E.M.S. in theE.M.S. in the 21st Century21st Century

Jim Holliman, M.D., F.A.C.E.P.Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineProfessor of Military and Emergency MedicineUniformed Services University of the Health Uniformed Services University of the Health SciencesSciencesClinical Professor of Emergency MedicineClinical Professor of Emergency MedicineGeorge Washington UniversityGeorge Washington UniversityBethesda, Maryland, U.S.A.Bethesda, Maryland, U.S.A.Medical Director, Paramedic ServiceMedical Director, Paramedic ServiceReading, Pennsylvania, U.S.A.Reading, Pennsylvania, U.S.A.

E.M.S. (Emergency Medical Services) E.M.S. (Emergency Medical Services) in the 21st Century : Lecture Outlinein the 21st Century : Lecture Outline

Ideas on the future of E.M.S. (or "prehospital care") :Ideas on the future of E.M.S. (or "prehospital care") :Vehicle-based computer communication systemsVehicle-based computer communication systemsElectronic patient monitoring unitsElectronic patient monitoring unitsTelemedicineTelemedicine

Patient carePatient careBusiness and EducationBusiness and EducationRobotsRobots

Simulator trainingSimulator trainingField lab testing and radiographsField lab testing and radiographsProvision of primary health care servicesProvision of primary health care servicesPublic education, illness and injury preventionPublic education, illness and injury preventionHome environmental assessmentsHome environmental assessments

Why is the Future for E.M.S. Why is the Future for E.M.S. Bright ?Bright ?

Lots of energetic and enthusiastic personnelLots of energetic and enthusiastic personnel Support by the publicSupport by the public Recognition of importance by the governmentRecognition of importance by the government Caseload should not decreaseCaseload should not decrease

Increasing populationIncreasing populationIncreasing percentage of elderly patientsIncreasing percentage of elderly patients

Potential to further utilize existing technologyPotential to further utilize existing technology Multiple roles and responsibilitiesMultiple roles and responsibilities "Core" component of national health care "Core" component of national health care

systemsystem

Advanced Vehicle-Based ComputerAdvanced Vehicle-Based ComputerCommunication & Monitoring Communication & Monitoring SystemsSystems

Perhaps the most important and greatest Perhaps the most important and greatest potential advance for E.M.S.potential advance for E.M.S.

All motor vehicles can be equipped with small All motor vehicles can be equipped with small electronic monitoring & communication electronic monitoring & communication devicesdevices

Should be made standard required equipmentShould be made standard required equipmentContinually monitor vehicle position via GPS Continually monitor vehicle position via GPS (Global Positioning System, satellite based)(Global Positioning System, satellite based)Activate in event of vehicle collisionActivate in event of vehicle collision

Then automatically send report to central Then automatically send report to central communications facilitycommunications facility

Information Relayable from Information Relayable from Vehicle Monitoring SensorsVehicle Monitoring Sensors

Type and severity of vehicle Type and severity of vehicle damagedamage

Vehicle GPS locationVehicle GPS location Condition of humans in the Condition of humans in the

vehiclevehicleMental status and major injuriesMental status and major injuries

Environmental hazards or Environmental hazards or conditionsconditions

Use of Relayed Information Use of Relayed Information from Vehicle-Based Sensorsfrom Vehicle-Based Sensors

The receiving communications center can The receiving communications center can then send the closest EMS unit to the scenethen send the closest EMS unit to the sceneCan inform EMS units of victim numbers Can inform EMS units of victim numbers and conditionsand conditions

Other types of units can be mobilized if Other types of units can be mobilized if neededneededFire, police, heavy rescue, HAZMATFire, police, heavy rescue, HAZMAT

Prearrival instructions can be sent to the Prearrival instructions can be sent to the vehicle occupantsvehicle occupants

Advantages of GPS Devices Advantages of GPS Devices on EMS Vehicleson EMS Vehicles

