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PREHOSPITAL

PREHOSPITAL

EMERGENCY CARE

EMERGENCY

CARE

TENTH EDITION

PREHOSPITAL PREHOSPITAL EMERGENCY CARE EMERGENCY CARE TENTH EDITION CHAPTER 1 Emergency Care Medical Systems, Research, and

CHAPTER

1

Emergency Care Medical Systems, Research, and Public Health

Learning Readiness

Learning

Readiness

EMS Education Standards

  • Preparatory

  • Public Health

Learning Readiness

Learning

Readiness

Objectives

Objectives

Please refer to pages 1 and 2 of your text to view the objectives for this chapter.

Learning Readiness

Learning

Readiness

Key Terms

Key

Terms

Please refer to page 2 of your text to view the key terms for this chapter.

Setting the

Setting

the Stage

Stage

Overview of Lesson Topics

  • The emergency medical services (EMS) system

  • Roles, responsibilities, and attributes of EMTs

  • State EMS agencies, medical direction, and quality improvement (QI)

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Setting the

Setting

the Stage

Stage

Overview of Lesson Topics

  • Patient safety

  • Research in EMS

  • Public health and EMS

Case

Case Study

Study Introduction

Introduction

Every Saturday Ben Melton has breakfast at Dave’s Diner, a favorite with locals in the small tourist town. Despite having diabetes and carrying an extra 40 pounds around his waist, 51-year-old Ben finds it hard to pass on Dave’s breakfast platter of eggs, steak, and fried potatoes.

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Case

Case Study

Study Introduction

Introduction

This morning, by the time his coffee arrives, Ben isn’t feeling so well. Just as his friend, Arnie, notices that Ben has turned pale and broken into a sweat, Ben collapses, pulling the tablecloth with him to the floor.

Case

Case Study

Study

What components of a health care system must be in place for Ben to receive immediate help?

What weaknesses in a system could decrease Ben’s chances of getting help?

Introduction

Introduction

Sudden loss of life and disability from catastrophic accidents and illnesses is a major public health problem.

Every year thousands of people die or suffer permanent harm because of lack of access to adequate to emergency medical services.

EMTs can make a positive difference.

The

The EMS

EMS System:

System: History

History

What happens to an injured or ill patient before he reaches the hospital can make a critical difference.

Lessons learned from observations in the Korean and Vietnam wars have impacted the development of modern EMS systems.

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The

The EMS

EMS System:

System: History

History

In the past, care did not begin until the patient reached the hospital.

In 1966, the EMS “white paper” identified deficiencies in prehospital medical care, including lack of EMT training and lack of organized systems.

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The

The EMS

EMS System:

System: History

History

Modern EMS is part of a continuum of care that begins at the scene of the emergency and continues through hospital discharge and rehabilitation.

Several significant developments helped lead to this EMS system.

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The

The EMS

EMS System:

System: History

History

The Highway Safety Act of 1966

  • Required each state to establish a highway safety program that included emergency services

  • The National Highway Transportation Safety Administration (NHTSA), part of the Department of Transportation (DOT), led the development of EMS.

  • An early initiative was the development of national standard curricula for EMS.

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The

The EMS

EMS System:

System: History

History

The Emergency Medical Services System Act of 1973 provided access to millions of dollars of funding for EMS.

The American Heart Association (AHA) began to teach CPR to the public.

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The

The EMS

EMS System:

System: History

History

In 1993 the National Registry of EMTs (NREMT) released the National Emergency Medical Services Education and Practice Blueprint, which:

  • Defined issues related to EMS training and education

  • Served as a guide to the development of national training curricula

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The

The EMS

EMS System:

System: History

History

NHTSA documents

  • 1996 EMS Agenda for the Future

Focused on making EMS a greater component in the health care system

  • 2000 EMS Education Agenda for the Future: A Systems Approach

Focused on the need for nationwide consistency in the education, training, certification, and licensure of entry-level EMS personnel

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The

The EMS

EMS System:

System: History

History

NHTSA documents

  • 2005 National EMS Core Content

Defined the domain of knowledge of the National EMS Scope of Practice Model

  • 2006 National EMS Scope of Practice Model

Defines four levels of EMS licensure

  • National EMS Education Standards

Outline minimum terminal objectives for EMS education programs

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The

The EMS

EMS System:

System: History

History

The 2006 Institute of Medicine (IOM) report The Future of EMS Care: EMS at the Crossroads recommends:

  • Common scopes of practice to allow reciprocity between states

  • National accreditation for all paramedic programs

  • National certification as a prerequisite for state licensure and local credentialing

The

The EMS

EMS System:

System: Standards

Standards

NHTSA provides a set of recommended state standards, the Technical Assistance Program Assessment Standards.

