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EMERGENCY MEDICAL SERVICES
Photo of EMS treating a cardiac arrest patient.
The Emergency Medical Service system (known by the acronym "EMS" in the USA, Australia and Canada) is responsible for providing pre-hospital (or out-of-hospital) care by paramedics, emergency medical technicians (EMT's), and medical first responders (MFRs in US terminology).
EMS is also synonymous with: First Aid Squad, Emergency Squad, Safety Squad, Rescue Squad, Ambulance Squad, Life Squad or its initials spelled out, Emergency Medical Service. They usually all do the same thing but with different names, all representing the same basic thing: emergency patient care.
The goal of EMS is to provide early treatment to those in need of urgent medical care, and ultimately rapid transportation to an Emergency department. Stabilizing patients early (within the golden hour) significantly increases their chances of survival, particularly in the event of a heart attack, diabetic emergency, or severe physical trauma. Many EMT responsibilities also require the EMT to extricate the patient from where they are whether it is in a tight location in a home, or from a vehicle using the jaws of life.
EMS providers work under the license and indirect supervision of a medical director or board-certified physician who oversees the policies and protocols of a particular EMS system or organization. Due to the nature of the environment in which EMS personnel must work, equipment and procedures are necessarily limited; however, prehospital personnel are able to provide a high level of advanced care.
EMS professionals are trained to follow a formal and carefully designed decision tree, more commonly referred to as a protocol or standard of care, which has been created and approved by physicians. The emphasis in emergency services is on following correct procedure quickly and accurately rather than on making in-depth diagnoses that require much professional training and experience. The use of a decision tree allows EMS workers to be trained in a much shorter time than physicians, with EMT-Basic classes, for example, as short as 1-5 months.
Paramedic training is the highest level of EMT, and allows advanced airway skills including airway tube placement, emergency creation of an airway (crichothyrotomy), cardiac monitoring, 12 Lead EKG Interpretation, intravenous cannulation, intraosseous cannulation, transcutaneous cardiac pacing, central IV line placement, Pediatric Advanced Life Support (PALS) , Neonatal Resuscitation Program (NRP), Prehospital Trauma Life Support (PHTLS), Advanced Burn Life Support (ABLS), Rapid Sequence Intubation (RSI), and Advanced Cardiac Life Support. In addtion to the Paramedic level, Critical Care Paramedics specialize in the management of critical trauma and medical patients during interfacility ground and aeromedical transports to include: ventilator management, IV pump infusion maintenance, aortic balloon pump monitoring, and specialized hemodynamic monitoring.
National EMS standards for the US are determined by the U.S. Department of Transportation and modified by each state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Committees (usually in rural areas) or by other committees or even individual EMS providers. In addition, the National Registry of Emergency Medical Technicians, an independent body, was created in 1970 at the recommendation of President Lyndon B. Johnson in an effort to provide a nationwide consensus on protocols and a nationally accepted certification. National Registry certification is widely accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.
History
Emergency care in the field has been rendered in different forms since history began to be recorded. The Bible includes the Old Testament account of the Israelites being bitten by poisonous snakes. (Numbers 21:6-9) God commanded Moses to make a bronze snake and mount it on a pole. Then, anyone bitten must only look at the bronze snake and they would be healed. Some credit this account as the basis for the United States' EMS symbol, the Star of Life, where a single snake wrapped around a pole is seen in the center of a blue, six-barred cross. The six sides represent the six essential functions of EMS:
- Detection
- Reporting
- Response
- On Scene Care
- Care in Transit
- Transfer to Definitive Care
(from Rescue-EMS Magazine, July-August 1992)
However, others attribute this snake symbol to the Greek mythological figure Asclepius, the son of Apollo. Asclepius was trained as a healer by Cheron the Centaur. Once, when he consulted a serpent about a very difficult patient, the snake coiled around his staff in order to speak with him as an equal. Later, Asclepius was slewn by Zeus, but because of his remarkable healing ability, people began to worship in his temples. Eventually, Zeus brought him back to life as a god.
The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaratin. Luke 10:34 (NIV) - "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him."
During the Middle Ages, the Knights of St. John, also known as the Knights of Malta, began to help their injured comrades. The Knights of Malta began using a modified form of the Christian Cross, the Maltese Cross, to identify one another, and it is from this symbol that today's firefighter cross was developed. Many firefighters wear these crosses over their hearts to symbolize their willingness "to lay down his or her life for you, just as the Crusaders sacrificed their lives for their fellow man so many years ago." (http://www.lawrencefire.com/maltese_cross.asp)
The first modern account of EMS dates back to the days of Napoleon, when the French army used horse drawn "ambulances" to transport injured soldiers from the battlefield. One of the first civilian EMS services in the United States can be traced back to 1869, when Dr. Edward L. Dalton at Bellevue Hospital, then known as the Free Hospital of New York, in New York City started a basic transportation service for the sick and injured. The component of care on scene began in 1928, when Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad in the nation. Over the years EMS continued to evolve into much more than a "ride to the hospital."
