EMERGENCY MEDICAL SERVICES

• Emergency Medical Services (EMS) has grown from funeral homes using hearses as ambulances to one of the fastest growing industries in the United States!

What is EMS?• A coordinated network of professionals whose

function is to provide a variety of medical services to people who need emergent care.

Mission of EMS

Three-fold:1. Provide out-of-hospital patient care in

anticipation of transport to more definitive care at the hospital.

2. Public Safety: injury and illness prevention to disaster preparedness - The goal is for citizens to be free from risk and harm.

3. Public Health: caring for the entire community by identifying public health concerns and to work with the public health system to resolve issues.

3-Fold Mission of EMS

History of EMS

Military Contribution to EMS

• Before there were antibiotics and immunizations, war deaths were a result of disease more than from injury and wounds.

• 1500 B.C. Roman WarsRomans and Greeks used chariots to remove wounded from the battlefield

• 1797 The Napoleonic WarsNapoleon’s Chief Surgeon, Baron Dominique-Jean Larrey constructs a horse-drawn carriage called the ambulance volante, or “flying ambulances.”

Ambulance Volante

• 1860’s The U.S. Civil War– The first U.S. Ambulance Service is developed by

U.S. Army Surgeon, Jonathan Letterman.

1860’s The U.S. Civil War

– Clara Barton volunteers on the Civil War battlefields.

– Barton founds the American Red Cross.

• 1910 – 1940 The World Wars– 1917 – the first air medical transport utilizing a

French fighter aircraft– Advanced procedures are brought to the frontlines

including: intravenous solutions, antibiotics, and intraosseous (into bone) needles

– Improved systems for trauma care including field hospitals

– Mechanized ambulance with Red Cross symbol on the side

1950 – 1970 Korean and Vietnam War

– Mobile Army Surgical Hospitals (M.A.S.H.) units developed

– Transportation of wounded soldiers by helicopter– The HU-1, Huey, helicopter is deployed ; it’s large

patient compartment allows emergency care to begin while in flight

1970’s – Present (Iraq War)– The 68W, healthcare specialist, Army medic, is

introduced– Advances include special blood-stopping

dressings, one-handed tourniquets, and special surgical procedures for extremity injuries and burns.

Civilian Contribution to EMS

• In the civilian realm, ambulances used solely for transporting the sick and injured were rare.

• By 1966, most ambulances (> than half) were still owned by funeral homes.

• During the 1960’s, rescue squads began emerging out of fire departments.

Civilian Contribution to EMS

• 1865 – 1950 U.S. Ambulance Services– 1865 First civilian ambulance service established

in Cincinnati– 1869 New York City establishes an ambulance

service with hospital interns riding in horse-drawn carriages

Civilian Contribution to EMS

• 1865 – 1950 U.S. Ambulance Services– 1910 One of the first ambulances, called the

“Invalid’s Car”, with a nurse and resident from the hospital

– 1928 The Roanoke Life Saving and First Aid Squad is formed as the first volunteer rescue squad in the U.S.

Civilian Contribution to EMS

• 1950’s Out-of-Hospital Medical Advances– American Red Cross takes the lead in providing

basic medical training– Late 1950’s and early 60’s - CPR is taught to

civilians for the first time

Dr. Peter Josef Safar

• Father of Cardiopulmonary Resuscitation (CPR)• Pioneer in critical care medicine and a three-time

Nobel Prize nominee for medicine.• Mouth-to-mouth ventilation is demonstrated by Dr.

Safar. • His lifelong goal was to "save the hearts and brains of

those too young to die.“

Dr. Peter Josef Safar

• In 1966, while Dr. Safar was away at a medical conference, his 11 year old daughter, Elizabeth, fell into an asthma-induced coma and died. Safar became convinced that lay people, not just doctors, had to be trained in resuscitation if lives were to be saved.

Dr. Peter Josef Safar

• One year after his daughter’s death, he designed and implemented the first ambulance service with a physician and volunteers trained in CPR.