There are ten components.

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The

The EMS

EMS System:

System: Standards

Standards

Regulation and policy

  • Laws, regulations, policies, and procedures that govern the EMS system

  • A state-level EMS agency to provide leadership to local jurisdictions

Resource management

  • Central control of EMS resources so that there is equal access to acceptable emergency care

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The

The EMS

EMS System:

System: Standards

Standards

Human resources and training

  • All personnel who staff ambulances and transport patients must be trained to at least the EMT level

Transportation

  • Safe, reliable transportation by ground or air ambulance

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The

The EMS

EMS System:

System: Standards

Standards

Facilities

  • Patients must be delivered to appropriate medical facilities

Communications

  • Public access to the system

  • Communication among dispatcher, EMS personnel, and hospital

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The

The EMS

EMS System:

System: Standards

Standards

Public information and education

  • EMS personnel should participate in programs to educate the public in injury prevention and how to access the EMS system.

Medical direction

  • A physician medical director to provide medical oversight

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The

The EMS

EMS System:

System: Standards

Standards

Trauma systems

  • A system of specialized care for trauma patients

Evaluation

  • A quality improvement system

EMS System

EMS

System Access

Access

The most common way of accessing EMS is dialing 911.

Enhanced 911 (E-911) allows:

  • Automatic number identification

  • Automatic location information

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Communications play a vital role in the Emergency Medical Services (EMS) system.

Communications play a vital role in the Emergency Medical Services (EMS) system.

EMS System

EMS

System Access

Access

Benefits of 911

  • Public safety answering point (PSAP) is staffed by specially trained dispatchers.

  • The number is easy to remember and use.

  • All emergency services—police, fire, and EMS—are accessible by dialing one number.

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EMS System

EMS

System Access

Access

Cell phones pose some challenges to 911 systems.

  • They are not identified with a fixed site, so the location is identified as the closest cell tower.

  • Calls near geographic boundaries can go to a different PSAP.

  • FCC rules are being implemented to improve cellular access to 911.

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EMS System

EMS

System Access

Access

Voice over Internet Protocol (VoIP) also poses potential challenges that are addressed by FCC rules.

  • 911 service must be a standard feature to all customers.

  • The subscriber must give the physical location of where the service will be used.

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EMS System

EMS

System Access

Access

Voice over Internet Protocol (VoIP) also poses potential challenges that are addressed by FCC rules.

  • The provider must transmit all 911 calls and associated information to the appropriate PSAP.

Case

Case Study

Study

Charlene, one of the waitresses in the restaurant, pulls a cell phone from her pocket and dials 911. The dispatcher immediately transfers the call to a specially trained emergency medical dispatcher. The EMD asks Charlene a series of questions to get help on the way, and gives her instructions for checking and monitoring Ben’s condition until help arrives.

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Case

Case Study

Study

What components of the EMS system have been used in this case so far? Click each item you select.

Regulations & Regulations & Policy Policy
Regulations &
Regulations &
Policy
Policy
Resource Resource Management Management
Resource
Resource
Management
Management
   
 

Human

Human

Resources &

Resources &

Training

Training

Transportation
Transportation
Facilities Facilities
Facilities
Facilities
Communication Communication
Communication
Communication
Public Public Information & Information & Education Education
Public
Public
Information &
Information &
Education
Education
Medical Medical Direction Direction
Medical
Medical
Direction
Direction
Trauma Systems
Trauma
Systems
Evaluation Evaluation
Evaluation
Evaluation

Case

Case Study

Study

EMTs Juliana Smock and Peter Saylor, who had just finished their check of the ambulance, respond to the dispatch, heading down Highway 129 toward Dave’s. An anxious customer holds open the front door as Juliana and Peter pull to a stop in front of the restaurant. Taking a look around at the scene, the EMTs grab their equipment and head for the door.

