Emergency Medical Services What it is and how we got there

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Emergency Medical ServicesWhat it is and how we
got there

• Jeffrey Linzer Sr., MD, MICP
• Pre-hospital Care Coordinator

Emergency Pediatric Group Childrens Healthcare
of Atlanta
Emergency Medicine Department of Pediatrics Emory
University School of Medicine
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Its not rocket science
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What is Emergency Medical Services (EMS)?

• A system of coordinated response and emergency
  medical care, involving multiple personnel and
  agencies that provides emergency medical care
• activated by a call for help after an incident of
  serious illness or injury
• While the focus of EMS is emergency medical care
  it is much more than a ride to the hospital

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What is EMS?
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What are the components of an EMS system?

• Pre-response
• Prehospital
• Emergency Department/Hospital
• Critical Care
• Rehabilitation

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EMS System
9-1-1
Dispatch
First Responders
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EMS System
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EMS System
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System Objectives

• Tired response
• Closer first responder (EMT-Basic, EMT-D)
  begins stabilization while more distant, advanced
  trained provider responds
• Response time
• First responder arrival within a few minutes
• Advance responder arrival in less than 10 minutes

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System Objectives

• Advanced life support
• Brings the emergency department to the scene
• Mutual-aid
• Links providers from different areas to provide
  closest EMS unit

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History of EMS

• More then just the story of the Good Samaritans
  who would bound the injured travelers wounds
  with oil and wine at the side of the road

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History of EMS

• 1797 - Napoleons chief physician Baron
  Dominique-Jean Larrey, is credited with the
  institution of the first prehospital system
  designed to triage and transport the injured from
  the field to aid stations
• 1870 - First documented aeromedical
  transportation occurred during the Prussian siege
  of Paris when hot air balloons were used to
  transported wounded soldiers

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History of EMS

• In the US, the first ambulance services were
  provided by hospitals in Cincinnati (1865) and
  New York City (1869)
• Grady provided first ambulance for Atlanta in 1891

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History of EMS

• 1928 - First volunteer rescue squads organized in
  Roanoke, Virginia
• Physicians usually staffed hospital based
  ambulances until World War 2
• In urban areas municipal hospitals or fire
  departments would run inhalator calls

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Advances in Emergency Medical Care 1950s

• Nurses required a physicians order to take a
  temperature
• Nurses could be fired for questioning physicians
• An ambubag could only be used by a physician
• CPR was experimentally only used in a few
  hospitals
• Defibrillators were investigational
• If your heart stopped you were pronounced dead
• Ambulances were fast taxi rides often without
  bandages or oxygen

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History of Emergency Medical Care

• 1732 - The first recorded use of mouth-to-mouth
  ventilation involving a coal miner in Dublin
• 1896 - First major publication describing the
  resuscitation of near drowning victims

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History of Emergency Medical Care

• 1947 - Beck reported the first successful case of
  AC defibrillation in a human
• common household current (110 V) was applied
  directly to the heart using a stripped lamp cord
  of a 14 y/o who arrested during thoracic surgery
• 1958 - Safar demonstrated mouth-to-mouth
  ventilation to be superior to other methods of
  manual ventilation
• used Baltimore firefighters in his studies to
  perform ventilation of anesthetized surgical
  residents

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Birth of Modern Pre-hospital Care

• 1959 First hospital AC external defibrillators
• these heavy (100 lbs) units were moved around on
  top of a cart which had a tendency to tip over,
  thus the name "Crash Cart
• DC defibrillator developed in 1960
• 1960 Article by Kouwenhoven, Jude, and
  Knickerbocker's the technique of "Closed Chest
  Cardiac Massage" is published in JAMA
• 1962 - Cardiopulmonary resuscitation (CPR),
  closed chest cardiac massage combined with
  mouth-to-mouth, shown to be efficacious

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Birth of Modern Pre-hospital Care

• Until the late 1960s and early 70s ambulance
  service was usually provided by the local funeral
  home
• at best, the ambulance attendants had a
  first-aid card
• 1967 - First textbook for pre-hospital care
  Emergency Care and Transportation of the Sick
  and Injured is published by the American Academy
  of Orthopedic Surgeons
• 1968 - ATT reserves the digits 9-1-1 for
  emergency use

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1966 - Turning point for EMS
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1966 - Turning point for EMS

• The National Research Council of the National
  Academy of Sciences publishes a White Paper
  Accidental Death Disability The Neglected
  Disease of Modern Society, bringing the harsh
  reality of the poor quality of EMS to the
  attention of the public
• Expert consultants returning from both Korea and
  Vietnam have publicly asserted that, if seriously
  wounded, their chances for survival would be
  better in the zone of combat than on the average
  city street.

