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SECTION Emergency Medical Services C. Crawford Mechem INTRODUCTION EMS is the extension of emergency medical care into the prehospital setting. Today’s EMS systems have their roots in legislative and clinical developments of the 1960s and 1970s. The 1966 report “ Accidental Death and Disability—The Neglected Disease of Modern Society” high lighted the deficiencies of prehospital care of trauma victims, attribut able to inadequate equipment and training. Until that time, more than half of ambulance services were run by funeral homes because hearses were among the few vehicles able to transport a stretcher. The National Highway Safety Act of 1966 established the Department of Transporta tion and made it the lead agency responsible for upgrading EMS systems nationwide. In 1967, J. F . Pantridge began using a physician-staffed mobile coronary care unit in Belfast, Northern Ireland, to provide prehospital car diac care.2 Physician staffing of ambulances never gained popularity in the United States. However, in the late 1960s and 1970s, nonphysician personnel began learning advanced skills, including IV administration of medications, cardiac rhythm interpretation, and defibrillation. The U.S. EMS Systems Act of 1973 made available federal grants to develop regional EMS systems. Approximately 300 EMS regions were established. To receive funding, the Act required that EMS systems address 15 key elements ( Table 1-1). These elements form the founda tion of many EMS systems today. The 1970s became a Golden Age for EMS. The U.S. Department of Transportation developed curricula for emergency medical techni cians, paramedics, and first responders. EMS communications systems were formalized. In 1972, the Federal Communications Commission recommended 9-1-1 be adopted as the emergency telephone number nationwide. In addition, the concept of designated trauma centers was introduced, with the idea being that EMS personnel would transport injured patients preferentially to these facilities. The Omnibus Budget Reconciliation Act of 1981 eliminated direct federal funding for EMS. Instead, federal funds were distributed as block grants. The result was a decrease in both EMS funding and coordination. EMS systems took on a decidedly local flavor, with great variation between systems. This trend has had long-term consequences for the field. In 2011, the American Board of Emergency Medicine recognized EMS as its seventh subspecialty. The certification examination is based on the Core Content of EMS Medicine with four major content areas: Clinical Aspects of EMS Medicine, Medical Oversight of EMS, Quality Management and Research, and Special Operations. EMS SYSTEM OVERVIEW A review of the 15 elements of EMS systems identified by the EMS Sys tems Act of 1973 (Table 1-1) provides insight into the structure of EMS systems and the challenges they face.  MANPOWER In most urban areas, paid public safety and ambulance personnel provide prehospital care. In contrast, suburban, rural, or wilderness EMS systems commonly use volunteers. Personnel fall into one of four licensure levels in accordance with the National EMS Scope of Practice Model, set forth by the National Highway Traffic Safety Administration. These are emergency medical responder, emergency medical techni cian, advanced emergency medical technician, and paramedic. Each type of provider must master a minimum set of skills. Emergency medical responders are often first on the scene of an emergency.

