Emergency care system of a city: Sum is more than its components.

The citizen of any city requires a robust emergency care system for feel safe in case of any emergency. We all know that those emergencies never come announced and if there is no system of care in place then patients are at the mercy of whatever services they can find out themselves. It does have the potential to create more harm, if it is not well organized. A city administration owe it to the citizens to provide a better system for the health care in emergency situations. This system should have following components to run smoothly.

1. Emergency response:
   1. First responders: These are trained members of the community who respond to any emergency situation. Their role is very important especially in places where the Emergency Medical Services(EMS) staff will take a bit longer to reach. They are called CFR (Community First Responders) or MFR (Medical First Responders). They have basic training for emergency situation, and usually they are non-medical people. They are trained on safety principle and on “do no harm” principle. They stabilize the patient and try to prevent further harm till the help arrives. Their presence in any community is an important safety aspect in times of emergency.
   2. Emergency Medical services: The Emergency Medical Services (EMS) provide the backbone of pre-hospital care. These are highly trained individuals in life saving skills who respond to any emergency situation. They are trained in life saving skills, medical management, airway and trauma management skills and also experienced in rescue and transfer. They respond quick as time is essence in all those cases. Their areas of expertise is vast, and their teamwork is their biggest strength. They take patients to the nearest or most suited emergency department for the definitive care. They cover the areas of whole city and create a network of care in association with all hospitals of the area. This collaboration helps provide timely care in all cases of emergency or trauma. They also serve as first responders in cases of large level emergencies or disaster.
2. Care provision.
   1. Emergency Department(ED).The emergency departments(ED’S) are seen as the safety net and 24/7 lifeline for the entire community. For the obvious reasons of being open all the time, having a physician available, ready to treat all diseases, all age groups and all socioeconomic aspects of the society in need. The ED takes care of all medical emergencies, trauma emergencies, and any situation which is perceived by the patients as emergency. Its scope is very wide and most people require very timely care which can only be provided in the ED. It is essential part of any healthcare system and needed to be supported by robust pre-hospital care as well as expeditious definitive care by the hospital. The job of emergency care staff is to rapidly stabilize the patient, do timely investigation and then dispose the patients appropriately. It coordinates well with pre-hospital system and so receives patients from the site of emergency to the hospital. A pre-notification helps arrange the resources needed to care for the patients coming to the ED, so the care becomes well-coordinated.
   2. Trauma Center: The trauma centers are emergency departments but with provision to care for trauma patients. The trauma patients require services of a well-run team with surgeon at the center of that team. An expedited and coordinated care of trauma patients give them maximum chance of coming back to active life after recovery. In a city all hospitals need not to be geared towards trauma care as it is resource intensive to run as 24/7/365 service. But every city must have atleast one such center to care for trauma victims. A full scale trauma service includes everything a patient can need after the trauma to its prevention. So a team of trauma surgeons and nurses, the trauma care units and its caring staff, the rehabilitation team and lastly an outreach program in the community to work on prevention.
3. Communication and coordination:
   1. Dispatch centers: All pre-hospital care should be coordinated through a dispatch center. The dispatch gets the information from the field and it coordinates with the ambulance crew. It sends appropriate staff to the scene of any emergency to provide needed help on the scene and then takes them to the emergency department for further care. The dispatch center should have all the information about all local hospitals and resources so it would use that information to send patients to appropriate places to get needed treatment. The patients requiring trauma care should be diverted towards trauma centers even when it means bypassing one of two local emergency departments with no trauma capabilities. Similarly a patient having heart attack should be sent to a hospital with 24/7 cath lab services so that whenever these services are needed the patient need not to be moved again.
   2. Communication network: A communication network is similar to dispatch center, but it involves all resources including pre-hospital, hospital ED, and hospitals resource or bed-management services along with local health department and other officials. The idea is to keep every person involved in any form of emergency healthcare should be well informed and on the same page as regards to the burden of emergencies and available resources of the city. The city should have a documented capacity known all the time and whenever it changes the information should be updated real-time. On the basis of this information plenty of decision will be made about patients. This system makes flow of information available to all stakeholders to get the benefit or provide the needed help.
   3. Trauma care network: Trauma care network can be local, citywide or nationwide. The trauma care improves when we collect an outcome data and see what worked and what needed to be improved. It also means deciding how the trauma care will be imparted when the resources start depleting. Also at the city level it should be known that how many people can be taken care of by the system. When the number of patients exceed this number, a citywide alert and escalation will help deal with the additional burden. 
4. Additional resources:
   1. Urgent care centers: Urgent care center or urgent care clinics are places where a patient can go for any urgent or out of normal hours care. It has a defined scope and limitation, and serves the purpose of helping the emergency departments decrease their burden of walking or less sick patients. In Pakistan this concept has not materialized yet, but with increasing number of trained emergency physicians, we will start seeing these centers coming nicely along to care for patients. These urgent care centers sometimes are also called “mini emergency room” or “mini ER”, but it is a misnomer. The urgent care centers are not meant for emergencies, as most of the emergencies require extensive work up and potential need for either cardiac cath lab or operating room needs. An urgent care can not provide these services. Similarly a trauma patient or head injury patient or patient with severe abdominal pain should go to ED and not come to urgent care.
   2. Mental health centers: This is another area that has wide acceptance in the west but is not well developed in Pakistan. We need to develop these centers to make sure our citizen have access to centers proving mental health. There should also be helplines for depression, anxiety or suicide.
   3. Poison control centers: It is an excellent service which serves the ED staff as well as for the general public. It comes handy whenever there is an overdose, or accidental ingestion of a liquid or drug, and we need to know what needs to be done. This service is available for all in USA, but in Pakistan we have no widespread availability of Poison Control Center, although there are a few services which can provide limited information on poisoning, toxicity and overdosage.
5. Technology support:
   1. EMR: Electronic Medical Record (EMR) is making its way in Pakistan. It serves great purpose which is well known to all of us. In order to establish a citywide emergency care system, it is imperative for the city to ask for the EMR to be implemented in all the emergency departments. This will help the city to know the realtime burden of the emergency departments as well as the number of sick patients needing ICU care. In this day and age the data is everything and any system which uses realtime data to adjust or tailor its functions can do much better job then system without EMR.  
   2. GPS tracking: It helps in locating the ambulances and also finding clusters of diseases if our medical first responders are also part of this system. We know that our ambulance system is equipped with GPS tracker atleast 1122 system, which helps the dispatcher is their day to day function. We also would need all ambulances take heed and be fitted with GPS tracker to help the system get equipped with right information realtime.
   3. Telemedicine: Although it was expected that Pakistan may be a country which will lag in this areas also, but due to COVID-19, it got expedited. Plenty of physicians individually and some healthcare organizations have started realizing the telemedicine as form of better utilization of scarce resources. In our cases, our specialists. We know that it is not a solution at this time and age for Pakistan to have all types of consultants in all areas of Pakistan. A more practical solution is through utilization of the Telemedicine systems across Pakistan.
6. Education and prevention.

