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Emergency Medical Service

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Emergency medical service (known by the acronym of "EMS" in the USA) is a branch of medicine that is performed in the field, pre-hospital, (i.e., the streets, peoples' homes, etc.) by paramedics, emergency medical technicians (EMTs in US terminology), and certified first responders (CFRs - US terminology).

In the US, although not commonly understood, EMS systems provide emergency care that is almost on par with that of an emergency room. Equipment and procedures are obviously limited, due to the nature of the environment that EMS personnel must work in. EMS providers work under the license and indirect supervision of a medical director or board-certified physician who oversees the policies and protocols of a particular EMS system or organization.

EMS professionals are trained to follow a formal and carefully designed decision tree, more commonly referred to as a protocol or standard of care, which has been created and approved by physicians. The emphasis in emergency services is on following correct procedure quickly and accurately rather than on making in-depth diagnosis which requires much professional experience. The use of a decision tree allows EMS workers to be trained in a much shorter time than physicians, with EMT-Basic classes, for example, as short as 4-5 months.

National EMS standards for the US are drawn up by the U.S. Department of Transportation and modified from state to state by the state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Comittees (usually in rural areas) or by other committees or even individual EMS providers. Also see emergency medical technician. In addition, the National Registry of Emergency Medical Technicians (http://www.nremt.org/), an independent body, was created in 1970 at the recommendation of President Lyndon B. Johnson in an effort to provide a nationwide consensus on protocols and a nationally accepted certification. National Registry certification is widely accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.

Contents

History

The origins of EMS date back to the days of Napoleon, when the French army utilized horse drawn "ambulances" to transport the injured soldier from the battlefield. One of the first civilian EMS services can be traced back to 1869, when Dr. Edward L. Dalton at Bellevue Hospital, then known as the Free Hospital of New York, in New York City started a basic transportation service for the sick and injured. The component of care on scene began in 1928, when Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad in the nation. Over the years EMS continued to evolve into much more than a "ride to the hospital."

In particular in the US state of California and in Seattle, Washington state (see Medic One), projects began to include paramedics in the EMS responses in the late 1960s. Groups in Pittsburgh, Pennsylvania and Portland, Oregon were also early pioneers in prehospital emergency medical training (see paramedic). Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the television series, Emergency! which in part followed the adventures of two Los Angeles County Fire Department paramedics as they responded to various types of medical emergency. James O. Page served as the series technical advisor and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.

Photo of EMS treating a cardiac arrest patient.

In a return to the military roots of EMS, the United States Army has developed the combat lifesaver program to instruct soldiers in advanced first aid and limited paramedic skills including intubation. The combat lifesaver is intended to bridge the gap between self-aid / buddy-aid and the platoon medic on the 21st century decentralized battlefield.

Levels of Care

Two levels of care are provided by EMS systems: BLS and ALS (Basic Life Support and Advanced Life Support). BLS providers are CFRs (Certified First Responders) and EMTs, or EMT-Bs (Emergency Medical Technicians-Basic), and provide all care outlined in the EMS standard of care, except for invasive procedures and (to a certain extent) giving medications. EMTs also rarely receive training in EKG interpretation, one of the most basic ALS skills. ALS providers are principally paramedics and EMT-Intermediates (EMT-I), who are certified to perform invasive procedures and to give a wide variety of drugs. The biggest difference between EMT-I's and Paramedics is that while EMT-I's handle advanced airway management like Paramedics, they do not have as in-depth cardiac training and usually administer fewer medications.

In times of economic crisis and in poorer areas, much normal medical care is provided through emergency services to patients who do not have regular physicians or regular medical attention.

Prehospital Care Strategies: "Scoop and Run", "stay and play" or "play and run"?

The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" is best exemplified by the MEDEVAC aeromedical evacuation helicopter, where the "stay and play" is best exemplified by the French SMUR emergency mobile resuscitation unit.

The strategy developed for prehospital care in North America is called Scoop and Run. It is based on the golden hour concept, i.e. a victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This is especially true in case of internal bleeding. Thus, the minimal prehospital care is performed (ABCs, i.e. ensure airway, breathing and circulation; external bleeding control; spine immobilization; endotracheal intubation) and the victim is transported as fast as possible to a trauma center. This philosophy is aptly summarized by the following quotation from "The Rules of EMS" (http://www.thelunatick.com/ems/rules.html): "Trauma is treated with diesel first." The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival; hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. It should be noted the "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations(e.g. cardiac or respiratory emergencies).

The stay and play strategy was designed in France with the SMUR (Service Mobile d'Urgence de Réanimation, emergency mobile resuscitation unit) and SAMU (Service d'Aide Médicale d'Urgence), as it was noted that an unacceptable number of patients were dying during transport. The French thus developed a strategy based on maximum care before transportation. Prehospital medical care is provided by a medical doctor MD, a nurse and an ambulance technician, with almost all the equipment and drugs that can be found in an emergency department. The priority here is the stabilization of the patient prior to transport, including intravenous drip to raise the blood pressure (one of the causes of death during transportation is the drop in pressure, which decreases perfusion of the brain and heart; see shock).