t forth by the National Highway Traffic Safety Administration. These are emergency medical responder, emergency medical techni cian, advanced emergency medical technician, and paramedic. Each type of provider must master a minimum set of skills. Emergency medical responders are often first on the scene of an emergency. They are trained to perform CPR, spine immobilization, and hemorrhage control and to use auto-injectors, automated external defibrillators, and other basic interventions while awaiting an ambulance. Emergency medi cal technicians function as part of an ambulance crew. Their training includes oxygen administration, CPR, hemorrhage control, and patient extrication, immobilization, and transportation. They assist patients in using some of their own medications and can administer certain over-the-counter medications. Advanced emergency medical technician training includes additional assessment skills plus placement of IVs and supraglottic airway devices and administration of some medica tions. Paramedics have the highest skill level. Because of their advanced level of training, paramedics function under a designated physician’s supervision.  TRAINING Training includes initial provider training and continuing education. As EMS call volume increases, providers often care for a disproportionate number of patients with minor medical issues. Maintaining proficiency in skills to manage critically ill patients may be difficult. Innovative training methods to ensure skills retention must be sought. Use of computerized human patient simulators is one option, both for reviewing skills and learning new ones.  COMMUNICATIONS The adoption of 9-1-1 as a nationwide emergency number has greatly facilitated public access to emergency care. In many systems, the local public safety answering point has software that provides the number and location of a caller (enhanced 9-1-1). Widespread use of cellular telephones has prompted the development of technology to identify and locate these callers as well, in accordance with Federal Communications Commission regulations. Emergency call takers are trained to collect necessary information, dispatch appropriate resources, and offer first aid or prearrival instructions while the ambulance is en route. Ambulance personnel should also be able to communicate with the destination hospital. Most EMS personnel operate under standing orders and protocols. However, there are times when providers may require online medical control, talking directly with a physician for direction. 7 Historically, communications represent the weakest link in disasters. It is important that EMS communication systems have built-in redundancy to ensure uninterrupted service.  TRANSPORTATION Ambulance design must enable EMS personnel to provide care such as airway and ventilatory support while transporting the patient safely. Basic life support ambulances carry equipment appropriate for personnel trained at the emergency medical technician level, such as automated external defibrillators, oxygen, bag-mask ventilation devices, immobilization and splinting devices, and wound dressings. They carry few medications and cannot transport patients requiring IVs or car diac monitoring. Advanced life support ambulances are equipped for advanced emergency medical technicians or paramedics, including IV CHAPTER Prehospital Care Tintinalli_Sec01_p0001-0018.indd 1 7/31/19 6:43 PM

ng devices, and wound dressings. They carry few medications and cannot transport patients requiring IVs or car diac monitoring. Advanced life support ambulances are equipped for advanced emergency medical technicians or paramedics, including IV CHAPTER Prehospital Care Tintinalli_Sec01_p0001-0018.indd 1 7/31/19 6:43 PM 2 SECTION 1: Prehospital Care fluids and medications, intubation equipment, cardiac monitors, and pulse oximeters. Ground transportation is appropriate for the major ity of patients, especially in urban and suburban areas. However, air transport, generally by helicopter, should be considered for critically ill patients when ground transport time would be long or if the terrain is difficult to navigate.  FACILITIES AND CRITICAL CARE UNITS Patients are often transported to the closest appropriate hospital. In recent years, the number of specialty hospitals has increased, including pediatric hospitals, trauma centers, burn centers, stroke centers, and centers with advanced cardiac or resuscitation capabilities. 8 Tertiary care centers provide many of these services and may also have a large number of critical care unit beds. The decision to bypass hospitals to go directly to a specialty center, often at a greater distance, is not a simple one. Although specialty hospitals often have more resources, transporting an unstable patient past an ED to get to the specialty hospital is not without risks. Furthermore, bypassing hospitals may have negative financial consequences for bypassed facilities. 1 It is wise to solicit input from the local medical community before developing destination policies involving specialty centers. Due to ED overcrowding, even the largest hospitals may not always have adequate resources to care for EMS patients. This may result in prolonged offload times of ambulance patients, long wait times for patients to be seen, and ED boarding of admitted patients. Furthermore, some EDs may request EMS divert elsewhere. 9 Because of these issues, regional EMS systems should develop methods to monitor available resources of their receiving hospitals. A secure, Internet-based website of hospital resources, including ED and inpatient bed availability, is one option.  PUBLIC SAFETY AGENCIES EMS systems should have strong ties with police and fire departments. Many large EMS systems are run by fire departments. In addition to providing scene security, public safety agencies can provide first responder services because they are often first on the scene. Fire and police automated external defibrillator programs are common. 10,11 Police administration of naloxone to opioid overdose victims is also a growing trend. 12 Such practices have been shown to improve patient outcomes. Finally, EMS personnel often provide medical support to police and fire departments in hazardous circumstances.  CONSUMER PARTICIPATION Public support, both political and financial, is necessary for a good EMS system. It is important that laypersons contribute to policymaking. One way to accomplish this is to encourage representation of the public on regional EMS councils. The public can also participate by volunteering for local EMS agencies.  ACCESS TO CARE Successful EMS systems ensure all individuals have access to care regardless of ability to pay. The EMS system is often a patient’s primary entry point into the healthcare system. There should be no barriers preventing access. A more difficult problem exists when terrain or low population densities result in longer response times for some citizens, as in rural or wilderness areas. EMS telemedicine programs may be one way to bring high-level medical expertise to patients in remote areas.  PATIENT TRANSFER Patients are often transferred from one medical facility to another for a higher level of care.

