Transcript EMS 101: History and Modern Realities

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
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EMS System Basics
Enhanced 911
“E-911”
 Called ID – like function
 Name
 Phone Number
 Location
 Linked to computer assisted dispatch
system
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– Previous location history
History of EMS
Military History
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Baron Larrey
– Napoleon’s surgeon
– “Ambulance volante” 1792
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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
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WW II
– Fluid resuscitation, as blood and plasma are sent to all
theaters (many die of renal failure later)
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Korean War
– MASH
– Helicopter evacuation
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Viet Nam
– Trauma research in the field
– “Golden hour” is born
Military History
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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
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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
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– 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
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– Defined and funded the crucial 15 elements of
EMS Systems
EMS Personnel
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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
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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)
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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
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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
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Basic Life Support
– Emergency First
Responders and
EMTs
– First Aid Level
Skills
– Oxygen
– Basic assessment
skills
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Advanced Life
Support
– Advanced EMTs
and paramedics
– Advanced
assessment skills
– More “doctor-like”
interventions
– Drugs, advanced
airways, etc
EMT - Intermediate
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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
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EMT-Paramedic
Advanced patient assessment skills
 Full ACLS and other drugs
 Endotracheal intubation
 Some surgical skills
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– Surgical airway
– Chest decompression
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EKG interpretation
– Monitor and 12 Lead
EMS Personnel
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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
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Agency Medical
Directors
Base Command
Physicians
National Association
of EMS Physicians
New Subspecialty
– 2013 First Exam
– Fellowships
– Practice Track
Medical Oversight of EMS
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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
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Standing orders
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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
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Prospective oversight
– Involvement in training
– Protocol development
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Real-time oversight
– Field observation
– On-line command
– ED Feedback
Medical Oversight of EMS
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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
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– Trauma center
– Burn center
– Hyperbarics
National Trends and Issues
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Limited resources
– Longer response times
– Poor outcomes
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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
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– Preventative health measures
– Triage initiatives
» San Francisco model
National Trends and Issues
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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
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Suburban EMS
– Loss of hospital based paramedic units
– Transition to local “volunteer” fire departments
responsible for advanced care
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Philadelphia Fire Rescue
– Over-worked
– Not fully cross trained and integrated as firefighters
(2nd Class Citizen Syndrome)
QUESTIONS ?