A fundamental part of any healthcare system should be prevention. If the prevention part id not appropriately tackled, it becomes more expenses to address the health issues of the community or the city. We all know the disease has a genetic basis, yet there are factors very important that make these diseases manifest early or be more aggressive. These are modifiable factors, and educating citizens about them would lead to less burden of disease and less burden onto the healthcare system. Below is a very small list of those issues which should be part of education that healthcare stakeholders should keep in mind to educate their patients and other citizens about.

1. 1. Public education for:
      1. Prevention of infection: Infections are significant part of our daily occurrence. We treat patients for them and also are concerned about the spread of infections. We know more about it as the world has just recovered from COVID and that was the most significant influencer of prevention in our lifetime. Similarly Tuberculosis is rampant in Pakistan and needs proper preventive education to all to about TB in our patients.
      2. Injury prevention: Another issue that requires efforts of the healthcare community is injury prevention. It is a vast topic and is not just accidents that most of us may think. It includes road traffic accidents, and also accidents happening to adults and kids at home, like falls, electrocution, accidental ingestion of substances and burns of various kinds. There should be significant time spent on educating our patients and other citizens on all aspects of injury prevention, especially making houses safe for kids.
      3. Rehabilitation: It is another way of preventive strategy. It prevents further escalation of disease or the condition and also prevents complications arising from lack of rehabilitation. All healthcare related staff should focus on getting people back to their previous way of active living or atleast close to that condition. Most neglected are cardiac rehab, pulmonary rehab and we should make sure our patients get maximum chance of going back at maximal medical and physical improvement.
   2. Disaster preparedness: Disaster management is now a science in itself and all cities should have a system to deal with disasters. This system needs to be tested also and updated based upon result of the test, or drill. It’s a collaborative task and tests the hospitals way on making sure everyone knows how to act smart and collaboratively so everyone working together help the victims of disaster maximum chance of returning to their previous life styles with least amount of disturbance.

Islamabad is Capital of Islamic Republic of Pakistan, and a very beautiful and clean city. Its population is over 1.2 million in the year 2024.(1)  There is sufficient infrastructure to support not just the city dweller but also people from northern part of Pakistan. It needs a collaborative system of pre-hospital, emergency departments and other areas of hospital as well as community involvement to provide better and quality care to patients. The Government officials should make sure that the city develops a robust system of integrated healthcare provision. 

1. Islamabad. (2024, April 1). In Wikipedia. https://en.wikipedia.org/wiki/Islamabad