ion densities result in longer response times for some citizens, as in rural or wilderness areas. EMS telemedicine programs may be one way to bring high-level medical expertise to patients in remote areas.  PATIENT TRANSFER Patients are often transferred from one medical facility to another for a higher level of care. Safe and seamless transfer is an important concept and may be facilitated if transferring and receiving facilities develop transfer agreements in advance. The Emergency Medical Treatment and Active Labor Act of 1986 sets forth rules hospitals participating in the Medicare program must follow. Under the Emergency Medical Treat ment and Active Labor Act, all patients must receive a medical screen ing exam and be stabilized before transfer. There must also be explicit acceptance of the transfer by the receiving hospital.  COORDINATED PATIENT RECORD KEEPING Maintaining good medical records is important to any patient encoun ter. Prehospital medical records must be legible and readily accessible to hospital providers. Standardization of EMS records among differ ent agencies within a region helps streamline transfer of information between prehospital and hospital providers. The adoption of electronic charting and cloud-based electronic medical record keeping by EMS systems is a step toward this goal. Electronic charts can be printed out in the receiving ED or downloaded from a secure Internet website. Regardless of the system used, EMS agencies must comply with the Health Insurance Portability and Accountability Act of 1996, designed to protect the privacy of patient health information.  PUBLIC INFORMATION AND EDUCATION EMS systems have a responsibility to train the public on how to access EMS and use it appropriately. As EMS call volumes rise and available resources decline, educating the public to use 9-1-1 for true emergen cies is an appropriate goal. However, given the obstacles that many patients encounter in accessing office- or hospital-based care, convey ing this message is not simple. The public needs to know that EMS will always be there when needed. Another important message EMS can convey to the public is the importance of learning CPR, first aid, and basic disaster preparedness. Recent disasters have illustrated that, at times, the emergency response infrastructure may be so seriously disrupted that it may take hours or longer for help to arrive. A public that is adequately prepared and trained will be in a better position to safely await help.  REVIEW AND EVALUATION To ensure proper functioning of an EMS system and high-quality care, there must be a process for ongoing review and evaluation. This requires input from EMS providers and active involvement of a physician medical director. A continuous quality improvement program should be estab lished to assess system performance and formulate improvements. Routine audits of communications, response and scene times, and patient care records should be performed. Focused audits of conditions such as cardiac arrest and trauma are valuable. However, obtaining patient outcomes may be problematic. An unforeseen consequence of the Health Insurance Portability and Accountability Act is that hospitals are often hesitant to release patient information, even to EMS services, for fear of liability. EMS research is invaluable in advancing prehospital care. It should not be assumed that what works in the hospital will work in the TABLE 1-1 Fifteen Key Elements of EMS Systems Defined by U.S.

tability Act is that hospitals are often hesitant to release patient information, even to EMS services, for fear of liability. EMS research is invaluable in advancing prehospital care. It should not be assumed that what works in the hospital will work in the TABLE 1-1 Fifteen Key Elements of EMS Systems Defined by U.S. EMS Systems Act of 1973 •  Manpower •  Training •  Communications •  Transportation •  Facilities •  Critical  care units •  Public  safety agencies •  Consumer  participation •  Access  to care •  Patient  transfer •  Coordinated  patient record keeping •  Public  information and education •  Review  and evaluation •  Disaster  plan •  Mutual  aid Tintinalli_Sec01_p0001-0018.indd 2 7/31/19 6:43 PM