Emergency medicine includes two major parts: pre-hospital emergency and in-hospital emergency. At present, pre-hospital emergency is mainly based on 120 emergency system, while in-hospital emergency is mainly based on emergency departments of hospitals, and in some areas, 120 emergency and emergency departments of local hospitals are combined to become one.
Whether pre-hospital or hospital emergency, are involved in emergency software and hardware issues. The so-called software is the personnel quality and regulations. From the point of view of the development history of China's first aid, the establishment of a real secondary discipline for a short period of time, the lack of effective and sound emergency medical practitioners training system and access system, so the personnel is not whole, uneven technology, standardization is not enough, affecting the development of emergency medicine. In addition, most of the medical schools lack of emergency medicine professional training and training, only a very small number of colleges and universities have established emergency medicine department and emergency medicine teaching and research department, medical graduates also lack of standardized training rotation system. The author discusses the development and standardization of emergency medicine in China in the light of the situation of emergency medicine in foreign countries.
Hardware equipment
Current situation of emergency department Emergency department is often not large enough, the layout is unreasonable, emergency room access is not smooth, no independent access, access to the rescue room is not smooth, more curves, not conducive to rapid access; clinic set up or layout is not in place, clinic is not large enough, no necessary examination equipment, no movable examination beds, the occurrence of emergencies, is not conducive to the patient transfer into the rescue room; not in place clinic set up or layout, clinic is not large enough, no necessary examination instruments, no movable examination beds, not conducive to the patient transfer into the emergency room; not in place, not in place, not in place, clinic is not big enough, no essential examination instruments, no movable examination beds, the occurrence of emergencies, not conducive to the patient transfer into the rescue room. Into the rescue room; do not have an operating room and orthopedic plaster room (or too simple), can not meet the trauma first aid used; emergency vehicle equipment is unreasonable, no oxygen, ventilator, monitor and defibrillation equipment, etc., the stretcher can not be folded and lifting, no special shovel stretcher.
First aid car should be equipped with equipment First aid car should be equipped with simple first aid box, including simple auxiliary respirator, conventional oxygen equipment, oral protection equipment, endotracheal intubation equipment, open vein equipment, trauma protection equipment (including neck brace, etc.), cardiac and electric monitoring and defibrillator, etc.;
First aid section should be equipped with equipment As a first aid section, the equipment should be sound, including respirator, hemofiltration machine, Ultrasonography, cardiac monitor, defibrillator, gastric lavage machine, etc.; In addition, flat car and wheelchair is seriously insufficient, resulting in unnecessary aggravation of the patient's condition in the examination process, and even sudden death in the emergency department. Emergency sub-specialty clinics should be set up reasonably, a variety of diagnosis and treatment of instruments required to be equipped with a comprehensive, such as checking the buckle diagnostic whacking, flashlight, sphygmomanometer, funduscope, laryngoscope and suction, etc., should be equipped in each clinic.
The emergency department needs more than one rescue car, each rescue car should have a set of rescue medicines, guardian defibrillator, surgical bag and tracheal intubation and other equipment, and listed in the list of medicines and auxiliary items, every day by the nurse in charge of the inventory and signature, and record the inventory time.
More importantly, the equipment and instruments for emergency examination (including X-ray and ultrasound equipment, gastroscopy and tracheoscopy, etc., of which the X-ray machine should be placed above the resuscitation bed, mobile) should be fully in place, and convenient, 24 hours a day, all the way to the green light.
In addition, the emergency should be set up in isolation, in the event of special cases, the corresponding measures can be implemented, can not be temporary.
Emergency, emergency medical personnel training
Emergency department professionals are lacking, the past situation is that medical students are directly assigned to the emergency department after graduation, there is no corresponding specialized training, or by the internal medicine transferred to the emergency department. At present, although there is a part of the training, but the training is not standardized, standardized items can not reach, rotation time is not enough, the necessary training is not or not enough, especially cardiovascular and respiratory internal medicine training, surgical care unit, anesthesiology, neurology, surgery, infectious diseases, radiology and so on, at least 3 years to reach the degree of general practice.