In case of a severe myocardial infarction (or heart attack), all care is performed onsite (including the possibility of thrombolysis), and the victim is transported only if the heart starts again or the patient is declared dead. Defibrilation is performed by a firefighter rescue team with an automated external defibrillator if they arrive before the medical team. Note that this example is one of the only "real" stay and play approaches performed in France; in most cases, the treatment by the physician is fast and the patient is transported to the hospital within the golden hour.

Both strategies have their advantages and drawbacks.

The confrontation of these two opposite strategies has led recently to a new concept: the play and run. The time that cannot be reduced (e.g. while extracting a victim trapped in a car) is used to perform medical care. The treatment aim is no longer to recover a "normal" blood pressure, but a minimal blood pressure, using not only intravenous drip but also vasocompressing drugs and antishock pants (to compress the legs and push the blood into the rest of the body). The aim is to reduce the risk of death due to transportation trauma while respecting the golden hour. The difficulty with play and run lies in the difficulty of getting a good IV stick in a moving vehicle and controlling the volume of IV fluids given to the patient. Too little fluid will cause inadequate circulation and heart failure, while too much fluid will cause excessive loss of oxygen-bearing blood.

Organization and Funding

EMS in the US is delivered through various models. These include;

  • Public EMS
    • Third Service stand alone
    • Third Service hospital based
    • Fire Service fully integrated and cross trained
    • Fire Service based, non-integrated(includes volunteer fire services)
    • Police service based, includes Sheriff's Offices (Police and Fire Services being the first two emergency services)
  • Private EMS
    • large national companies
    • Regional companies
    • Small local "mom and pop" companies, and
    • Funeral homes in some places, once the largest providers.

Funding and manpower models include:

  • Volunteer Public, non-billing, subsidized by property or sales taxes
  • Volunteer Public, calls billed, partially subsidized through property or sales taxes
  • Full time paid Private Enterprise, calls billed, partially subsidized through property or sales taxes
  • Full time paid Private Enterprise, calls billed, no subsidy
  • Full time paid Public Utility Model, calls billed, usually no subsidy

As in the fire service, EMS in the US is largely provided by volunteers. As of 2004, the largest "Private Enterprise" provider of contract EMS services in North America is AMR or American Medical Response, a subsidiary of Laidlaw International, Inc., a North American corporation also the major provider of contract school bus service, intercity passenger route and charter bus service, contract paratransit and public transit services in the United States and Canada.

Fire Service in the US is rated through ISO classes and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. On the contrary it may be financially advantages for a person to die rather than accumulate large medical bills in rehabilitation. (depending on the size or existence of a life insurance policy) This relegates EMS funding to an emotional plea for funds during difficult financial times.

Challenges of the future

In the United States, fire service-based EMS may face funding crises due to rapid increases in EMS calls in a department still devoted to and funded primarily for fire suppression. Compounding these financial difficulties are third party payers such as Medicare which view EMS as a transportion service and not a medical care service. Much of the public has been aware of EMS's medical capabilities since the early 1970s but many third party payers still seem clueless after over 30 years of EMS successes, and a great number of private EMS providers are happy to fill the lucrative niche of non-emergency transport, perhaps adding to this impression.

Many feel, however, that this state of affairs is bound to change as new technologies continue to spur a drop in the number of fires annually. Already, most firefighters are required to have basic medical training, and many, as noted above, are fully cross-trained as EMTs or even paramedics. In New York City, for example, FDNY firefighters are all trained at least to the CFR level, and many others are EMTs. Furthermore, the focus on homeland security since the September 11, 2001 terrorist attacks has aided in the integration of what many municipalities still regard as their fire departments' 'bastard son.'

In France, most of the medical emergency services are already carried out by firefighters.

The future of EMS

The future development of an artificial blood substitute that will carry oxygen will greatly enhance the provision of emergency medical services, as natural blood is rarely available for field transfusions outside military medicine due to scarcity and fragility.

An interim life-saving technique being pioneered by the US military is the use of blood clotting powders such as QuikClot (http://www.quikclot.com/) which make it easier to stop previously uncontrollable bleeding from major wounds.

Pioneering advances in telemedicine, including the use of videocameras, now make it possible for advanced medical direction and advice to be supplied to emergency medical technicians, military medics, and nurses or other community health care providers in remote or isolated areas or even aboard cruise ships. One future possibility is the use of robotics to permit a surgeon thousands of miles away to provide life-saving surgery from the comfort of their own office, without requiring emergency travel or exposing themselves to hazards.

See also

External links

de:Rettungsdienst fr:Aide médicale urgentecs:Záchranná služba de:Rettungsdienst fr:Aide médicale urgente

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