Emergency Medical Aid

EMERGENCY MEDICAL AID, a medical-sanitary organization whose task is to provide first aid in life-threatening accidents and sudden severe diseases accompanied by danger to life, and the transportation of relevant patients and victims to medical institutions. The first rudiments of the emergency aid organization date back to deep antiquity. Already in the first centuries of the new era, on the most bustling roads traveled by masses of pilgrims, shelter-hospitals (xenodochia) were organized, which also provided emergency aid. With the development of trade relations between states, these institutions were deployed on the main trade caravan routes. In the Middle Ages, various religious orders also set themselves the task of providing emergency aid. The first forms of independent emergency aid organization are found in Holland in the 15th century, but emergency aid here was organized only for the rescue of drowning people. This period marks the appearance in Holland of the first regulations on the provision of emergency aid (1417 and 1455). The first societies for providing emergency aid ("rescue societies") were also organized here—in Amsterdam in 1767. A year later, such a society was opened in Hamburg. Gradually, to the initial task of rescuing drowning people, there were added the tasks of rendering assistance to victims of various accidents, those who had fallen into an unconscious state, and the seriously ill. In the era of industrial capitalism, with the unusual growth of industrial enterprises, the introduction of machines into all branches of production, the number of accidents increased extremely strongly in connection with the exorbitant exploitation of workers, the difficult working environment, and the unwillingness of capitalists to make expenditures on necessary measures to ensure the safety of workers. The huge growth of cities, the increase in traffic, the mechanization of transport caused a significant increase in the number of accidents in capitalist countries. There arose an acute need for a special emergency aid organization, which in all countries was at first the subject of care of various private societies and only gradually in a number of cities passed into the jurisdiction of municipal self-governments. However, even now emergency aid in many countries is organized by voluntary societies, the Red Cross, with some financial support from municipal bodies. The first foundations of a rationally organized emergency aid were laid in Germany by the famous surgeon Friedrich von Esmarch. On his initiative, Samaritan schools and societies arose. A particularly large role in the organization of emergency aid was played by the Red Cross and fire brigades. The lack of opportunity to timely receive first medical aid in sudden illnesses served in a number of countries as one of the driving impulses for the organization of emergency aid, in which functions of providing first aid in various diseases initially prevailed. This took place, for example, in Berlin and other cities of Germany even at a time when industry and transport were little developed, whereas in Vienna, with the most ancient emergency aid organization, the impulse for organizing emergency aid was given by a horrific fire in the city theater (in 1881), which entailed a huge loss of human life. The deployment of a planned organization of emergency aid was strongly hindered in capitalist countries by the opposition of interests between private-practicing doctors and the population. Thus, for example, in Germany, where in 1892 disability insurance funds organized well-equipped emergency aid stations in various districts of large cities and small clinics to provide necessary medical assistance in accidents, which began to be used also by sickness insurance funds and the rest of the population, private-practicing doctors through their corporate organizations entered into a struggle with the indicated institutions and achieved in 1897, under the leadership of Ernst von Bergmann, the organization of the Berlin Emergency Aid Society, which opened its own emergency aid stations guarding the interests of private-practicing doctors. Even the Central Committee of Emergency Aid, organized in 1901 on the initiative of Bergmann and Dietrich to coordinate the work of the indicated emergency aid stations, could not reconcile the contradictory interests of the warring organizations. Only in 1913 did the transfer of all stations to the jurisdiction of the magistrate take place. According to the rules for organizing emergency aid issued in Germany in 1912, the latter can be organized by all sorts of voluntary societies, but in this case, constant supervision over them by certain doctors in state service or in the service of communal bodies is mandatory. A similar organization of emergency aid existed until recently in all other countries. The organization of emergency aid in American cities is concentrated at hospitals, at which special premises easily accessible from the street are allocated for the emergency aid station. To send victims to hospitals, the latter have sanitary automobiles that depart accompanied by a physician. Depending on the severity of cases, patients come under the charge of resident physicians or senior doctors of the respective hospital departments. In the matter of exchanging international experience on the organization of emergency aid, international congresses of emergency aid were of great importance; they were held—the 1st in 1908 in Frankfurt am Main, the 2nd in 1913 in Vienna, and the 3rd in 1926 in Amsterdam. In pre-revolutionary Russia, where the first emergency aid station was opened in Warsaw in 1897, and then in Odessa in 1903, emergency aid carriages, purchased with private funds, were