A significant event in the development of modern standards of care in the U.S. was a report published in 1966 by the National Academy of Sciences entitled Accidental Death and Disability: The Neglected Disease of Modern Society, commonly referred to as "the White Paper." In this study, it became apparent that many of the deaths occurring every day were unnecessary, and could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments.
In particular, in the US state of California and in Seattle, Washington state (see Medic One), projects began to include paramedics in the EMS responses in the late 1960s. Groups in Pittsburgh, Pennsylvania and Portland, Oregon were also early pioneers in prehospital emergency medical training (see paramedic). Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the television series, Emergency! which in part followed the adventures of two Los Angeles County Fire Department paramedics as they responded to various types of medical emergency. James O. Page served as the series technical advisor and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.
Many EMS units are typically the same as a first aid, rescue, EMS, emergency or safety squad. However, a rescue squad may also be part of a fire department, race car team, or military unit. Frequently, certain members of these organizations will be cross-trained as EMS providers as well as being fully functional in their primary roles. In the U.S., the fire department may provide initial care, then transfer care to a different agency or organization who will transport the patient to the hospital. This is known as a two-tiered response. In many states or regions, transporting personnel will determine which hospital the patient will be transported to, such as a trauma facility, childrens hospital, etc., depending on severity of injuries, type of injuries, protocols, distance, and possibly othor factors.
In a return to the military roots of EMS, the United States Army has developed the combat lifesaver program to instruct soldiers in advanced first aid and limited paramedic skills including intubation. The combat lifesaver is intended to bridge the gap between self-aid / buddy-aid and the platoon medic on the 21st century decentralized battlefield.
Levels of Care
Two levels of care are provided by EMS systems: Basic Life Support (BLS) and Advanced Life Support (ALS). The National Registry of EMTs recognizes four levels of Emergency Medical Services providers:
Generally speaking, BLS providers provide all care outlined in the EMS standard of care, except for invasive procedures and (to a certain extent) giving medications. ALS providers can perform invasive procedures (intravenous cannulation, endotrachael intubation, etc.), give medications, analyze electrocardiograms, and so forth.
There are also Rescue EMTs who are certified and/or have the training in water rescue or in motor vehicle extrication using the jaws of life in medically directed rescue. There are also Rescue Technician certifications EMS providers are able to achieve. Many EMS providers offer any kind of rescue service, from rope rescue, to cave rescue, to water, extrication, search and rescue and so forth, as being medically capable is an obligation of any rescue member, no matter what department they work for (fire, police, ems, rescue, etc). Firefighters specifically, must comply with NFPA regulations that state that any rescue member be medically certified, and as some Fire Departments do not have FF/EMT's, leave all rescue up to EMS departments.
ALS providers are principally EMT-Paramedics (EMT-P) and EMT-Intermediates (EMT-I), who are certified to perform invasive procedures and to give a wide variety of drugs. Like paramedics, EMT-I's handle advanced airway management. EMT-I's, however, do not have the in-depth training that EMT-P's have and in many jurisdictions administer fewer medications.
In certain states other classifications exist, such as in New York, where there are 5 levels of EMS: CFR, EMT, AEMT-Intermediate, AEMT-Critical Care, and AEMT-Paramedic. Virginia has an EMT-Enhanced level as its entry-level ALS provider role, although this certification is not used in all local jurisdictions.
Aside from nationally-registered levels, in all emergency medical services, local protocols dictate the skills and procedures that can be legally performed by providers of the various levels.
Prehospital Care Strategies
See Organization of the emergency medical assistance: Prehospital care strategies.
Organization and Funding
In the USA
EMS in the US is delivered through various models. These include;
- Public EMS
- Third Service stand alone
- Third Service hospital based
- Fire Service fully integrated and cross trained
- Fire Service based, non-integrated (includes volunteer fire services)
- Police service based, includes Sheriff's Offices (Police and Fire Services being the first two emergency services)
- Private EMS
- large national companies
- Regional companies
- Small local "mom and pop" companies, and
- Funeral homes in some places, once the largest providers.
Funding and manpower models include:
- Volunteer Public, non-billing, subsidized by property or sales taxes
- Volunteer Public, non-billing, subsidized by donations
- Volunteer Public, calls billed, partially subsidized through property or sales taxes
- Volunteer Public during nights and weekends and per diem paid during weekdays with combination billing.