Today's international generalist literacy is very much in line with the characteristics of emergency care, both pre-hospital and in-hospital, which is timely, accurate, and comprehensive, without delay, without delay, and without medical disputes due to waiting or untimely calls. Emergency physicians in the United States and Singapore are required to rotate for at least three years, rotating departments including surgery, orthopedics, pediatrics, ophthalmology, urology, otolaryngology, neurology, dermatology, obstetrics and gynecology and anesthesiology, etc., and to pass the critical care, resuscitation, toxicology and traumatology training assessment.
An access system for emergency physicians should be established, and all medical personnel involved in the emergency system must complete the training program, take the examination, and obtain a certificate of resuscitation. It is impossible to become an emergency physician without all the training certificates. Resuscitation training should include primary cardiopulmonary resuscitation, advanced cardiopulmonary resuscitation, primary trauma resuscitation, and advanced trauma resuscitation techniques in order to produce true emergency physicians. In order to accomplish or achieve the above objectives, it is necessary to establish training centers at all levels and to domesticate, institutionalize and standardize our training. It is a long-term institutionalized task to train not only medical personnel, but also relevant personnel in the society.
At present, our country still follows the system of running training courses (such as temporary, irregularly organized Chinese and American resuscitation training, etc.), which can not achieve the purpose of popularization and standardization, and even more can not achieve the goal of regular updating.
Rules and regulations of the Emergency Department
At present, people's awareness of the law, self-protection awareness has increased, which requires doctors to regulate their behavior, especially the standardization of diagnosis and treatment behavior, in strict accordance with the standard of diagnosis and treatment operations to do, too much or too little, will bring problems. For different levels of doctors and nurses, it is necessary to set the scope of their operations. At present, what we lack is no one to formulate the diagnosis and treatment operation standard, completely based on experience and feeling, this situation is bound to occur for medical disputes and accidents buried hidden danger.
As an academic institution, the Society should be responsible for the development of a variety of emergency medicine, including a variety of diagnosis of acute and critical illnesses, treatment and other specific steps, such as chest pain diagnostic and treatment procedures, abdominal pain diagnostic and treatment procedures, gastrointestinal hemorrhage diagnostic and treatment procedures, trauma diagnostic and treatment procedures, and poisoning disposal norms, etc., should also be made to record the form in detail. As long as the doctor's advice suggests that the patient's chest pain observation, the nurse will naturally follow the procedures to carry out electrocardiogram, cardiac enzymes and other tests. When the results are available, the nurse will call the doctor for the results. This can form a virtuous circle and reduce the occurrence of errors. Another example is head trauma observation protocol, nurse triage when the patient's vital signs are stable, there is no obvious contusion of the skull, Glasgow score is normal. However, if not according to the head trauma hospital observation, it is easy to ignore the subsequent changes in consciousness, may lead to intracranial hemorrhage of missed diagnosis, and then delayed treatment, resulting in the patient's coma, or even death.
Pre-hospital first aid
The purpose of pre-hospital first aid is to grab time, the so-called golden time. In addition to the organization, command, communication and other factors, the scene of the first aid personnel to use modern high-tech patient comprehensive, correct diagnosis and treatment is very important, otherwise talk about the golden time. On-site first aid should emphasize the first life-saving, after the treatment of injuries, after the identification of disease, to fast, accurate, timely and efficient as the principle.
There have been experts on pre-hospital emergency standardization issues and emergency medicine education and other recommendations, but there seems to be no more follow-up. There are many aspects of pre-hospital emergency care that need to be improved and standardized, including the establishment and improvement of a unified medical record on the emergency vehicle, which should record in detail the condition of the casualty or patient at the time of receiving, the scoring of vital signs and reasonable initial treatment. At present, there is no written record of the patient's complaints and physical examination results and condition, and there is no standardized tabular medical records.
In addition, the lack of appropriate treatment and protection of trauma patients, especially bleeding patients, bandaging measures and the necessary open intravenous rehydration therapy is insufficient, which will inevitably increase the risk of transport and lead to the loss of opportunities for in-hospital treatment.
There is a lack of effective advance notification and liaison between the emergency center and the hospital's emergency department, and the emergency department is often in a passive, hasty situation when there is a critical patient in need of rescue or a large number of casualties.
