Emergency Medical Services

Joseph Sabato, Jr, MDAssistant Professor of Emergency MedicineDirector of Special Operations

Mary Tang, MD, MPH, PGY-3Robert Williams, MD, PGY-3

Pre-Hospital Care

1966 National Highway Safety Act

Authorized the US Department of Transportation (DOT) for prehospital medical services to fund:

AmbulancesEquipmentCommunicationsTraining programs

Emergency Medical Services Systems Act of 1973 (public law 93-154)

Funded and authorized the Department of Health, Education and Welfare to develop EMS throughout the country.

Public Law 93-154

Communications Training Manpower Mutual aid Transportation Accessibility Facilities Critical care units

Transfer of care Consumer

participation Public education Public safety agencies Standard medical

records Independent review

and evaluation Disaster linkage

Identified the following 15 components as essential to an EMS system:

911 Emergency telephone numberessential front door of the EMS system

Enhanced 911 (E-911) equipmentprovides automatic number and location

identification

Emergency Medical Dispatch (EMD)

Based on the principle that good information gathering during the dispatch phase of an emergency can better prepare responding EMS providers to deal with the situation at the scene.

Deliver basic emergency care instruction to people on the scene.

Prioritize request for emergency medical assistance.

Ensure only appropriate agencies or prehospital providers are dispatched.

Emergency Medical Dispatch (cont’d)

May be carried out by a variety of agencies, including:

Law enforcement agency (LEA)EMS agencySeparate public safety dispatch

center

Why is 911 better than dialing “0” ?

1st: Additional call and routing process, which takes precious time.

2nd: The caller may not be connected with the correct jurisdiction or service that he needs.

Training

Community education

First aidChild safety EMS system accessCardiopulmonary resuscitation (CPR)

Dual-response System

First responders (FRs) followed by ambulance personnel.

FRs: Firefighters, police, park rangers, or citizen volunteers.

Emergency Medical Technician (EMT):EMT basic (EMT-B) - CPR, AED, extrication,

immobilizationEMT intermediate (EMT-I) - IV access, PASGEMT paramedic (EMT-P) - Intubation/RSI, EKG,

synchronized cardioversion, manual defibrillation, & drug therapy

Public interest and participation: Key ingredients in any EMS system!

Urban areas: Public safety and ambulance personnel.

Rural or wilderness areas: Volunteers, park rangers, or ski patrols.

Mutual Aid Agreements

EMS services have agreements with neighboring jurisdictions so that uninterrupted emergency care is available when local agencies are overwhelmed and/or unable to provide services.

Mutual Aid Agreements

Mutual Aid Agreements

Transportation

Ground ambulancesProvide most EMS transportation.The most important aspect of ambulance

design is that the attendants must be able to provide airway and ventilatory support while safely transporting the patient.

Air transportHelicopter (Rotor-wing)Airplane (Fixed-wing)

Access to Care

A successful EMS system ensures that all individuals have access to emergency care regardless of their ability to pay or type of insurance coverage

Emergency physicians must serve as the patients’ advocate!!

FACILITIES

General: Transport to the closest appropriate hospital.

If multiple hospitals within the same transport time: patient’s choice.

Specialized receiving facilities Higher level of care warranted

Transport to that institution (by passing closer hospitals).

• i.e. trauma, burn, stroke or angioplasty center

Shandstastic!

Critical Care Units (CCU’s)

Trauma High-risk obstetrics Cardiac care Burns Neonatal intensive care Spinal cord injury Neurosurgery Pediatric Specialty Hospitals

Tertiary care facilities should be identified by every EMS system to provide specialty care that is not available in typical community hospitals.

Most common reasons for tertiary care emergency transfer:

Transfer of Care

Must be made with maximum safety for the patient!

Consumer Participation

Laypersons should be represented on EMS councils.

Two important components of a successful EMS system:Lay public first aid trainingImplementation of a 911 system

Public Information and Education

In designing a public information program, the EMS council’s goal should be for the public:

1. Understand how the community stands to benefit from an excellent EMS system.

2. Be prepared to render first aid care.3. Know how to access the EMS system

quickly.4. Understand that patients may not be

delivered to the hospital of their choice under life-threatening conditions.