usually located at police stations in large cities; these carriages also served for the paid transportation of patients. Emergency aid was then barely accessible to the population and was rendered with a great delay. In Moscow at the end of the 1890s, several carriages were purchased with private funds. These carriages were stationed at police directorates. Along with the paramedic, a policeman also went out with the carriage to draw up a report. In 1908, the organization of emergency aid passed to the voluntary society "Skoraya Pomoshch" (First Aid), which had 1 emergency aid automobile, but even this single emergency aid automobile was transferred during the imperialist war to the city administration for the transportation of the wounded, and emergency aid ceased to exist. There was no special emergency aid organization in other large cities—in Leningrad, Kharkov, Rostov, etc. Before the war in the territory corresponding to the modern RSFSR, the emergency aid organization outside of Moscow existed only in 4 cities (Samara, Tula, Yaroslavl, Perm) in the form of 1-2 paramedics serving 1 emergency aid carriage. Only after October [the Revolution] did emergency aid begin to develop strongly; already by 1927 there were 50 emergency aid stations in cities. At the present time, in all cities and industrial centers, there is an emergency aid organized in one form or another. Organization of emergency aid. The need for the provision of emergency aid by a special uninterruptedly functioning organization arises in isolated accidents and sudden severe diseases, poisonings, and especially during mass gatherings of people—in transport, in mining operations, in factory and plant enterprises, on the streets with heavy traffic of automobiles, trams, etc., during mass festivities accompanied by huge crowds of people, at airfields, stadiums, at horse races, racing events, physical culture competitions, during large fires, during various natural disasters—earthquakes, floods, etc., during mass sudden severe illnesses (poisonings); although catastrophes causing a large number of victims happen very rarely, nevertheless, a rationally organized emergency aid must anticipate all these possible cases of the necessity for mass transportation of victims and the provision of emergency medical care to a large number of people. In isolated accidents and sudden life-threatening diseases, emergency aid is dispatched upon calls for wounds and fractures, severe bruises with loss of consciousness, severe burns and poisonings, prolonged fainting, sunstroke, electric shock or lightning strike, freezing, drowning, acute mental derangement, etc. The main requirement demanded of the emergency aid organization is the provision of proper medical care without any delay, which is of great importance for the outcome of an accident and sudden severe disease and poisoning from the standpoint of saving life and more or less rapid and full restoration of working capacity. To fulfill this requirement, emergency aid must not only provide the necessary first aid at the scene of the incident, having qualified medical personnel for this purpose, but also, if necessary, immediately deliver the patient or accident victim to the nearest medical institution in the most comfortable position excluding the possibility of deterioration of the patient's condition during transportation. For this purpose, emergency aid must have the necessary appropriately equipped transport means—emergency aid automobiles, emergency aid carriages, motor boats, etc. The forms of emergency aid organization depend on the size of the settlement, the number of inhabitants, their territorial distribution by districts, the degree of development of industry and its character, the degree of intensity of street traffic, the degree of provision with medical institutions and their location.

In small towns and workers' settlements, emergency medical aid is organized at medical institutions, usually at a hospital, where there are doctors specially invited for this purpose to make emergency calls, or where a duty roster is established for hospital and polyclinic doctors who receive special remuneration for calls or duty shifts. In these cases, the corresponding medical institution has an automobile (Figure 1) or an emergency carriage, and the reception desk always keeps ready an emergency medical kit containing all the necessary instruments, medications, and dressings to provide emergency care. The doctor dispatched from the emergency station on a call takes this bag along. The doctor is accompanied by a medical assistant or a nurse. Stretchers are placed in the ambulance or emergency carriage and are secured by special devices in order to spare the patient from excessive jolting during transport. In large cities and major industrial centers, emergency medical aid exists in the form of a special organization—the emergency aid station. In the largest cities, besides the central emergency station, peripheral emergency posts are set up in various districts, usually at hospitals (Moscow, Leningrad). The emergency station and posts provide emergency care for accidents and sudden illnesses that threaten the patient's life. Where home care does not operate at night, emergency aid provides home care in cases that cannot be delayed until the next day. In large cities, for example in Moscow and Leningrad, emergency stations perform a number of additional functions: transporting acutely infectious patients, severe non-infectious patients, restless psychiatric patients, alcoholics in the stage of acute psychosis, and gathering information on available vacant beds in hospitals and providing corresponding information.

Figure 1. Interior view of an ambulance carriage with two stretchers.