Allows central control facility to monitor Allows central control facility to monitor exact positions of all vehicles at all timesexact positions of all vehicles at all times

Dashboard computerized maps allow crews Dashboard computerized maps allow crews to determine fastest ingress and egress to determine fastest ingress and egress routes to scenes, and avoid getting lostroutes to scenes, and avoid getting lost

Supervisors can also monitor speed of Supervisors can also monitor speed of vehiclesvehicles

Allows more effective Systems Status Allows more effective Systems Status ManagementManagement

Electronic Medical Electronic Medical Monitoring Units for PatientsMonitoring Units for Patients

Small sized units can be carried by patients Small sized units can be carried by patients with recurrent or chronic illnesseswith recurrent or chronic illnesses

Monitor patient's geographic position using Monitor patient's geographic position using GPSGPS

Activate if patient has sudden illness or Activate if patient has sudden illness or incapacitation, and then send location & incapacitation, and then send location & condition message to communications centercondition message to communications centerCenter can then send EMS unit directly to patientCenter can then send EMS unit directly to patient

Could also be used for emergency remote Could also be used for emergency remote treatment :treatment :External defibrillation if dysrhythmia sensedExternal defibrillation if dysrhythmia sensedMedication injection for other sensed conditionsMedication injection for other sensed conditions

Computerized Communications Computerized Communications Between EMS Vehicles and Between EMS Vehicles and E.D.'sE.D.'s

Hand held or voice activated computers can send Hand held or voice activated computers can send detailed info from scene to E.D. (via cell phone detailed info from scene to E.D. (via cell phone transmission)transmission)Hand held P.D.A.'s also useful as references for Hand held P.D.A.'s also useful as references for protocols & medical reference infoprotocols & medical reference info

E.D. can then print the info to be part of the patient's E.D. can then print the info to be part of the patient's medical recordmedical record

This saves the need for the EMS crew to do any other This saves the need for the EMS crew to do any other documentationdocumentation

Continuous 2 way info from E.D to EMS units allows Continuous 2 way info from E.D to EMS units allows updating on E.D. bed availability & hospital condition updating on E.D. bed availability & hospital condition or capacityor capacity

One type of hand-held computer for recording EMS patient information

Ambulance vehicle – mounted computer system

Advantages of Computerized 2-Way Advantages of Computerized 2-Way Communications Between EMS & Communications Between EMS & E.D.'sE.D.'s

Allows better management of Allows better management of multicasualty situationsmulticasualty situations

Helps avoid overload of any one Helps avoid overload of any one receiving facilityreceiving facility

Patient medical information can be Patient medical information can be transmitted much more quickly & transmitted much more quickly & completely than can be done verballycompletely than can be done verbally

Enables more rapid turnaround of EMS Enables more rapid turnaround of EMS units after delivering patientsunits after delivering patients

NATO nurses transporting patient on military “mini-ICU” stretcher

U.S. military stretcher with built-in ICU equipment

Telemedicine in the Future of Telemedicine in the Future of EMSEMS

Miniaturized television (TV) cameras can be Miniaturized television (TV) cameras can be carried on helmet, hat, or uniform of EMS carried on helmet, hat, or uniform of EMS personnelpersonnel

Sending live video images of the scene to the Sending live video images of the scene to the communications center helps determine need communications center helps determine need for additional responding resourcesfor additional responding resourcesHelps manage multicasualty situations & Helps manage multicasualty situations & terrorist incidentsterrorist incidentsAlso allows monitoring for scene dangers Also allows monitoring for scene dangers not noticed by the EMS crewnot noticed by the EMS crew

Other Telemedicine Uses in Other Telemedicine Uses in EMSEMS

Allows hospital-based doctors to assist field Allows hospital-based doctors to assist field EMS personnel to make diagnoses & EMS personnel to make diagnoses & treatmentstreatments

Allows hospital physicians to direct EMS Allows hospital physicians to direct EMS personnel to do medical or surgical personnel to do medical or surgical proceduresprocedures