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Case

Case Study

Study

What EMT responsibilities have Juliana and Peter demonstrated so far?

What EMT responsibilities do you predict they will perform next?

How will the EMTs’ appearance and actions determine how they are perceived by others?

Levels of

Levels

of Providers

Providers

The National EMS Scope of Practice Model identifies four levels of EMS practitioners.

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The four levels of EMS practitioners.

The four levels of EMS practitioners. continued on next slide

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Levels of

Levels

of Providers

Providers

Emergency Medical Responder

  • Provides immediate lifesaving care to patients while awaiting response from a higher-level EMS practitioner

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Levels of

Levels

of Providers

Providers

Emergency Medical Technician

  • Provides basic emergency medical care and transportation using the basic equipment found on an ambulance

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Levels of

Levels

of Providers

Providers

Advanced Emergency Medical Technician

  • Provides basic and limited advanced emergency medical care and transportation to patients in the prehospital environment

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Levels of

Levels

of Providers

Providers

Paramedic

  • Performs advanced assessments, forms field impressions, and provides invasive and drug interventions as well as transport

The Health

The

Health Care

Care System

System

A health care system is a network of medical care that begins in the field and extends to hospitals and other treatment centers.

EMS providers are part of a community’s health care system.

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The Health

The

Health Care

Care System

System

The different health care facilities to which EMTs may transport patients have different capabilities.

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The Health

The

Health Care

Care System

System

Trauma center Burn center Obstetrical center Pediatric center Poison center

Stroke center Cardiac center Hyperbaric center Spine injury center Psychiatric center

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The Health

The

Health Care

Care System

System

Trauma centers

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A trauma center can provide rapid surgical intervention and treatment of injuries that generally exceeds hospital emergency department capabilities. (© Edward T. Dickinson)

A trauma center can provide rapid surgical intervention an d treatment of injuries that generally exceeds

The Health

The

Health Care

Care System

System

EMTs work as team members with other public safety personnel.

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The EMT works closely with other public safety personnel.

The EMT works closely with other public safety personnel.

You will often work as a team with paramedics and others.

You will often work as a team with paramedics and others.

Case

Case Study

Study

After quickly determining the nature of Ben’s problem, the EMTs head toward the closest hospital, a 35-minute trip, with Juliana behind the wheel and Peter in the back of the ambulance, caring for Ben. Having arranged for a paramedic unit to meet them en route, Peter gives the paramedics a quick radio report.

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Case

Case Study

Study

Peter continues patient care, following protocols until they meet with the paramedic unit.

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Case

Case Study

Study

How can requesting a paramedic intercept benefit the patient?

What are some of the potential pitfalls in patient safety at this phase of the call?

EMT Responsibilities

EMT

Responsibilities

All EMTs share a common set of responsibilities.

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Table 1-1 Roles and Responsibilities of the Emergency Medical Technician
Table 1-1
Roles and Responsibilities of the
Emergency Medical Technician

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EMT Responsibilities

EMT

Responsibilities

Personal safety and the safety of others

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The EMT must ensure personal safety at all times. (© Pat Songer)

The EMT must ensure personal safety at all times. (© Pat Songer) continued on next slide

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EMT Responsibilities

EMT

Responsibilities

You cannot help the patient, other rescuers, or yourself if you are injured.

  • Use safe driving habits.

  • Do not enter or stay on an unsafe scene.

  • Be alert to situations with a risk for violence.

  • Wear reflective clothing and protective clothing as indicated.

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EMT Responsibilities

EMT

Responsibilities

Patient assessment and emergency care

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The EMT is responsible for providing competent patient care.

The EMT is responsible for providing competent patient care. continued on next slide

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EMT Responsibilities

EMT

Responsibilities

Gain access to patients, recognize and evaluate problems, and provide emergency care.

  • Primary assessment

Identify and manage immediate threats to life.