Emergency stations are headed by a medical director of the station, who in large cities is assisted by a senior station doctor. Usually, therapeutic doctors with administrative experience in evacuation are appointed as responsible senior duty doctors (in Leningrad, the duty instructor), who themselves take all calls by telephone. Doctors and junior medical personnel designated for calls are on duty at the emergency station at all times. Emergency stations usually organize telephone and signaling communication between the senior duty doctor receiving calls and the medical personnel designated for dispatch, the garage where the emergency cars are ready, and the drivers' room, so that from the moment an outside call is received to the departure of the car from the emergency station yard, only a few minutes pass, in Moscow no more than 3 minutes. In Moscow and Leningrad, the personnel are dispatched 1 minute after receiving the call from the duty doctor. Appropriate signaling enables the senior duty doctor to check whether the doctor and driver have already gone to the car and when the car left the emergency station yard. To prevent false alarms, the senior duty doctor, after issuing the dispatch order and if a false alarm is suspected, calls back the telephone number from which the call was placed to verify whether a call was indeed made from that number. When the duty doctor is talking on the phone regarding a call, a nurse or medical assistant in the neighboring room picks up an extension telephone from the apparatus used by the senior duty doctor and records the address and the reason for the call, usually on a special emergency call card. Having received the assignment from the doctor taking the call, the nurse or medical assistant proceeds to the automobile, where the departing doctor and driver are already located; they received the signal to depart in their rooms at the very moment the call was being taken by the senior duty doctor (while talking on the phone, the latter presses the appropriate electric signaling button). Upon the departure of the car from the yard, the gatekeeper also signals this to the senior duty doctor via an electric signal. The latter is also able to signal the gatekeeper about a car delayed at the gates; the gatekeeper signals returning cars to the senior duty doctor. The senior duty doctor has a secretary who assists in keeping records, handling telephone conversations regarding calls, receiving signals from the gatekeeper, etc. In order to know in which district of the city an emergency automobile is located at any given time, the senior duty doctor marks their location with pins on a city map. This is especially important for very large cities where there are emergency car parking posts attached to medical institutions, mostly hospitals, in various districts; a car that has traveled to a remote district of the city stops at the nearest parking post at a hospital, where it waits for the next call from the emergency station. In some large cities (e.g., Leningrad), almost all hospitals are connected by direct telephone lines to the central emergency station. The district emergency posts also have at their disposal dispatch doctors, junior medical personnel, and emergency automobiles. Usually, the central

Figure 2. Interior view of an emergency medical aid post.

The Emergency Medical Aid station is directly connected by wire to peripheral district Emergency Medical Aid stations, to which the call from the corresponding district accepted by the central Emergency Medical Aid station is transmitted. The transmission of the call from the on-duty physician at the district station to the departing personnel is also mostly radio-equipped. The time of receiving and transmitting the call to the district station is immediately recorded on special automatic clocks. When district Emergency Medical Aid stations are present, assistance is provided within 2-15 minutes. The district Emergency Medical Aid station has the following premises: room of the senior on-duty physician, dressing room (Fig. 2), room for the on-duty middle medical personnel and drivers, room for the on-duty physician, dining room, bathroom, and kitchen. Physicians responding to the scene of an incident must be qualified physicians capable of providing emergency medical aid, quickly orienting themselves in the situation, and deciding on the necessary further medical intervention. Usually, physicians with at least 5 years of hospital experience, predominantly surgical, are admitted to the positions of Emergency Medical Aid physicians. After delivering the patient or injured person to the hospital, the physician fills out a referral slip, in which he notes the illness or nature of the traumatic injury and the assistance provided. These slips are sewn to the patient's medical record and, upon discharge or death of the patient, are returned to the Emergency Medical Aid station with the diagnosis of the illness indicated. If the visiting physician, called for a sudden illness, finds it necessary to send the patient to the hospital, he arranges for the transportation of the patient by issuing a requisition to the patient transport department at the Emergency Medical Aid station. For assistance in sudden illnesses, physicians-therapists are usually dispatched. In large cities, Emergency Medical Aid physicians do not have the right to issue sick leave certificates or certificates, and they are prohibited from prescribing prescriptions, as all necessary for providing Emergency Medical Aid must be carried with them. When responding to a call, the Emergency Medical Aid physician takes with him a bag or case containing necessary medications