Can be used for followup visits or "checkups" Can be used for followup visits or "checkups" for patients with chronic illnessesfor patients with chronic illnessesCan obviate need for "face to face" meeting Can obviate need for "face to face" meeting with doctorwith doctor

Telemedicine with Robot Telemedicine with Robot UnitsUnits

Video camera equipped robot units :Video camera equipped robot units :Can search dangerous environments for victims :Can search dangerous environments for victims :

Building firesBuilding firesBuildings at risk for collapseBuildings at risk for collapsePossible chemical, biological, or radiation Possible chemical, biological, or radiation contaminationcontaminationBoat or submarine robots can search water areas Boat or submarine robots can search water areas for victimsfor victims

Can have chemical detectorsCan have chemical detectorsCan perform remotely directed medical or Can perform remotely directed medical or resuscitation proceduresresuscitation procedures

Telemedicine for Video Telemedicine for Video ConferencingConferencing

Limits travel time & expense for Limits travel time & expense for business meetings or educational business meetings or educational conferencesconferences

Video based training & education Video based training & education materials are easy to transmit & updatematerials are easy to transmit & update

Allow personnel to conduct training or Allow personnel to conduct training or receive education in "down time" receive education in "down time" between callsbetween calls

Having personnel log on to on-line Having personnel log on to on-line training programs allows supervisors to training programs allows supervisors to monitor completion of training & monitor completion of training & conduct testsconduct tests

Use of Simulator Training in EMSUse of Simulator Training in EMS

Computerized mannequin patient simulators Computerized mannequin patient simulators can be used for more realistic clinical trainingcan be used for more realistic clinical training

Allows demonstration of student's ability to Allows demonstration of student's ability to recognize problems & take actionrecognize problems & take action

Allows more accurate testing of studentsAllows more accurate testing of students Requiring completion of extensive simulator Requiring completion of extensive simulator

training prior to licensing is protective for the training prior to licensing is protective for the publicpublic

Vehicle driving simulators can improve driving Vehicle driving simulators can improve driving skills for low costskills for low cost

Ambulance vehicle driving simulator

Field Laboratory Testing by Field Laboratory Testing by EMSEMS

Hand held miniaturized devices can rapidly Hand held miniaturized devices can rapidly measure a wide variety of blood & body fluid measure a wide variety of blood & body fluid components (using only small amounts of components (using only small amounts of blood)blood)

Permits broader & more accurate prehospital Permits broader & more accurate prehospital diagnosesdiagnoses

May obviate need to transport patient to E.D.May obviate need to transport patient to E.D. Results may determine type of receiving Results may determine type of receiving

facility (such as cardiac enzymes or toxin facility (such as cardiac enzymes or toxin levels)levels)

Radiographic Equipment for Radiographic Equipment for EMSEMS

If more portable & less costly radiographic If more portable & less costly radiographic equipment is developed, this may be utilizable equipment is developed, this may be utilizable by EMS unitsby EMS units

Transmission of images back to hospital Transmission of images back to hospital emergency physician or radiologist could be emergency physician or radiologist could be donedone

Interpretations may obviate need to transport Interpretations may obviate need to transport patient to hospital, or permit early patient to hospital, or permit early thrombolysisthrombolysis

Can be used for verification of endotracheal Can be used for verification of endotracheal tube placementtube placement

Ultrasound may help with intravenous line Ultrasound may help with intravenous line placementplacement

Expanded Roles for EMS Expanded Roles for EMS Personnel : Primary Health Care Personnel : Primary Health Care ServicesServices

Proposals in U.S.A. for EMS personnel to Proposals in U.S.A. for EMS personnel to undertake more primary care servicesundertake more primary care servicesDue to faults in the U.S. health care system, Due to faults in the U.S. health care system, with deficiencies in access to primary health with deficiencies in access to primary health care & health maintenance servicescare & health maintenance services

Also proposed to more fully utilize the "down Also proposed to more fully utilize the "down time" of EMS personnel between runstime" of EMS personnel between runs

