COMMUNITY HEALTH 181
fluids. All ambulance equipment and EMT-A training is
approved by official boards of physicians and other health
care professionals; it is used in accord with tested protocols
and the support of hospital physicians via radio communica-
tion when needed.
Helicopter emergency transport of patients, first used
by several municipal ambulance systems in the early 1960s,
was proven of value in military use. Helicopters and emer-
gency technicians provide rapid patient evacuation over dif-
ficult terrain or locations that wheeled vehicles can reach
only with difficulty. Helicopters are dispatched from a cen-
tral location and radio communication provides directions
to the helicopter pilot and continuous medical consulta-
tion for the medical attendants. As in any other ambulance,
expert patient care is provided both initially on the ground
and then in the air en route to a designated hospital center,
thus avoiding rough highway carries. Vital data for on-going
patient care is supplied by electrocardiograms (ECGs) and
other clinical information is transmitted directly to a base
hospital trauma center where a skilled physician is in direct
voice radio contact and guides the prompt resuscitation of
patients. Additional electronic support for advanced mobile
sick care, including image transmission and limited or spe-
cial laboratory services can be expected to be developed in
this decade.
Regional hospital-based trauma centers receive casualties
according to protocols that have been developed by regional
emergency medical service committees. Each is staffed
and equipped to provide complete skilled care for critically
injured or severely ill patients. Trauma centers are regulated
by a state agency and based at hospitals after a careful selec-
tion process that considers need, existing transport networks,
and available staffing. Each must agree to maintain superior
medical and surgical staff capability, and be ready to receive
patients with urgent medical problems or extensive injuries
around the clock. Critical care support must be extended in
hospitals allied with the trauma center to provide patients
needed long-term care through expected periods of recovery
and initial rehabilitation. A trauma center concept best fits
hospitals that are closely allied with medical schools, and it
relieves small community hospitals of legal and economic
burdens of severe trauma. Trauma centers may also accept
urgent transfers from efficient community hospitals when
severe injuries have been stabilized sufficiently for transport.
A community hospital need not operate an emergency
care department but, if it does, all persons seeking medical,
surgical, or psychiatric help must be accepted. Each patient
must receive prompt and appropriate treatment and dispo-
sition, even if continued care is accomplished elsewhere.
Although residents of a community may view a nearby
emergency department as a walk-in clinic for the manage-
ment of minor ailments, each of these special departments
must be fully equipped and adequately staffed for critical
care conditions. Physicians should be qualified for advanced
life support care (ALS) and the nurses for basic life support
(BLS), as a minimum. Emergency physicians preferably are
certified by an appropriate emergency specialty board. The
high costs of hospital emergency care is offset by assuredpayments for a wide range of costly services to patients with
full insurance coverage who are admitted.COMPUTERS AND TELEMEDICINEComputer storage and transmission of information in clini-
cal practice has lagged behind industrial usage, largely due
to the confidential nature of patient data. A relative inad-
equate computer literacy of older, experienced physicians
who must learn to enter data according to prescribed formats
may account for some continued reluctance in the accep-
tance of electronic clinical data systems. Despite more gen-
eral availability of more compact personal computers and
electronic bookkeeping systems now installed in the offices
of most physicians and clinics, maintaining patient records
in computerized systems has advanced slowly.
In 1991, the Institute of Medicine (IOM) released a
report that urged adoption of a computer-based patient
record as standard medical practice in the United States.^15 In
1995, Beverly Woodward discussed many aspects of com-
puter use in medical care.^16 Attempts to design algorithms
that replicate complex thought processes a trained physi-
cian uses to probe the history of a patient’s illness or solve
a clinical problem have not been uniformly commercially
successful. Generation, storage, and easy retrieval of clini-
cal records expose the data to improper use by persons who
are not entitled to confidential information. Data that include
treatment for AIDS or psychiatric illnesses, for example, are
particularly sensitive because of their possible misuse by
employers, insurance companies, or legal systems.
Computers have proven useful in hospitals to store and
have readily available cumulative information that records
hourly and daily patient care data and provides easy review of
a patient’s progress. But start-up costs are high and training
of hospital staffs includes nursing personnel, administrators,
and other care givers, such as visiting personal physicians
and consultants. Lindberg and Humphreys of the National
Library of Medicine (NLM) have discussed other uses for
computers in medicine that are now being explored.^17
Boards in each state that license physicians and national
professional specialty societies regularly use computers to
store data and track careers of individual physicians and other
regulated health care professionals. State licensing boards
that need to research a physician’s application for medical
licensure can access information in the National Practitioner
Data Bank that briefly describes pertinent disciplinary expe-
riences in any of the 50 states.^18 National specialty societies
have computerized the credits earned in cumulative continu-
ing medical education (CME), critical information that each
member can access when applying for license or specialty
certification renewals.
Telemedicine and related modem technology provide
access through e-mail or the World Wide Web to specialists
and the National Library of Medicine in Bethesda, MD for
instant consultations, making it possible for distant and iso-
lated communities quickly to obtain needed expert medical
and surgical advice and guidance.C003_002_r03.indd 181C003_002_r03.indd 181 11/18/2005 10:17:42 AM11/18/2005 10:17:42 AM