Editorial: “Pre” Prehospital Care

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.

In recent months, state and federal legislation has been enacted to place lifesaving prescription medications and devices in the hands of nonhealthcare providers present at the scenes of medical emergencies. In 1973, the Emergency Medical Services Development Act ushered in the modern era of advanced prehospital care; current legislation may initiate a new era of advanced “pre-prehospital care.”

The 1970s
The origins of prehospital care can be traced to the years immediately following the Civil War when the horse-drawn wagons used to rapidly evacuate battlefield casualties were quickly adapted to civilian life—sometimes with a physician on board to administer care at the scene. But it wasn’t until the 1970s—more than 100 years later—that the most potent lifesaving medications and powerful electronic devices available to physicians would also be made available to paramedics operating at the scene with written protocols and online medical control.

The success in providing advanced treatment at the scene to those who might not survive transport to an ED led to the realization that in order to survive, patients with ventricular fibrillation (VF) and tachycardia, (VT), respiratory arrest from opioid overdoses, and anaphylaxis, required interventions even before paramedics could get to them.

The 1990s
A new era of “pre-prehospital care” began when the first automatic external defibrillators (AEDs) were placed in public spaces for use on any person who might be in cardiac arrest from VF or VT. The advances in computer programing of the 1990s made it possible to build compact defibrillators capable of delivering jolts of electricity only when indicated and at precisely the right time, without causing harm from inappropriate application or timing. Though initial deployment of AEDs was accompanied by an emphasis on training nonhealthcare workers in their use, many untrained people have since successfully defibrillated dying victims. In 2010, Weisfeldt et al (J Am Coll Cardiol. 55(16):1713-1720.) published the results of a study on survival after AED application prior to the arrival of EMS; of 13,769 out-of-hospital cardiac arrests, application of an AED in 259 cases was associated with a nearly doubling of survival, and the success rate of 40% by lay persons using the devices suggested that speed is more important than training.

Current Efforts
Though spring-loaded epinephrine syringes have been available for many years to individuals (and their families) at risk for anaphylaxis or severe asthma attacks, recent concerns have focused on the need to stock these devices in classrooms and other locations where they could be used on any child in need, with or without a prior history of severe allergic reactions.

At present, over 30 states permit or mandate stocking epi syringes in schools, and on November 13, 2013 President Obama signed into law the School Access to Emergency Epinephrine Act authorizing the Department of Health and Human Services to preferentially fund asthma treatment applications of states that both maintain emergency supplies of epi pens, and insure the availability of trained personnel to administer them throughout the school day.

Adding to the “pre-prehospital care” armamentarium, the FDA last month approved, by prescription, spring-loaded autoinjectors containing doses of naloxone for family members or care providers to rapidly administer to a person overdosed on a legal or illicit opioid. Also available, though not yet FDA approved, are intranasal doses of naloxone for use by nonhealthcare providers.

Emergency physicians should give all of these new developments our full support. Just as we frequently keep seriously traumatized patients alive until surgeons can arrive and operate, these newly available, lifesaving, “pre-prehospital care” measures will help patients survive until they can get to an ED. EPs can play an extremely important role in educating the public on their proper use, encouraging those who might be reluctant to apply them when needed, while decreasing any possible adverse effects from their use.