May be less expensive for EMS units to see May be less expensive for EMS units to see multiple patients at home versus transporting multiple patients at home versus transporting these patients for exams by doctorsthese patients for exams by doctors

Proposed Primary Health Proposed Primary Health Care Services for EMS to Care Services for EMS to UndertakeUndertake

Regular checkups on patients with chronic Regular checkups on patients with chronic illnessesillnesses

Administer immunizationsAdminister immunizations Administer long term parenteral medsAdminister long term parenteral meds Chronic wound careChronic wound care Blood draws for medication level monitoringBlood draws for medication level monitoring Education reinforcement about managing Education reinforcement about managing

chronic illnesses and need for preventive chronic illnesses and need for preventive measuresmeasures

Some aspects of hospice-like careSome aspects of hospice-like care

Important Roles for EMS in Important Roles for EMS in Public EducationPublic Education

Illness prevention and healthy lifestylesIllness prevention and healthy lifestyles Injury preventionInjury prevention

Promote seatbelt & helmet usePromote seatbelt & helmet useViolence preventionViolence preventionSafe drivingSafe driving

Greater EMS personnel involvement Greater EMS personnel involvement with local, state, & national with local, state, & national governments can promote public health governments can promote public health improvements via legislation & improvements via legislation & regulationregulation

Proposed Home "Environmental Proposed Home "Environmental Assessments" by EMS PersonnelAssessments" by EMS Personnel

Important to evaluate the home environment, Important to evaluate the home environment, especially for the elderly, for potential especially for the elderly, for potential problems that could affect healthproblems that could affect healthCheck heating & cooling unitsCheck heating & cooling unitsAlter furniture, rugs, etc. to limit risk of fallsAlter furniture, rugs, etc. to limit risk of fallsIdentify need for safety equipment such as Identify need for safety equipment such as stair railsstair railsIdentify patients with inadequate nutrition Identify patients with inadequate nutrition or finances who may be candidates for other or finances who may be candidates for other social service agency interventionssocial service agency interventions

Aspects of Future EMS About Aspects of Future EMS About Which We Need to be CarefulWhich We Need to be Careful

Realization of the limitations of the Realization of the limitations of the prehospital environmentprehospital environment

Avoidance of new & aggressive treatments Avoidance of new & aggressive treatments until they are proven MORE effective until they are proven MORE effective prehospital than if waited to be done in the prehospital than if waited to be done in the E.D.E.D.

Avoidance of expansion of the types of Avoidance of expansion of the types of medications carried by EMS units until proven medications carried by EMS units until proven that new or additional medications offer clear that new or additional medications offer clear benefitbenefit

Important to maintain cooperation & Important to maintain cooperation & coordination of care between EMS and coordination of care between EMS and hospitalshospitals

Research Important to Research Important to Conduct in EMSConduct in EMS Patient outcomes from EMS Patient outcomes from EMS

interventionsinterventions International comparisons of outcomes International comparisons of outcomes

in different EMS systemsin different EMS systems Comparisons of outcomes between Comparisons of outcomes between

patients transported by ground versus patients transported by ground versus aeromedical unitsaeromedical units

Effectiveness of different personnel Effectiveness of different personnel training techniquestraining techniques

Effectiveness of public education Effectiveness of public education programsprograms

EMS in the 21st CenturyEMS in the 21st CenturyLecture SummaryLecture Summary

The future for EMS in the 21st Century is very The future for EMS in the 21st Century is very brightbright

Expanded use of present technology will allow Expanded use of present technology will allow improved & more efficient EMS careimproved & more efficient EMS careVehicle monitoring systemsVehicle monitoring systemsTelemedicine and robotsTelemedicine and robotsSimulator trainingSimulator trainingField lab & radiographic studiesField lab & radiographic studies

EMS can provide more primary & followup EMS can provide more primary & followup carecare

EMS has much research potentialEMS has much research potential