Public Safety Agencies

Strong ties with police and fire departments

Often provide first-response service because their personnel are often the first on the scene of an emergency.

I.e., police carrying oxygen and automatic defibrillators

Standardization of Patients’ Records

All ambulance services within a specific region should use a similar reporting form that can be quickly and easily be interpreted by receiving nurses and physicians.

flow sheetsuniform dataNEMSIS/EMSTARS

Disaster Planning

The EMS system is an integral element of disaster preparedness and planning.

Important role in initial response and transportation Establish a regional disaster preparedness plan in

coordination with public safety agencies, government and medical community

Disaster management, communication, treatment and destination of casualties

Periodic disaster drills MCIs Hazmat

Medical Direction

The process by which a dedicated physician(s) guides and oversees the patient care that is provided by an EMS system.

Why do paramedics, who are licensed by the state, need a medical director or physician advisor?

On-line Medical Direction (OLMD)

a.k.a. direct medical control, on-line medical command, or real-time medical control.

Direct medical communication to personnel in the field.

in personradiophone communication

• landline (traditional telephone)• cellular

Off-line Medical Control

Responsibility of the service medical director1. Development and implementation of

protocols and standing orders2. Development of medical accountability (QA)3. Development of ongoing education

initial and recertifying training programs.

Physicians must remember that they have the ultimate responsibility for the overall quality of prehospital medical care.

Qualifications of an EMS Medical Director

Licensed physician with interest, experience, and knowledge in emergency medicine and prehospital care.

Preferable if full-time, practicing, emergency physician at the lead hospital for the EMS system, with additional training and experience in EMS.

Medical Basis for EMS

Emergency Cardiac Care

ALS saves lives after sudden cardiac arrest. The number of lives saved and the cost are debated.

Without treatment at the scene, the survival rate of out-of-hospital cardiac arrest is virtually zero.

Seattle and King Count, Washington 26% patients successfully resuscitated from out-of-hospital

cardiac arrest.

New York City 1.4% overall survival

Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) study.

JAMA 1994 Mar (Lombardi, Gallagher, and Gennis)

Hypothermia

Recommended for witnessed cardiac arrest (Vtach, Vfib) with spontaneous return of circulation

Administer as soon as possible, i.e, pre-hospital with ice packs to groin, axillae, and neck

Howes et al. "Evidence for the use of hypothermia after cardiac arrest." CJEM 2006;8(2):109-15

Minimal Interruption of CPR

MICR = initial series of 200 uninterrupted chest compressions, rhythm analysis with single shock, then 200 post-shock compressions before pulse check or rhythm-reanalysis; also done before admin of epi, intubation

Shown to improve survival in out-of-hospital cardiac arrest

Bobrow et al. “Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest.” JAMA 299(10)1158-1165.

Improve Survival

Shorten interval between collapse and defibrillation.

Local system must optimize the “chain of survival”

early accessearly CPRearly defibrillationearly ALS

First respondersAEDs

Pilot programs

Jim Alexander - Security officer

Las Vegas security officer saves two lives in less than one year

U.S. Air Force retiree Jim Alexander works as a security officer at Stardust Resort and Casino in Las Vegas. In less than one year, Alexander saved the lives of two casino guests: one in September 1997 and another in August 1998.

Trauma Care

Delivery of critically injured trauma patients to trauma centers saves lives.

Controversial: IV on scene (field) vs. en route Houston: no IVF in Prehospital or

E.R. for hypotensive victims of penetrating truncal trauma.

EMS For Children

Leadership in the area of injury and illness prevention Leadership in local, regional, and state EMS and EMSC systems by

involvement in the provision of medical direction (oversight), education of providers, quality improvement, and legislative advocacy

Collaboration with other physicians and health care professionals to enhance the medical home for children, including referral to primary care, specialized care, and rehabilitation services

Research in the design and function of EMS systems, education of providers, out-of-hospital and emergency care interventions, and outcomes of emergency care

Expertise for and collaboration with the National EMSC Program (Maternal and Child Health Bureau in collaboration with the National Highway Traffic Safety Administration)

In 1990, the American Heart Association introduced a treatment model for victims of sudden cardiac arrest called the Chain of Survival. It outlines the specific sequence of events that need to happen for a victim to survive and recover from sudden cardiac arrest.