  • Secondary assessment

Identify other problems.

  • Treat the conditions you find.

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EMT Responsibilities

EMT

Responsibilities

Safe lifting and moving

  • Prevent further harm to the patient.

  • Prevent yourself from being injured through good body mechanics and having an adequate amount of help.

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EMT Responsibilities

EMT

Responsibilities

Transport and transfer of care

  • Make a destination decision according to protocols.

  • Notify the receiving facility of the patient’s condition.

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The EMT can get on-line medical direction by telephone, cell phone, or radio.

The EMT can get on-line medical directio n by telephone, cell phone, or radio. continued on

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EMT Responsibilities

EMT

Responsibilities

Transport and transfer of care

  • Continue care en route.

  • Drive safely.

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Assessment and emergency care are continued en route to the medical facility.

Assessment and emergency care are continued en route to the medical facility. continued on next slide

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EMT Responsibilities

EMT

Responsibilities

Transport and transfer of care

  • Give verbal and written reports.

  • Provide additional assistance as needed.

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The EMT is responsible for properly transferring the care of the patient to the appropriate medical personnel.

The EMT is responsible for properly transferring the care of the patient to the appropriate medical

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EMT Responsibilities

EMT

Responsibilities

Record-keeping and data collection

  • Log the call.

  • Complete patient care reports.

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As soon as possible, complete the written or electronic prehospital care report.

As soon as possible, complete the writte n or electronic prehospital care report. continued on next

continued on next slide

EMT Responsibilities

EMT

Responsibilities

Patient advocacy

  • EMTs are responsible for protecting the patient’s rights.

Secure and transport personal belongings if needed.

Protect the patient’s privacy.

Make sure that the patient’s family knows how to get to the hospital.

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EMT Responsibilities

EMT

Responsibilities

Patient advocacy

  • EMTs are responsible for protecting the patient’s rights

Provide necessary information to hospital personnel.

Honor any patient requests you reasonably can.

Maintain patient confidentiality.

Case

Case Study

Study

At the designated point, the EMTs meet the paramedic unit and give an update on Ben’s status. The paramedic, Alexis Brady, further assesses Ben and implements advanced life support (ALS) treatment. Following the treatment, which was administered to increase Ben’s abnormally slow heart rate, Ben regains consciousness and is confused about what is happening.

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Case

Case Study

Study

Now that Ben is conscious, what do you think are his expectations for how Peter and Alexis interact with him?

How could the nature of those interactions affect the quality of patient care?

EMT Professional

EMT

Professional Attributes

Attributes

Certain professional attributes are important to maximize effectiveness as an EMT.

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Table 1-2 Characteristics of Professional Behavior for EMTs
Table 1-2
Characteristics of Professional Behavior
for EMTs

EMT Professional

EMT

Professional Attributes

Attributes

Appearance

  • Excellent personal grooming and a neat, clean appearance help instill confidence in patients and help protect them from contamination that caused by dirty hands, fingernails, or clothing.

  • Proper appearance can send the message that you are competent and can be trusted to make the right decisions.

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EMT Professional

EMT

Professional Attributes

Attributes

Knowledge and skills

  • Required coursework

  • Use and maintenance of equipment

  • Safety and security procedures

  • Geography and travel routes

  • Traffic laws

  • Continuing education

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EMT Professional

EMT

Professional Attributes

Attributes

Physical demands

  • Ability to lift and carry up to 125 pounds

  • Good (or correctable) eyesight and color vision

  • Ability to communicate effectively orally and in writing

  • Good hearing

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EMT Professional

EMT

Professional Attributes

Attributes

Personal traits

  • Patients look toward someone to re- establish order in a suddenly chaotic world.

  • That requires the characteristics listed on the following slides.

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EMT Professional

EMT

Professional Attributes

Attributes

Leadership ability

  • Assess a situation quickly.

  • Step forward to take control when appropriate.

  • Set action priorities.

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EMT Professional

EMT

Professional Attributes

Attributes

Leadership ability

  • Give clear and concise directions.

  • Be confident and persuasive enough to be obeyed.

  • Carry through with what needs to be done.

