Emergency Medical Services
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Wikipedia-Article "Emergency Medical Services"
Emergency medical service (known by the acronym of "EMS" in the USA and Canada) is a branch of medicine that is performed in the field, pre-hospital, (i.e., the streets, peoples' homes, etc.) by paramedics, emergency medical technicians (EMTs in US terminology), and Medical first responders (MFRs in US terminology).
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 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), and Advanced Cardiac Life Support.
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.
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History
The origins of EMS date back to the days of Napoleon, when the French army utilized horse drawn "ambulances" to transport the injured soldier from the battlefield. One of the first civilian EMS services 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."
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.
New Jersey has a unique system, as they rely solely on volunteer services in most areas of the state. In most non-urban settings, a municipal and donation-funded organization that is made up of people who live close enough to a station to respond within a short period of time. Most of them operate as Para-military organizations, having elected officers that oversee and control most of the protocol and monitor the other EMTs. The very first of these squads, which is still operational, was in Belmar New Jersey. Unfortunately, due to the overpopulation of what used to be small town New Jersey, some of these orgnizations have had to switch over to a paid service because the amount of calls that they handle has become very inflated.
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 and Advanced Life Support (BLS and ALS). BLS providers are CFRs (Certified First Responders) and EMTs, or EMT-Bs (Emergency Medical Technicians-Basic), and provide all care outlined in the EMS standard of care, except for invasive procedures and (to a certain extent) giving medications. EMTs also rarely receive training in EKG interpretation, one of the most basic ALS skills. ALS providers are principally paramedics and EMT-Intermediates (EMT-I), who are certified to perform invasive procedures and to give a wide variety of drugs. The biggest difference between EMT-I's and Paramedics is that while EMT-I's handle advanced airway management like Paramedics, they do not have as in-depth cardiac training and usually administer fewer medications.
In times of economic crisis and in poorer areas, much normal medical care is provided through emergency services to patients who do not have regular physicians or regular medical attention.
Prehospital Care Strategies
The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, where the "stay and play" is exemplified by the French SMUR emergency mobile resuscitation unit.
Scoop and run
The strategy developed for prehospital care in North America is called Scoop and Run. It is based on the Golden Hour theory, i.e., that a victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This is appers to be true in cases of internal bleeding, especially penetrating truama such as gunshot or stab wounds. Thus, the minimal prehospital care is performed (ABCs, i.e. ensure airway, breathing and circulation; external bleeding control; spine immobilization; endotracheal intubation) and the victim is transported as fast as possible to a trauma center. This philosophy is aptly summarized by the following quotation from "The Rules of EMS": "Trauma is treated with diesel first." The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival; hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. It should be noted the "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies).
Stay and play
The stay and play strategy was designed in France with the SMUR (Service Mobile d'Urgence de Réanimation, emergency mobile resuscitation unit) and SAMU (Service d'Aide Médicale d'Urgence), as it was noted that an unacceptable number of patients were dying during transport. The French thus developed a strategy based on maximum care before transportation. Prehospital medical care is provided by a medical doctor MD, a nurse and an ambulance technician, with almost all the equipment and drugs that can be found in an emergency department. The priority here is the stabilization of the patient prior to transport, including intravenous drip to raise the blood pressure (one of the causes of death during transportation is the drop in pressure, which decreases perfusion of the brain and heart; see shock). The German EMS is very similar to the French system.
In case of a severe myocardial infarction (or heart attack), all care is performed onsite (including the possibility of thrombolysis), and the victim is transported only if the heart starts again or the patient is declared dead. Defibrilation is performed by a firefighter rescue team with an automated external defibrillator if they arrive before the medical team. Note that this example is one of the only "real" stay and play approaches performed in France; in most cases, the treatment by the physician is fast and the patient is transported to the hospital within the golden hour.
Play and run
Both the scoop and run and the stay and play strategies have their advantages and drawbacks. The confrontation of these two opposite strategies has led recently to a new concept: the play and run. The time that cannot be reduced (e.g. while extracting a victim trapped in a car) is used to perform medical care. The treatment aim is no longer to recover a "normal" blood pressure, but a minimal blood pressure, using not only intravenous drip but also vasocompressing drugs and antishock pants (to compress the legs and push the blood into the rest of the body). The aim is to reduce the risk of death due to transportation trauma while respecting the golden hour. The problem with play and run lies in the difficulty of getting a good IV stick in a moving vehicle and controlling the volume of IV fluids given to the patient. Too little fluid will cause inadequate circulation and heart failure, while too much fluid will cause excessive loss of oxygen-bearing blood.
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
- 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 in the USA was once largely provided by volunteers. 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. On the contrary it may be financially advantages for a person to die rather than accumulate large medical bills in rehabilitation. (depending on the size or existence of a life insurance policy) 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 comes under Basic level, and is the level most fire fighters hold in Tennessee and Virginia. States may also attach add ons to an existing certification. 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 examples such as Intermediate 85 and Intermediate 99 exist, as well as Critical Care Paramedic. Each state decides what it needs based on manpower and money and alters the U.S. Governments recommendations accordingly.
Challenges of the future
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 clueless after over 30 years of EMS successes, and a great number of private EMS providers are happy to fill the lucrative niche of non-emergency transport, perhaps adding to this impression.
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 others 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.
In France, most of the medical emergency services are already carried out by firefighters.
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.
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 videocameras, 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 a surgeon thousands of miles away to provide life-saving surgery from the comfort of their own office, without requiring emergency travel or exposing themselves to hazards.