EMS 101: History and Modern

Realities
Edward T. Dickinson, MD
Professor
Director of EMS Field Operations
Department of Emergency Medicine
 Lecture Overview
 EMS Basics
 EMS History
 EMS Personnel
 National Trends
 Local Realities
EMS System Basics
 Enhanced 911
 “E-911”
 Called ID – like function
 Name
 Phone Number
 Location
 Linked to computer assisted dispatch system
– Previous location history
History of EMS
 Military History
 Baron Larrey
– Napoleon’s surgeon
– “Ambulance volante” 1792
 WW I
- Mr. Thomas British surgeon
- Developed the traction splint during the war to reduce
mortality
- Post war insight in the medical literature
- Shock physiology
- Time and speed of care recognized to reduce mortality
 Military History
 WW II
– Fluid resuscitation, as blood and plasma are sent to all
theaters (many die of renal failure later)
 Korean War
– MASH
– Helicopter evacuation
 Viet Nam
– Trauma research in the field
– “Golden hour” is born
Military History
 Iraq and Afghanistan
– Traumatic Brain Injury
– Hallmark Injury due to
IEDs
– New paradigm of
Federal funding for
simultaneous civilian
research
Civilian History
 Civilian History

 1947 Beck develops AC defibrillation

 1958 Safar rediscovers CPR
 1966 National Highway Safety Act
 1967 Pantridge describes mobile ICUs
 A Mobile Intensive Care Unit in the
Management of Myocardial Infarction

 The Lancet August 5, 1967

 Pantridge and Geddes at the Royal Victoria
Hospital in Belfast
 Fifteen month experience
– 10 Cardiac Arrest out-of-hospital
– All patients resuscitated
– 5 Patients discharged “alive and well”
 Civilian History
 1971 AAOS publishes Emergency Care and
Transportation of the Sick and Injured
 1973 Emergency Medical Services Act
– Defined and funded the crucial 15 elements of
EMS Systems
 EMS Personnel
 Curriculum set by the Federal Department of
Transportation
 Scope of Practice set by each state
 Length of training minimums set by the DOT, but
overseen by the states
 Certifications by the states with local credentialing
Emergency Medical Dispatcher
 24 Hours of training
 Utilization of
medically driven card
or CAD system
 Medical priority
dispatch
 Provide “pre-arrival
instructions”
Emergency Medical Responder
(Certified First Responder)
 First on scene
 Police, firefighters, etc
 45 Hours of training
 CPR
 Automated external
defibrillators (AEDs)
 Splinting and bleeding
control
 “BLS”
Emergency Medical Technician
EMT- Basic
 120 hours of training
with 10 hours of ER
observation
 All EMR skills
 Oxygen administration
 Basic extrication skills
 Assist with patients’
meds (NTG, MDI)
 CPAP, Epi-pens®
 BLS vs. ALS
 Basic Life Support  Advanced Life
– Emergency First Support
Responders and – Advanced EMTs and
EMTs paramedics
– First Aid Level – Advanced assessment
Skills skills
– More “doctor-like”
– Oxygen
interventions
– Basic assessment – Drugs, advanced
skills airways, etc
EMT - Intermediate
 EMT-B who goes on to
advance training
 Hours vary by states (80 -
1000 hours)
 Additional assessment
skills
 IV’s
 Some medications
 Advanced airway skills
(ET, Combi-tube)
 ALS Provider
 EMT-Paramedic
 EMT-B training plus > 1000 hours of
training.
 Clinical rotations in the ED, ICU, CCU,
Labor & Delivery and anesthesia
 Field internship
 Strict continuing education requirements
 ALS provider
 EMT-Paramedic
 Advanced patient assessment skills
 Full ACLS and other drugs
 Endotracheal intubation
 Some surgical skills
– Surgical airway
– Chest decompression
 EKG interpretation
– Monitor and 12 Lead
 EMS Personnel
 National “Board
Certification” by the
National Registry of
Emergency Medical
Technicians
 EMT-B, EMT-I, and
EMT-P
 Written, oral and practical
exams
 Requires CME to maintain
 EMS Physician
 Agency Medical
Directors
 Base Command
Physicians
 National Association of
EMS Physicians
 New Subspecialty
– 2013 First Exam
– Fellowships
– Practice Track
 Medical Oversight of EMS
 Paramedics and other advanced life support
(ALS) providers practice under the
delegated authority of physicians
– Paramedics are generally certified not licensed
– In PA, a physician Medical Director verifies a
paramedic’s authority to provide care annually
 Medical Oversight of EMS
 Standing orders
– Previously agreed protocols
– Actions do not require on-line physician contact
– Specific limits set by protocol
– Examples: defibrillation, intubation, ACLS
 On-line Medical Direction, ie “Command”
– Special procedures
– Controlled substances
 Medical Oversight of EMS
 Prospective oversight
– Involvement in
training
– Protocol development
 Real-time oversight
– Field observation
– On-line command
– ED Feedback
 Medical Oversight of EMS
 QA/PI
– Real-time feedback
– Revision and
development of
protocols
– Referral to the agency
Medical Director
 Patient Destination
 Patient wishes
 Nearest hospital
 Triage to regional referral centers
– Trauma center
– Burn center
– Hyperbarics
 National Trends and Issues
 Limited resources
– Longer response times
– Poor outcomes
 Shifting
reimbursement
structures
 Limited job
advancement
 National Trends and Issues
 Difficult to advance quality and level of
care given the current challenges
 RSI by paramedics
 Intubation by EMT-Basics
 Prehospital vs. Out-of-hospital care
– Preventative health measures
– Triage initiatives
» San Francisco model
 National Trends and Issues

 Diversion due to ER
overcrowding
 Expanding EMS Case
Law
 High profile errors with
large media exposure
 Does EMS make a
difference in patient
outcome?
 Regional Realities
 Suburban EMS
– Loss of hospital based paramedic units
– Transition to local “volunteer” fire departments
responsible for advanced care
 Philadelphia Fire Rescue
– Over-worked
– Not fully cross trained and integrated as firefighters
(2nd Class Citizen Syndrome)
QUESTIONS ?