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EMT Professional

EMT

Professional Attributes

Attributes

Calm, reassuring personality

  • Be able to calm anxious and agitated patients.

Good judgment

  • EMTs must make decisions in stressful situations.

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EMT Professional

EMT

Professional Attributes

Attributes

Good moral character

  • EMTs are in a position of public trust that cannot be defined by laws alone.

Stability and adaptability

  • EMTs are exposed to stressful situations and must delay expression of emotions until an appropriate time.

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EMT Professional

EMT

Professional Attributes

Attributes

Ability to listen

  • EMTs must accurately gather information from patients and bystanders.

  • EMTs must be accurate when receiving orders from medical direction.

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EMT Professional

EMT

Professional Attributes

Attributes

Resourcefulness and ability to improvise

  • Each call, situation, and patient is different, requiring that EMTs be resourceful to provide efficient, effective care.

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EMT Professional

EMT

Professional Attributes

Attributes

Cooperativeness

  • The care of a patient requires the cooperative interactions of many personnel.

Maintenance of certification and licensure

  • This is a personal responsibility that involves obtaining continuing education and submitting required forms and fees.

State EMS

State

EMS Agency

Agency Role

Role

There is overlap between the EMS, public safety, and public health.

State EMS agencies act in ensuring that high-quality EMS is provided in order to protect the health and safety of the public.

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State EMS

State

EMS Agency

Agency Role

Role

Primary responsibilities include:

  • Overall planning, coordination, and regulation of the statewide EMS system

  • Licensing EMS agencies and personnel

Case

Case Study

Study

En route to the hospital, Alexis and Peter continue their treatment and Alexis calls in a report to the receiving hospital. As Peter continues to reassure Ben and monitor his condition, Alexis begins some preliminary paperwork.

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Case

Case Study

Study

What is the legal basis for EMTs providing medical treatment to patients?

What mechanisms must be in place to ensure that the care provided is of the highest quality and conforms to the standards of the medical community?

Medical

Medical Direction

Direction

Every EMS system must have a physician medical director.

EMTs are designated agents of the medical director.

The medical director is legally responsible for the patient care aspects of the EMS system.

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Medical

Medical Direction

Direction

Medical directors participate in EMS provider education and EMS system quality assurance.

A primary charge of medical direction is developing and establishing the guidelines under which the emergency medical service personnel function.

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Medical

Medical Direction

Direction

Protocols are a complete set of guidelines that define the scope of medical care provided by EMS personnel.

Protocols may be used off-line or may require on-line medical direction.

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Medical

Medical Direction

Direction

Off-line medical direction consists of a set of written guidelines that allow EMTs to use their judgment to provide care without having to contact a physician.

Sometimes called standing orders

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Medical

Medical Direction

Direction

On-line medical direction requires that the EMT contact a physician for consultation and authorization prior to administering specific emergency care.

Quality

Quality Improvement

Improvement

Quality improvement (QI), or continuous quality improvement (CQI), is a system of internal and external reviews and audits of all aspects of an emergency medical system.

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Quality

Quality Improvement

Improvement

The purpose of QI is to ensure that the public receives the highest quality of prehospital care.

The goals of quality improvement are to:

  • Identify aspects of the system that can be improved.

  • Implement plans and programs to remedy shortcomings.

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Quality

Quality Improvement

Improvement

QI is focused on how effective the system is and to identify what improvements can be made to deliver a better service.

QI can assist individuals with poor performance, but is should be used an evaluation of system effectiveness, not as a punitive mechanism.

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The EMT takes an active role in quality improvement.

The EMT takes an active role in quality improvement.

Issues inin Patient

Issues

Patient Safety

Safety

Certain aspects of prehospital care are high-risk in terms of patient safety.