- Full time paid Private Enterprise, calls billed, partially subsidized through property or sales taxes
- Full time paid Private Enterprise, calls billed, no subsidy
- Full time paid Public Utility Model, calls billed, usually no subsidy
EMS is largely provided by volunteers outside of major cities. But due to the increasing intensity of training, EMS is becoming more of a paid profession. Even agencies that were once strictly volunteer have begun supplementing their ranks with compensated members in order to keep up with booming call volumes. As of 2004, the largest "Private Enterprise" provider of contract EMS services in North America is AMR or American Medical Response, based in Greenwood Village, Colorado. The second-largest US EMS provider is Rural/Metro Corporation, based in Scottsdale, Arizona; they also provide EMS services to parts of Latin America. Like AMR, Rural/Metro provides other transportation services, such as non-emergency transport and "coach," or wheelchair, transportation.
Fire Service in the US is rated through ISO classes and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. This relegates EMS funding to an emotional plea for funds during difficult financial times.
Each State in the USA has control over its EMS, and so more levels of certification may exist.
First Responder is usually the minimum level of certification and usually the level most fire fighters hold, especially in Tennessee and Virginia. In other states, such as Florida, volunteer firefighters are usually certified at the First Responder level but most career firefighters are certified at a minimum level of EMT Basic. States may also attach "add ons" to an existing certification. As an example, in Tennessee most basic level providers are Basic-IV, which simply means they can start IV lines in addition to their Basic level of certification. Other EMT levels in Tennessee exist as well, such as Intermediate 85, Intermediate 99, and Critical Care Paramedic. In Florida, as in several other states, there are only two levels of EMT: B (Basic) and P (Paramedic). The defibrillation or IV therapy "add ons" are available as well, but usually this is at a County or Department level. Each governing region decides what it needs based on manpower and money and alters the U.S. Government's recommendations accordingly.
Future challenges
In the United States, fire service-based EMS may face funding crises due to rapid increases in EMS calls in a department still devoted to and funded primarily for fire suppression. Compounding these financial difficulties are third party payers such as Medicare which view EMS as a transportion service and not a medical care service. Much of the public has been aware of EMS's medical capabilities since the early 1970s but many third party payers still seem oblivious after over 30 years of EMS successes.
Many feel, however, that this state of affairs is bound to change as new technologies continue to spur a drop in the number of fires annually. Already, most firefighters are required to have basic medical training, and many, as noted above, are fully cross-trained as EMTs or even paramedics, and furthermore, the focus on homeland security since the September 11, 2001 terrorist attacks has aided in the integration of what many municipalities still regard as their fire departments' 'bastard son.' In New York City, for example, FDNY firefighters are all trained at least to the CFR level, and many are EMTs. However, the FDNY firefighters are allowed only to perform at the level of CFR, and the duties of EMT and paramedic are still performed by members of the FDNY EMS Command. These members are employed solely to respond with ambulances to medical emergencies and do not engage in firefighting activities.
One of the major challenges facing EMS in general is the decline of Volunteer EMS units. Paid units typically have less manpower and less on their actual membership role books so that in major disaster, there are actually fewer amounts of trained and qualified rescuers.
Another future challenge facing EMS units is that medically directed rescue operations are being replaced with fire-based rescue. Also, many EMS units—both volunteer and paid—still perform medically-directed rescue operations such as search and rescue and motor vehicle extrication—and are losing some of their vital rescue functions as fire departments and police departments take over those rescue functions. Medical patient care during rescue operations has been pushed to the back burner in many areas and a major problem facing EMS and patients is the loss of medically-directed rescue which has been switching over to non-medical units in many areas. Some fire departments do have medically trained rescuers but that is not common outside of city areas. Consequently, as fire departments take over rescue functions, some EMT's and EMS organizations have been relegated to being transport only teams - which is a very critical problem to patient care and also to the very nature of what an EMT used to stand for.
Another future challenge is that many EMS organizations spend an increasing amount of time on NON-emergency runs that when an actual emergency occurs, the unit is not available. Many people have grown reliant on EMS organizations to be taxicabs and take advantage of this in order to get preferential treatment in emergency rooms, which much to their surprise, sometimes is not the case. This taxicab non-emergency scenario is increasing and taking its tolls on not just paid companies, but also the volunteers who get burned out by taking "stubbed toe" calls when the person can have a family member drive them.
The future of EMS
The future development of an artificial blood substitute that will carry oxygen will greatly enhance the provision of emergency medical services, as natural blood is rarely available for field transfusions outside military medicine due to scarcity and fragility.
The creation of effective automated CPR machines such as the AutoPulse device is allowing for more effective support of cardiac arrest while allowing for all on-hand paramedics to give a greater level of care.
An interim life-saving technique being pioneered by the US military is the use of blood clotting powders such as QuikClot which make it easier to stop previously uncontrollable bleeding from major wounds.
Pioneering advances in telemedicine, including the use of video cameras, now make it possible for advanced medical direction and advice to be supplied to emergency medical technicians, military medics, and nurses or other community health care providers in remote or isolated areas or even aboard cruise ships. One future possibility is the use of robotics to permit surgeons miles away to provide life-saving surgery from the office, without requiring travel or exposure to hazards.
See also
External links
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