulances it is in end-point able to promote the level of readiness of this important link in the system of health protection population and will assist the timely and more quality grant of urgent medicare on the prehospital stage.
An algorithm of initial actions of
Stage of actions of brigade of UM and her job performance in parallel instances are based on the so-called principles of “platinum half an hour” and “golden hour”.
Conditionally “platinum half hours” are divided into three 10 minutes:
10 minutes – arrival to the place of event;
10 minutes is an estimation of place of event including realization of the medical sorting, diagnostic measures and grants of the first aid in place;
10 minutes – transporting suffering in permanent establishment with continuation(after shows) of realization of untilshock measures and permanent monitoring of vitally -impotent organs and systems in the coach of UM.
The “Gold hour” includes for itself next 30 minutes, where to the victim in permanent establishment the various, including highly specialized methods of inspection are conducted in the urgent order, as then computer thomography, МRТ and others like that, up to beginning of operative intervention.
At the same time, there is another conception of “gold hour”, that interpritation weight of the state of trauma victims is with simultaneous realization of the primary medical sorting. In obedience to her all damages are divided into three categories:
1. Irreversible at that even immediate adequate interferences do not bring to the positive result (more often a trauma over, what not consonant with life (in the medical sorting are ” black victims”)
2. Damages at that consequences of trauma (death or disability) depend on timely and quality medical interference are “red victims”. Help they get near-term with further hospitalization for the grant of the specialized treatment in. possible operative intervention during 1 hour(!) from the moment of the got trauma.
3. Damages at that the grant of the specialized medicare can be deferred during 1 hour without an obvious risk for life and health of trauma are “yellow victims”.
How to approach the injured person
Approaching the injured, ask the witnesses, rescue workers or policemen what has happened, whether the accident scene is safe and how many injured people are there.
If the accident scene is, in your opinion, connected with criminal activity, immediately call the police. If there is a need of rescue workers, inform the rescue service. In case of crime or violence, law enforcement agencies have to provide safety for the rescue medical workers.
If there is lack of information, act independently, first of all giving heed to everything which can threaten your safety – the place has to be thoroughly examined. If there is the least danger (the containers are marked with special signs, some liquid is spilt, smoke, fog, fire, gas, electric wires, explosive objects, things which can fall from the top, etc), figure out if you are able to eliminate it without any risk. If not, call rescue workers. In this situation it is important to keep verbal contact with the injured, find out what bothers him/her and give him/her recommendations concerning self-help and mutual aid.
If you decide to approach the injured, figure out what has happened, to foresee the mechanism of trauma and to find out the way of providing medical help. Ask one medical worker or a driver to inspect all secluded corners of the accident scene in order to find other possible victims. In case they are found, you have to examine them and provide necessary medical help if needed.
Pay attention to all the details of the accident scene, keep constant control over the accident scene, since additional danger can occur, which will force you to save not only the life of an injured but your own as well. The priority should be your own life, then the life of an injured, and then – all people present at the accident scene.
Find out if you need any additional help or additional means.
Approach the injured, if possible, from the side of his/her head. First of all, visually assess patient’s general condition (age, sex, morphology of the body, language, skin colour, posture, availability of the movements (thorax, limbs), mimicry, eyes condition, visible injury made by traumatizing factor). Make initial resolution of its degree and further algorithm of help.
Figure out the condition of consciousness according to the algorithm AVPU:
A – Alert (conscious, gives adequate answers to the questions, is able to perform conscious actions when asked by the medical rescuer);
V – Responds to Verbal stimuli (to a loud sound near the ear);
P– Responds to Pain (responds to pinch in the area of left thoracic muscle at the turn of 180 degrees);
U – Unresponsive.
If there is a suspicion of simulation of unconsciousness, open patient’s eyelids, using 1st and 2nd fingers. The conscious patient will strain his/her eyelids muscles and they will open with tension.
Primary examination
Let’s make a priori assumption that cerebral trauma occurs at transport accidents, sports accidents, falling from high places, traumas in water and children’s traumas.
Fix with your hands a neck part of the spine in the position which you found the injured in. (medical assistant 1)
If that position does not promote breathing, carefully turn the injured on his/her back or to the position, which is close to a stable (on his/her side) (medical assistant 1 + medical assistant 2).
Start initial examination according to the A, B, C technique (optimal term of performance – 10 sec) (doctor)
Step A
Provide patency of airways support (medical assistant 1):
Evaluate if there is a need to examine oral cavity. In case of secretion available (blood, vomitive mass, outside objects (depending on the mechanism of an injury), it is necessary to open oral cavity (between molar teeth you should put a spreader to prevent accidental pressing of fingers), take out outside objects with a clutch and tampon, provide the cleaning of oral cavity and pharynx, clean them from secretion (if there are several injured, the priority is to arrange them, according to the relief of the area, head down);
throw the patient’s head back and raise his/her chin; in case of suspicion of cerebral trauma, it is prohibited to throw patient’s head back, you should raise only his/her chin.
Provide patency of airways support, find out if there are signs of life to confirm or oppose the circulatory arrest.
Patient’s response
Provide patency of airways support
Check respiration and pulse (not more than 10 sec)
Step B
Make sure if the patient is breathing. Count the frequency of respiration during 10 sec.