High-risk activities include:

  • Transfer of care from one provider to another

  • Communications with other providers

  • Carrying and moving patients

  • Ambulance transportation

  • Spinal immobilization decisions

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Issues inin Patient

Issues

Patient Safety

Safety

Errors during patient care can cause harm, and usually result from:

  • Improper skill performance

  • Not following the rules

  • Lack of knowledge

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Issues inin Patient

Issues

Patient Safety

Safety

Steps to reduce errors include:

  • Clear protocols

  • Providing enough light to work effectively

  • Minimizing interruptions during assessment and care

  • Clearly marking drugs and packaging

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Issues inin Patient

Issues

Patient Safety

Safety

Steps to reduce errors include:

  • Reflecting on all actions

  • Questioning assumptions

  • Using decision aids

  • Asking for assistance when needed

Research inin EMS

Research

EMS

Evidence-based medicine (EBM) uses research to provide evidence that certain procedures, medications, and equipment improve the patient’s outcome.

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Research inin EMS

Research

EMS

There are four steps in evidence-based decision-making:

1. Formulate a question that needs to be answered.

2. Search medical literature for applicable data.

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Research inin EMS

Research

EMS

There are four steps in evidence-based decision-making:

3. Appraise the data for validity and reliability.

4. If the evidence supports a change in practice, change protocols and implement the change in prehospital emergency care.

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Research inin EMS

Research

EMS

Research does not exist to support many practices in EMS.

Research in hospital settings does not always transfer well to EMS settings.

If the opportunity arises, every EMT has an obligation to participate in research that contributes to the profession.

Case

Case Study

Study

Ben was seen in the emergency department, and then admitted to the cardiac care unit of the hospital. Ben’s cardiologist told Ben that he has several risk factors for heart problems, but that some of the risk factors can be changed.

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Case

Case Study

Study

What are some public health efforts that can help decrease the rate of illnesses like Ben’s?

What role could EMS providers take in such public health efforts?

Public

Public Health

Health

EMTs are part of the public health team.

Public health deals with protecting the health of an entire population.

EMTs can play a role in identifying public health problems and in attempts to reduce injury and illness and promote health.

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Public

Public Health

Health

The ten greatest public health achievements in the United States in the 20th century were:

  • Vaccinations

  • Motor vehicle safety

  • Workplace safety

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Public

Public Health

Health

The ten greatest public health achievements in the United States in the 20th century were:

  • Control of infectious disease through clean water and sanitation

  • Reduction in death from coronary heart disease and stroke

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Public

Public Health

Health

The ten greatest public health achievements in the United States in the 20th century were:

  • Safer, healthier foods

  • Decreased maternal and infant mortality

  • Use of barrier devices during sexual contact

  • Fluoridation of drinking water

  • Reduction of tobacco use

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Public

Public Health

Health

Roles of EMS in public health include:

  • Health prevention and promotion through primary prevention (vaccinations, education), secondary prevention of complications of disease, and health screening

  • Disease surveillance through identifying and reporting certain diseases or conditions that are identified as public health issues

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The roles of the EMS in public health include participation in public education programs (CPR).

The roles of the EMS in public health include participation in public education programs (CPR). continued

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Public

Public Health

Health

Roles of EMS in public health include:

  • Injury prevention through education, promotion of the use of safety equipment (seat belt use, helmet use, falls prevention, fire prevention), and injury surveillance

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The roles of the EMS in public health include participation in health screenings.

The roles of the EMS in public health include participation in health screenings.

Case

Case Study

Study

After giving a report to the emergency department (ED) about Ben’s condition and prehospital treatment, Alexis compliments Peter and Juliana on their assessment and care. Peter takes the opportunity to ask Alexis a few questions about patients who present as Ben did.

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Case

Case Study

Study

Ben was discharged from the hospital with a cardiac pacemaker to keep his heart beating at the right rate. He participates in a cardiac rehabilitation program and is working with a nutritionist on his diet. He still frequents Dave’s, but more often than not, opts for a bowl of oatmeal with fruit.

Lesson Summary

Lesson

Summary

The shape of the modern EMS system has been influenced by many events throughout history.

EMS systems must address 10 specific areas as defined by NHTSA.

911 is the access number for EMS in the United States.

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Lesson Summary

Lesson

Summary

There are four nationally recognized levels of EMS providers in the United States.

EMTs have several specific responsibilities.

Medical direction and QI are essential components of all EMS systems.

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Lesson Summary

Lesson

Summary

EMS practices change over time, based on research findings.

EMS is part of the public health system and can make an impact on the health of the community.