                                                                                                   

“The Chain of Survival”

The Chain of Survival

Early Access: Someone suspects or determines the victim is in sudden cardiac arrest and calls for help

Early CPR: Someone trained in CPR keeps the victim’s blood flowing until defibrillation can begin

Early Defibrillation: Someone trained in defibrillation shocks the victim as quickly as possible

Early Advanced Care: Medical personnel provide advanced cardiac care which can include airway support, medications, and hospital services

Defibrillators

Automated external defibrillators (AEDs)

analyze the patient’s rhythm, determine whether a defibrillatory shock is indicated, charge the capacitors, and then inform the operator that a shock is advised.

defibrillate only for ventricular fibrillation and very fast wide QRS complex tachycardias (usually over 180/bpm)

used only in pulses and apneic patients.

Defibrillators

Zoll “M” SeriesPhysio Control Life Pack 12

HP CodeMaster 100

Automated External Defibrillators

Physio-Control LIFEPAK 500

Laerdal HeartStart

New CPR Guidelines

Current AHA/ACC ACLS guidelines for chest compression to breath ratio for single provider = 30:2 (vs. 15:2)

No pulse checks for layperson

Basic Airway Devices

Oropharyngeal airways (OPA)Nasopharyngeal airways (NPA)Bag-valve-mask ventilation

(BVM)Pulmonary Resuscitator

Advanced Airway Devices

Endotracheal tubes and blades End-tidal CO2 detectors (ETCO2) Pulse-Oximeter Laryngeal Mask Airway (LMA) Esophageal Gastric Tube Airway (EGTA) Esophageal Intubation Detector Esophageal Obturator Airway (EOA) Blind insertion

Pharyngeotracheal Lumen Airway (PTL) Esophageal-Trachea Combitube (ETC) King Tube

McGill forceps Cricothyrotomy equipment

Vascular Access Equipment

Paramedics are very adept at placing IV’s

IV access should not prolong scene times in a trauma patient, especially when “Load and Go” criteria are present

Spinal Immobilization ABC’s

The preservation of integrity of the spinal column is of paramount importance in the field.

C-Spine stabilization and airway assessment are performed simultaneously.

Manual stabilization of the neck is not released until the patient has been transferred and securely strapped to a board.

Spinal Immobilization ABC’s

Odontoid fracture & Atlantoaxial dislocation

Air Medical Transport

Association of Air Medical Services (AAMS)Domestic: 362 air medical providersInternational 23 air medical providers

Hospital(s) basedHelicopter cost: $1-5 million

• annual operating cost: $2 millionPatients transported 827 per program

1997 - survey of 126 United States air medical programs

Clinical Use of Helicopters

Fast ambulances125-175 mph

150-200 mile range

Two major types of helicopter missions(1) Trauma/medical scene responses

(30%)(2) Interfacility transfers

(70%)

Rotor-wing aircraft

Advantages

Can be based at a hospital or another location near your service area.

Do not require a runway for takeoff and landing.

Capable of landing in relatively small and secluded areas.

Usually ready for takeoff in a matter of minutes.

Jacksonville Fire Rescue

Ambulance Safety

Future of EMS

EMS will represent the intersection of public safety, public health, and health care systems.

EMS will continue to be diverse at the local level. As a component of health care systems, EMS will be influenced

significantly by their continuing evolution. There will be increasing need for information regarding EMS

systems and outcomes. It will be necessary to continue to make some EMS system-related

decisions on the basis of limited information. The media will continue to influence the public’s perception of

EMS. Federal funding/financial resources will be decreasing. To make good decisions, public policy makers will need to be well-

informed about EMS issues.NHTSA agenda guidelines: www.nhtsa.dot.gov/people/injury/ems/agenda/emsbro.html