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Accidental Death and Disability The Neglected
Disease of Modern Society (1966)

• ...(regarding ambulance service) a diversity of
  standards... ill-designed equipment and generally
  inadequate supplies.
• ...(no) standard for the competence or training
  of ambulance attendants.
• ...(though) it is possible to converse with the
  astronauts... communication is seldom possible
  between an ambulance and the emergency
  department...
• ... emergency facilities... (are) poorly
  equipped, inadequately manned...

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Results of the White Paper

• National Highway Traffic Safety Act of 1966
• established national standards for training
  emergency medical technicians, and minimum
  equipment required on an ambulance
• EMS Systems Act of 1973
• assisted system planners in establishing area
  wide or regional EMS programs
• Emergency Medical Services for Children (EMS-C)
  Program (1984)
• provide support for development of programs for
  emergency medical care for injured children and
  adolescents

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First Mobile Cardiac Care Units

• 1966 - Pantridge develops the first MCCU in
  Belfast
• 1968 First MCCU in the US is started by St.
  Vincent's Hospital (New York City) the program
  first used physicians
• 1968 - First paramedic program in the US is
  Miami-Dade County Florida
• 1970 programs start in Seattle and Los Angeles,
  first volunteer paramedic program in
  Charlottesville, VA

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What is an Emergency Medical Technician (EMT)?

• Person who receives training to provide
  pre-hospital emergency medical care
• Services provided depends on the level of
  training
• First responder
• EMT-Basic (EMT-1)
• EMT-D
• EMT-Intermediate (EMT-2)
• EMT-P (Paramedic)

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First responder and basic EMT

• First responder - provides basic first aid and
  CPR
• EMT-D - may provide defibrillation
• EMT-Basic - training emphasizes patient
  assessment skills and managing
• respiratory conditions (using suction devices,
  oxygen delivery systems)
• trauma (splints and immobilization)
• cardiac emergencies (CPR)

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EMT-Intermediate

• Foundation is Basic EMT training
• Skills include the use of advanced airway
  devices, intravenous fluids, and some medications
• Classroom and practical coursework up to 350
  hours based on scope of practice

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Paramedic

• Receives training in anatomy and physiology as
  well as advanced medical skills
• provide advanced airways including endotracheal
  intubation and cricothyrotomy
• needle chest decompression
• obtain intraosseous access
• may administer a large variety of medications
• Programs commonly conducted in community colleges
  and technical schools
• 1200-1800 hours of coursework (1 to 2 years)
• Extensive classroom, clinical and field
  experience is required

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Star of Life

• Designed in 1973, represents the six systems
  functions of EMS
• trademarked by NHTSA to control its use

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Working in a hostile environment

• Paramedics and EMTs are extension of the
  emergency department
• By using the ABCs they can stabilize and
  prevent deterioration of the patient
• They provide conditions to help ensure the
  survival of the patient during transport from the
  scene to the hospital

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Medical Control

• The process insuring pre-hospital procedures and
  providers follow accepted medical standards

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Medical Control

• Medical control may be prospective, immediate or
  retrospective
• Prospective developing practice standards,
  policies and protocols
• Immediate medical direction at the scene of an
  emergency
• Retrospective quality control and improvement

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Medical Control

• On-line
• Immediate
• Off-line
• Prospective
• Retrospective

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Georgia

• EMTs may perform any service or procedure
  authorized by the local medical director within
  the state-set scope of practice
• Oversight is by the Office of EMS Trauma
• EMS Advisory Council
• EMS Medical Directors Advisory Council

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Safe transport

• Most children with respiratory problems do not
  need emergent transport to the ED
• Place child in position of comfort
• Never place child on top of another person laying
  on the gurney

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• Recommended method for restraining children up to
  about 18 kg who can tolerate a semi-upright
  seated position, showing belt attachment to the
  cot and routing through the convertible child
  restraint.
• Bull MJ, Weber K, Talty J, Miriam M. Crash
  protection for children in ambulances
  recommendations and procedures. 45th Annual
  Proceedings Association for the Advancement of
  Automotive Medicine. 2001353-367.

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• Recommended method for restraining infants who
  cannot tolerate a semi-upright seated position,
  showing belt attachment to the cot and routing
  through the car bed loops.
• Bull MJ, Weber K, Talty J, Miriam M. Crash
  protection for children in ambulances
  recommendations and procedures. 45th Annual
  Proceedings Association for the Advancement of
  Automotive Medicine. 2001353-367.

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Safe transport

• Use of lights and siren for patient transport
  should be limited to emergency transport settings
• Local medical directors should take the lead on
  developing emergency transport guidelines
• NAEMSP and NASEMSD policy statement Prehospital
  and Disaster Medicine, April-June 1994

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Safe transport

• A patient should never be transported with lights
  and siren just because its a child

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Your responsibility

• Provide on-line medical control
• direct or approve treatment provided at the scene
• direct ambulance to appropriate facility
• provide guidance and education to EMS staff after
  arrival at hospital
• In Georgia, signing the PCR report form is
  giving approval for care provided in the field

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And so
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Bye-bye!