Dr. Joseph “Deke” Farrington

• The Father of EMS• 1958 - starts EMT-Ambulance course

Civilian Contribution to EMS• 1960’s Development of an EMS System– A report entitled “Accidental Death and Disability”

was released that stated that more Americans have died on U.S. highways than in all U.S. wars to date

– The National Highway Safety Act of 1966 encourages states to begin organized EMS programs

– 1968 St. Vincent’s Hospital in New York City establishes the first coronary care unit and mobile coronary care units staffed with cardiologists (now replaced with trained EMT’s)

• 1960’s Development of an EMS System

– 1969 the first nationally recognized EMT course held in Wisconsin

– First paramedic services established in Miami, FL

Civilian Contribution to EMS

• 1970’s The Star of Life and Voices of EMS– 1970 National Registry of EMT’s (NREMT), a

national EMS certification organization that maintains a registry of certifications, is established

– 1973 The Star of Life adopted as the national EMS symbol representing the six points of the complete EMS system

Star of Life

• This symbol can be found on ambulances, emergency medical equipment, patches and apparel worn by EMS providers.

• It can also be found on road maps and highway signs indicating the location of or access to qualified emergency medical care.

• 1979 the American Ambulance Association (AAA) is founded

• 1984 - the EMS for Children (EMS-C) program, under the Public Health Act, is established providing funds for enhancing the EMS system to better serve pediatric patients.

Modern EMS

• UNIVERSAL ACCESS - The first step in EMS is detection and reporting.

• In the past, it was standard across the country to use a seven-digit number to access emergency medical care, police, or fire assistance.

• Each community had a different number• Made it difficult for travelers to get help

quickly

9-1-1

• In 1968, a three-digit, universal access number was initiated by AT&T that was easier to remember.

• Dispatch centers have enhanced capabilities to help determine the exact location of the caller through the use of a computerized system that identifies the exact location of the caller

• Identifies the police, fire, and medical units closest to the location.

9-1-1• Over 200 million calls are made each year to a

public safety access point (PSAP) by citizens using 9-1-1.

• PSAP – a communication center where calls are routed to emergency response units by call-takers in over 6,000 primary and secondary regional PSAP’s throughout the U.S.

• These regional PSAP’s provide 9-1-1 coverage to more than 99% of the American population.

• 9-1-1 service is being expanded to include cell phones to pinpoint the caller’s location.

• Who answers the 9-1-1 call????

Emergency Medical Dispatch

• Answering the 9-1-1 call at the PSAP is the emergency medical dispatcher, or in some places is called the medical communicator (MEDCOM) or the communication specialist (COMSPEC).

• An emergency dispatcher is a trained call-taker who can take down the caller information while alerting emergency services such as fire, police, and emergency medical services.

Emergency Medical Dispatch

• Many PSAP’s try to have their dispatchers answer the 9-1-1 call within 30 seconds more than 95% of the time.

• They also try to dispatch appropriate first-responding emergency units within 90 seconds from the time the call is received in accordance with the National Fire Protection Association (NFPA) standards.

Emergency Medical Dispatch

• In the past, dispatchers would give simple instructions to the injured or ill or to family members, not detailed life-saving instructions until 1976 when emergency medical dispatch began.

• Now, specially-trained call takers, or dispatchers, provide specific pre-arrival medical care instructions to callers while emergency crews respond.

Emergency Medical Dispatch

• The instructions range from how to control bleeding from a wound to how to deliver a baby to how to perform CPR.

• Emergency medical dispatchers are the “first first-responders”

FIRST RESPONDERS

• The first person who arrives at the scene of an injury or illness can be referred to as a first responder (FR).

• Often are police officers, security guards, or members of the fire department, but can be citizens

• Classes are offered by the American Red Cross and the American Heart Association for citizens, but more advanced, specialized training is needed for police officers, security guards, and members of the fire department.

EMERGENCY MEDICAL RESPONDERS

• This advanced level of training is called Emergency Medical Responder (EMR).

• The EMR learns basic assessment, simple airway management, oxygen administration, bleeding control, rescuer CPR, and defibrillation

• An average course is about 50 hours

EMERGENCY MEDICAL TECHNICIAN

• A person who has completed the basic entry level of training for pre-hospital care is an Emergency Medical Technician (EMT Basic).

• Usually, EMT’s are found on an ambulance. In most jurisdictions, there must be at least one EMT attending to the patient at all times.

• EMT’s work in many different environments other than an ambulance.

EMERGENCY MEDICAL TECHNICIAN

• EMT’s can work as part of a SWAT team, in wilderness medicine, in public event venues, or in the field as soldiers.

• Skills include: airway maintenance, oxygen administration, bleeding control, CPR, defibrillation, patient assessment, limited medication administration, knowledge of basic illnesses, and the proper management of a patient during transport to a hospital.