At the same time, the injured and their families or witnesses at the scene also lack of self-help and mutual aid action. Therefore, the popularization of first aid knowledge to the whole society is also a task we must pay attention to now.
Triage system and nurse training
The triage system must be reformed. Triage is often overlooked, but it is a very important part of emergency care. Traditionally, in China, nurses have been asked to triage, and nurses have been asked to make diagnoses and differential diagnoses, especially between medical and surgical diseases, between neurology and internal medicine, and between general surgery and other surgical diseases.
In order to triage and to identify, it is really difficult for nurses. Nurses in the triage, by looking, asking, touching, checking, etc. to determine the condition, rather than through the results of objective vital signs indicators. For the triage, should make the triage table, different kinds of diseases, should go to different clinic area. According to the patient's vital signs indicators and the content of the complaint will be divided into several categories, so that you can grasp the priority, targeted treatment of patients.
If the unified management of the emergency department, you can free the nurses, so that nurses to pay attention to the more important vital signs, fully committed to the care and support the work of the doctor. Emergency department nurses not only have to learn the principles of nursing and pharmacology, but also have to undergo primary CPR, advanced CPR, primary trauma resuscitation and advanced trauma resuscitation training. When encountering a traumatized patient, the nurse is able to give the first initial bandaging treatment. And emergency department nurses should often participate in the department rotation, to ensure that nurses can be exposed to all kinds of cases.
The return of emergency patients
The final return of emergency patients, depending on the situation, there are hospitalization, observation, and leave the hospital to go home. Overseas emergency patients on average stay 5-6 hours, rarely more than 12 hours, all triage within 24 hours, the rear wards will never shirk or selection of patients, each patient has the right to be hospitalized to get treatment. The actual situation in our country is that a large number of patients stay in the emergency department, observation time can be up to a few months, many internal medicine non-emergency patients stay in the emergency department, so that the emergency department can not play the role of emergency medicine, emergency medical personnel can not be dedicated to the clinical and basic research in emergency medicine, these are not conducive to the development of emergency medicine.
The emergency department should be a large triage desk, all kinds of patients will be categorized, the patient to give the appropriate treatment and then transferred to various specialized wards, such as vital signs are not stable, then give the treatment of stabilizing vital signs, improve the medical record, and then according to the situation of the escort to the intensive care unit.
For those patients who can go home after the initial treatment, the emergency physician should give a letter to the community clinic, or write a letter of outpatient specialty follow-up appointment, attached to the patient's examination in the emergency room and medical advice. The emergency department can make appointments for specialty clinic visits for emergency patients directly by phone.
Each department should develop appropriate hospitalization standards and systems for emergency department doctors to refer to, so that emergency department doctors can act according to the rules, each department does not have to send people to the emergency room to see the patient before deciding to hospitalization, unless special cases, should call the specialist to the scene to guide the handling of the outside (including neurosurgery, orthopedics, etc.). For cardiovascular emergencies, the cardiovascular department should arrange for the chief resident to be on duty 24 hours a day, and to come on call to decide whether the patient should receive percutaneous coronary intervention or thrombolysis.
A hospital, its work must include outpatient, emergency, wards, logistics, research and teaching of five major parts of the emergency is one of the important parts of the hospital, should not be compared with other subdepartments.
China should develop a plan to cultivate emergency medicine personnel with generalist qualities, unified management, including the rotation of doctors from other departments in the emergency room, standardize medical behavior, and develop various guidelines; set up different treatment teams to adapt to the development of medicine and society, including the poisoning group, trauma group, resuscitation group, and critical care group, etc., and the staff of the groups have each other's intersection, and each has its own focus. This can ensure that emergency medicine to the depth of development, rapid progress.
The rapid development of modern society will inevitably be accompanied by disasters, earthquakes, poisonings, chemical injuries, fires and other non-conventional events, emergency medicine in the treatment of conventional diseases at the same time, in response to the above non-conventional events should play their own responsibility. It is imperative to vigorously develop emergency medicine and to formulate and standardize emergency procedures and guidelines.