Indications for carrying out trachea intubation^
apnoea;
risk of aspiration
danger or presence of respiratory disorder (damage of respiratory tracts, maxillary-facial trauma);
closed craniocerebral injury;
hypoxemia, in spite of carrying out oxygen therapy;
frequency of respiration less than 10 or more than 30 per minute (for adults)danger of respiratory standstill (sepsis, major burns)
If the breathing is pathological but not agonal (deep and noisy), and also in case of shallow breathing, a patient should be given oxygen therapy (10-
Objective criteria is the data of pulsoximetria: saturation <92 % – indication to oxygenotherapy; saturation <90 % – indication to intubation.
Simultaneously with making decision concerning necessity of artificial ventilation and providing oxygen, put a neck collar (a doctor, medical assistant or a driver can do it) and continue initial examination.
Step C
At the same time find out if there is pulse in the carotid artery (during 10 sec) (in case the patient is unconscious). (doctor)
If there is not – start doing closed chest-cardiac massage (doctor, while medical assistant 2 is preparing cardiomonitor and defibrillator) with frequency of 100 times per minute – 30 pressures on the chest and 2 ventilations (medical assistant 1). Simultaneously, connect electrodes of cardiomonitor, link it up and find out the reason of cardiac arrest (medical assistant 2).
Examine if there is any external haemorrhage (doctor). In case of its availability stop the haemorrhage – press the wound with your hand using sterile tissue. If the haemorrhage stops, put the clutch, bandage.
If you found a patient with an amputated limb, stop hemorrhage while evaluating the breathing and pulse condition.
Pay attention to the skin temperature (using the back of your hand), skin colour, time of colour return after pressure on the nail, skin moisture (doctor). This information will indicate the development of the shock.
Paleness, skin moisture, skin cooling and also increase of the time of nail skin colour renewal after pressing for more than 2 sec indicates a development of a shock.
In case of shock development, external hemorrhage, suspicion of internal hemorrhage, organize transfusion of the blood substitutes (medical assistant 2).
Check if the patient has trinkets, bracelets, or badges – medical markers, which may hold information about patient’s condition, allergy, need for certain medication (for example, when a patient suffers from diabetes, epilepsy, etc), especially, when the patient is unconscious. (medical assistant 2).
While examining the patient give priority to:
– dangerous mechanism of the trauma;
– decrease in the level of consciousness;
– respiratory failure;
– abnormalities at initial examination;
– considerable aberrations at general examination (it is possible to make immediate conclusion of patient’s condition, his/her viability, tactics of examination and medical treatment).
Category “Load and Go”after primary examination
This category includes patients, who have very serious mechanism of the trauma (fall from the top, severe sports injury, car accident, etc) or negative impression of the patient at initial examination (amputation of the limb, severe defects, etc);
at initial examination decrease in the level of consciousness is found;
malfunction of respiratory tracts or respiratory failure;
malfunction of cardiovascular activity (shock or uncontrolled hemorrhage);
injured children and pregnant women.
STATE PROGRAM
of creating a unified system for emergency medical care until 2010
Approved by the Resolution of Cabinet of Ministers of
November 5, 2007
The purpose of this program is to create conditions for expanding the availability and quality of emergency medical care provided to the population, reducing disability and death in accidents, injuries and poisoning, acute impairment of vital functions of man from cardiovascular and other diseases.
According to the Order of Ministry of Healthcare of
from 01.06.2009 “On a single system for emergency medical care”
3. Crew Leader , who first came to the scene :
3.1. Immediately notify the senior medical officer of another department ambulance on characteristics developments and the approximate number of victims , conducts medical triage.
3.2. Provides information on the dispatcher need to send additional Brigades 1 , Brigades 2 , team, organize emergency medical care to patients arriving at the scene of the compliance officer ambulance station with the elimination of medical emergency response .
3.3. Inform the responsible officer ambulance station manager or executive group of local territorial health authority , who arrived at the emergency, the number of victims , their status , the nature of injury measures and transmits the guide further work and to act according to his instructions.
According to the Concept of medical support during the preparation and holding in Ukraine EURO 2012 soccer (the concept), approved by the Cabinet of Ministers of Ukraine dated May 7, 2009 № 563-r, persons ieed of medical attention, divided by categories, each of which has a corresponding color:
Types of triage:
1) Initial triage – performed by policemen and firefighters – evacuation of injured from affected area;
2) Primary medical triage – dividing injured into groups depending on their condition and marking them with coloured sorting tags;
3) Secondary medical triage – determining priority in medical care among patients of red group.
4) Evacuational triage – determining priority in evacuation, body position, medical convoy, kind of transport and destination (concrete hospital).
Secondary triage criteria
Evacuation priority according to amount of points:
12 = priority 3 (minor)
11 = priority 2
10 and less = first priority
Patients with the least amount of points are prior to medical evacuation and are hospitalized as soon as possible. Patients with 11 points are hospitalized in second turn, with 12 points – in third turn
Problem of “Golden hour” concept’s implementation: During 1 hour after an accident a qualified or specialised medical care admitting is to be started in the hospital
The aim and the task of organisation and medical care providing at massive lesions / accidents is to save as much people as possible