and equipment for emergency aid, a rubber tourniquet, a stomach tube, a set of splints, and if necessary, an apparatus for artificial respiration. The physician who has responded and provided emergency aid must call the Emergency Medical Aid station by telephone to find out where he should go next. Similarly, Emergency Medical Aid automobiles, upon arriving at the hospital, immediately report by telephone to the Emergency Medical Aid station their location. In case of a false call, the physician draws up an act and the guilty parties are held responsible. In Leningrad, the number of incorrect calls averages about 2% per year of all calls; the number of patients or injured persons left at home after receiving first aid constitutes 15-20% of all calls. Hospitals are obligated to accept patients and injured persons brought to them by Emergency Medical Aid, regardless of the availability of free beds. According to data from Moscow, the arrival of Emergency Medical Aid at the scene of an incident occurs on average 10-12 minutes after the call. In large cities, Emergency Medical Aid also includes emergency psychiatric assistance. On-duty psychiatrists are attached to Emergency Medical Aid stations, who respond to Emergency Medical Aid calls to provide assistance to mentally ill persons suffering from acute psychoses or who are dangerous to others due to their condition, as well as to alcoholics in a state of acute alcoholic psychosis. If necessary, the on-duty psychiatrist directs the patient to a psychiatric treatment facility in an Emergency Medical Aid vehicle. According to data on the work of the Moscow and Leningrad Emergency Medical Aid stations in recent years, the average number of calls per year for accidents in major centers can be taken as approximately 5-8 calls per 1,000 population, and for sudden life-threatening illnesses, 10-13 calls per 1,000 population. The average number of patients (including those transported to hospitals by the patient transport department of Emergency Medical Aid, see below) and injured persons from accidents transported per 1 sanitary automobile per year is 7,000-7,200 persons. These data allow for an approximate calculation of the number of sanitary automobiles necessary for major centers. In a number of large cities, Emergency Medical Aid includes nighttime medical assistance, formerly called urgent medical assistance; it is provided in cases where patients do not require immediate assistance in the next few minutes, but at the same time cannot, due to their health condition, wait until morning for a physician to come to their home. Such cases include various pathological conditions with significant and rapid weakening of cardiac activity, severe and repeated vomiting and diarrhea, attacks of various colic, etc. Nighttime medical assistance points, operating at Emergency Medical Aid stations, usually accept calls independently via city telephones or from persons coming to the point to request nighttime medical assistance. On-duty physicians of nighttime medical assistance do not have the right to issue sick leave certificates. At the nighttime medical assistance point, there is a senior on-duty physician to whom the nighttime medical assistance physicians are subordinate. These physicians are supplied with special medical bags with necessary medications and equipment. The radius of operation of the point is 2-3 km; according to Leningrad data, there are on average 25-28 visits for nighttime medical assistance per 1,000 population per year. In the largest cities, Emergency Medical Aid stations have a special department for patient transport, accounting for and distributing free beds in hospitals. This department is served by specialists in patient evacuation-evacuators. All acute infectious patients (except for measles) are transported to hospitals in special vehicles that are thoroughly disinfected after each transport of a patient. The accompanying personnel must observe established personal hygiene requirements-showers, disinfection of clothing when necessary, etc. Severe non-infectious patients are also transported in special sanitary vehicles. To facilitate the movement of sanitary vehicles, they have special identification marks (special coloring, red cross) and special horns, sirens. Service by sanitary transport for the working population in the USSR is free, unlike in capitalist countries where patient transport to hospitals is paid for. The patient transport department at Emergency Medical Aid transports to medical institutions patients not requiring immediate assistance according to requisitions from outpatient clinics, polyclinics, dispensaries, and home care physicians. Hospitals are obligated twice a day to report to the patient transport department and accounting for free beds in hospitals information about the number of free beds. Summaries of this data, broken down by specialty and medical institutions, are transmitted to district health departments, to which requests for hospitalization from treating physicians are received. District health departments call for sanitary transport through the patient transport department at Emergency Medical Aid. This department is served by a special staff. In Moscow and Leningrad, Emergency Medical Aid is closely connected with Emergency Medical Aid institutes, specially created for providing highly qualified emergency medical aid and clinical study of accidents. In Moscow, the Sklifosovsky Emergency Medical Aid Institute, in Leningrad, such an institute has been created on the basis of certain medical institutions and scientific research institutes. These institutes pay special attention to scientific research work on studying