ADVANCED EMERGENCY MEDICAL TECHNICIAN

• The next level of EMS provider is the Advanced Emergency Medical Technician (AEMT).

• The AEMT is first an EMT who can provide basic and some advanced emergency medical care.

• The role of an AEMT is an EMT who can manage the first 10 min’s of a life-threatening emergency in the pre-hospital setting using advanced skills and specialized equipment often seen in the emergency room.

ADVANCED EMERGENCY MEDICAL TECHNICIAN

• The scope of practice of an AEMT includes non-intubating airways, deep suctioning of the lungs, IV access, intraosseous access in children, administration of IV fluids, and a limited number of IV drugs.

PARAMEDIC

• The highest level of EMS education.• Most paramedic education programs are

offered at local community colleges or teaching hospitals

• The training program is usually between 1,000 and 1,500 hours

PARAMEDIC

• Skills include: comprehensive patient assessment, advanced airway management, IV techniques, expanded medication administration, and cardiac arrest management.

• Works closely with a physician and follows the physician’s instructions regarding patient care (often in the form of written protocols).

EMERGENCY PHYSICIANS

• Physicians who are specially trained in rapid assessment and diagnosis of acutely ill or traumatically injured patients.

• The Emergency Physician is the leader of the EMS team.

• In 1968, the American College of Emergency Physicians (ACEP) was formed. It’s mission is to advance the cause of emergency medicine as a medical specialty.

• In 1979, emergency medicine was recognized as the 23rd specialty in medicine.

American College of….

• American College of Physicians (Internal Med)• American College of Surgeons (FACS)• American College of Radiology• American College of Rheumatology• American College of Obstetricians and

Gynecology

PRACTICE OF EMERGENCY MEDICINE

• Most Emergency Physicians practice in the Emergency Department (ED).

• The ED interacts with hospital services and pre-hospital services such as the EMS.

• A place to which people with medical emergencies can go, unscheduled, and receive immediate care.

• Open 24/7

SPECIALTY CARE CENTERS

• Trauma Center – the 1st specialty center• Trauma patients need expert surgical care

within the first hour of their injury, called “the golden-hour”.

• Proper surgical care within this golden hour is associated with the best chance of survival for a seriously injured patient

• In 1980, the U.S. Department of Health and Human Services released a paper that categorized hospitals and systems of trauma care. (i.e., Level 1 Trauma Center)

• Hospitals that have the capability to properly manage severely traumatized patients are designated as trauma centers.

AEROMEDICAL TRANSPORTATION

• Aeromedical services is another aspect of EMS that provide rapid transport.

• Today, more than 250 aeromedical services exist in the U.S.

• The mission is for pre-hospital emergency response and for interfacility transport.

• Flight teams are made up of a registered nurse and an Emergency Medical Technician Paramedic with specialized aeromedical training.

FUTURE OF EMS

• Aging Americans – After WWII, there was a huge increase in the number of births in the U.S. which came to be called the baby boom.

• Today, these children of the baby boom era known as the “baby boomers” are becoming middle-aged and elderly.

• The number of EMS calls to the elderly are increasing.

• Homelessness – many people with psychiatric illnesses live independently.

• These people sometimes cannot care for themselves.

• Because of their lack of regular health care and adequate housing, the homeless have come to rely on the EMS system and emergency departments for their medical care.

• Infectious Diseases – new infections such as MRSA and certain flu viruses are challenging the way that EMT’s perform their functions, increasing the importance of infection control practices and preventive immunizations.

OPERATIONAL CHALLENGES

• Staffing – In many rural areas of the U.S., EMS is provided by volunteers. With today’s economy, it is necessary for most households to have two incomes, reducing the number of volunteers available. This is a significant challenge to the EMS.

• Financial Restrictions – the requirements for equipment, training, insurance, and other costs in today’s out-of-hospital health care system can be overwhelming.

Volunteer organizations may find it difficult to fulfill these requirements with the minimal funding at their disposal. Many volunteer EMS agencies have been forced to close.

OPERATIONAL CHALLENGES

• Accountability – accountability for expenses is being demanded of every governmental organization, including EMS. Tax-payers want to know that their money is being spent wisely and cost-effectively.

Most EMS agencies are involved in either quality assurance or continuous quality improvement (QI) programs which are designed to find and address areas in need of improvement within the agency.

These types of programs help ensure that the EMS system is able to provide high-quality patient care at a reasonable cost.