treatment and prevention methods in accidents. The institutes have departments of emergency surgery with a traumatology department, therapeutic departments, mainly studying poisonings, pathological-anatomical and forensic medical departments. In the Leningrad Emergency Medical Aid Institute, there is also a department of social pathology and prevention with offices for industrial and domestic trauma, educational-statistical and museum departments. In recent years, in a number of countries, airplanes have begun to be used for providing Emergency Medical Aid, especially in cases where assistance must be provided to accident victims or severely ill persons in remote, inaccessible areas. Australia was the first country to begin widely using sanitary airplanes in the last decade not only for providing Emergency Medical Aid but also for regular medical service in remote sparsely populated areas. In the USSR, the practice of providing Emergency Medical Aid and directing patients to treatment facilities with the help of special sanitary airplanes is also beginning to be widely practiced. Sanitary airplanes can have wide application in providing Emergency Medical Aid to rural areas, the Red Army. In large cities, Emergency Medical Aid also includes the organization of rescue on water. In this case, in a number of places on the banks of rivers, canals, in addition to rescue rings, there are motorboats for rescuing drowning persons. Particularly large tasks fall on Emergency Medical Aid serving coal mines. Emergency Medical Aid stations serving mines are called mine rescue stations (see Mining, mine rescue work). For providing Emergency Medical Aid on railroads, in trains, at stations, there are special first aid kits. In some trains and especially at railroad stations, there are tools necessary for freeing passengers trapped between cars and those who came under cars during railroad disasters. At major stations, there are so-called auxiliary trains consisting of a car with equipment for providing technical assistance in railroad crashes, a car for workers and a sanitary car with an operating room, dressing room, equipped with necessary surgical instruments, dressing materials, medications, stretchers, splints, etc.

The operation of these auxiliary trains is regulated by special rules. In rural areas, Emergency Medical Aid is provided by the nearest local medical institutions. With the increase in the number of automobiles in state farms and collective farms and the improvement of roads, Emergency Medical Aid will become accessible to the rural population as well. To facilitate the provision of Emergency Medical Aid, especially during mass gatherings, in addition to medical personnel, members of the Red Cross Society, and workers trained in first aid are assigned to duty at special temporary Emergency Medical Aid stations. In many countries, there are extensive Red Cross organizations that form special sanitary columns, whose duties also include providing Emergency Medical Aid. An interesting innovation in the organization of Emergency Medical Aid exists in Berlin, where, in addition to scattered Emergency Medical Aid stations throughout the city (usually consisting of 3 rooms, one of which is an operating room), special Emergency Medical Aid cabinets in the form of round columns, 3½ meters high and 1.1 meters wide, have been installed on many of the busiest streets. In the upper part of these cabinets are instruments, medicines, and first aid supplies for providing initial Emergency Medical Aid in case of accidents on the streets; in the lower part are mobile (on wheels) stretchers, which can be easily removed and quickly used to transport the injured to the nearest Emergency Medical Aid station or the nearest medical institution. The Emergency Medical Aid station monitors the proper condition of the stretchers and the replenishment of first aid supplies. The equipment of such a cabinet costs 3,500 marks. Emergency Medical Aid should participate in the implementation of preventive measures against accidents, often taking the initiative in drawing attention to prevention issues, since Emergency Medical Aid has the necessary data on the causes and nature of accidents. To reduce the number of requests for Emergency Medical Aid, i.e., to reduce the number of accidents, it is necessary to implement a series of preventive measures: establishing proper traffic flow (regulation) and monitoring compliance with established rules, proper accounting for the prospective development of traffic when planning and replanning cities, laying out new streets and expanding old ones; educating the population on traffic rules (using cinema, radio, schools, lectures, clubs, posters, etc.); monitoring the proper functioning of all safety devices (supervision of engines, brake operation, etc.); explaining to the population the dangers of improper use of gas and electricity; bringing violators of safety rules to legal responsibility; mandatory swimming instruction for schoolchildren, publication of popular brochures on first aid, etc. All activities of Emergency Medical Aid stations are regulated by special provisions that cover the organization of Emergency Medical Aid in individual and mass accidents, transportation of patients and the injured, the tasks of medical institutions in providing Emergency Medical Aid, and the duties of medical and technical personnel serving at Emergency Medical Aid stations. There are special instructions for Emergency Medical Aid physicians, Emergency Medical Aid paramedics, for on-duty psychiatrists on the procedure for serving infectious patients, on disinfection of vehicles, etc. (see Health Department, First Aid).