Transcript EMS_Overview - Hatzalah of Miami-Dade

Emergency Medical
Services
EMS Overview & Medical Oversight
Introduction
•
•
•
•
•
•
History of EMS
EMS System
Levels of training and abilities
Overview of system designs
Local system design
Medical control
History of EMS
1917 Honolulu Police Department Ambulance
History of EMS
•Before 1966
•1966 - 1973
•1974 - 1981
•1981 - Present
Before 1966
• Jean Dominique Larrey
– Napoleon’s Chief Military Physician
– wounded treated on battlefield and horse drawn
carriages constructed to carry the wounded
• Civil War
– First organized pre-hospital system in U.S.
– Joseph Barnes, Johnathan Letterman - Military
physicians
– Union Army trained corpsmen - first “medics”
Before 1966
• Civil War
– Developed a transportation system
• Post Civil War
– Cincinnati, New York, London, Paris
• Horse Accidents, fires - need for transport
– Edward Dalton
• Former Surgeon in Union Army
• 1869 began New York City Ambulance
• Interns staffed ambulances
Before 1966
• World War I
–
–
–
–
Improved communications - signal boxes
Electric, steam, gasoline powered carriages
Thomas traction splint
Ambulances now equipped
• Post World War I
– Radios to dispatch ambulances
– Volunteer rescue squad
– Interns still on ambulance
World War II
• U.S. Entrance into WWII
–
–
–
–
Removed interns from ambulance
Deterioration of care - untrained
Little care, mostly transportation
Half of ambulances operated by mortuaries
• Post WWII
– CPR, defibrillation
– 1966 Belfast Ireland Mobile CCU
1966: A Turning Point
• National Academy of Sciences - National
Research Council
– Described pre-hospital care and compared it to
military pre-hospital in Korean Conflict
– Described lack of communication, lack of
helicopter services, archaic ED’s
– Led to the National Highway Safety Act
National Highway Safety Act
• Department of Transportation as Federal
Governing authority by finances
• Funded Training programs and national
minimum standards of skills
• Communications programs and equipment
• Funded Ambulances, equipment,
• Personnel and administrative cost
• 1968 - 1979, $142 Million
Other Federal Initiatives
• Health Services and Mental Health
Administration
– Lead Agency for EMS within Department of
Health, Education and Welfare (DHEW)
• Physician Responder Programs
– metamorphosed into “paramedic” programs
– close physician supervision
• mostly on-line medical control
• Telemetry programs begun
Public Law 93-154, 1973
• Goal to improve EMS on National Scale
• 15 Elements flawed - idea of chain of
survival
• State control of EMS efforts
• BLS and ALS Terminology spread
• Communications
– 1 in 20 ambulances voice communication
– advocated 911 access and central dispatch
EMS System
•
•
•
•
•
Access
First Responder
EMT / Paramedic
Medical Control
Transport to definitive care
911 System
• Centralized access
number
• >90% of country
covered
• Enhanced System
provides name,
address, telephone
number
• Abuse of system
Providers - Scope of Practice
• First Responders
– CPR
– First Aid
– Basic Airway
Management
– Emergency Delivery
– Spinal Immobilization
– Oxygen Administration
– Assisted Ventilation
Scope of Practice EMT - A
• Scope of First
Responders
• On Scene Triage
• Fracture Splinting
• Extrication and
Transport
• MAST
Scope of Practice EMT-I
•
•
•
•
Scope of EMT-A
EOA, Combi-tube
Orotracheal Intubation
Peripheral IV
cannulation
• Basic determination of
death (obvious)
• Defibrillation (AED)
Scope of Practice - Paramedic
• Needle
cricothyroidotomy
• Needle Decompression
of pneumothorax
• Defibrillation,
Cardioversion
• Administration of most
drugs, antiarrhythmics,
benzodiazepines, and
narcotics
Georgia EMS
• No registered First Responder
• EMT (Basic EMT) - national EMT-I
– D50, Epi-pen
• Cardiac Technicians - Closely approximates
National Paramedic
• Paramedic - Expanding Curriculum
System Structure
• Municipality
– City or County run organization
– Fire Department based
• Hospital Based
– Hospital owned and operated
– County 911 provider
• Private and volunteer
• Combination and Tiered Response
Response Systems
•
•
•
•
BLS EMS
ALS EMS
BLS EMS with ALS Back-up
Tiered Response
– Fire BLS or ALS Response
– ALS Transport Service
– Police, Fire and ALS
Medical Control
• Direct (On-line) Medical Control
– Direct physician to medic contact
• Radio
• Telephone
• Off-Line Medical Control
– Writing and approving protocols
– Quality Assurance
Protocols
•
•
•
•
•
•
Written standards
Do not require physician contact
Require a physician signature
Governed by local EMS council
Sparingly used in Region 6 EMS
Liberally used in most of U.S.
Direct Medical Control
• Telephone and Radio contact most common
• Radio
– “Key-up” 1-2 seconds before speaking
– Speak clearly and slowly
– Its not a telephone - most radio systems are
Simplex not duplex
– Break-up common making understanding
difficult
Medical Control Scenarios - 1
• “Medical Control this is Rural Metro 416 Basic EMT Johnson. I am on the scene with
a ***STATIC*** year old male who is
complaining of shortness of breath, he has a
history of asthma and has used his albuterol
inhaler with some relief but is still short of
breath. The patient is refusing treatment and
transport… What do you advise ?
Medical Control Scenario - 1
• Vital Signs BP 116/76, HR 110, R - 20, No
wheezing noted, noted to be using some
accessory muscles
• Alert and Oriented answering questions
appropriately
Medical Control Scenario - 2
• Medical Control this is Horizon Medic 6. I
am enroute to you with 67 year old female
patient who was complaining of substernal
chest pain, and is now is cardiac arrest. She
is intubated. Has been defibrillated X 3 and
remains in V-fib. I have an IV initiated of
normal saline. What do you advise?
Medical Control Scenarios - 3
• Medical Control this Rural Metro 702 at
incident command. I am on the scene of a
chemical release and have a multiple
casualty incident. We approximate 45
patients have been exposed to an unknown
gas believed to be sulfur trioxide. I have 6
category I patients, 10 category II, and the
remainder are category III. I need
destination orders. All 45 patients are
“requesting your facility”
Medical Control Scenario - 4
• Med Control this is Smith County EMA
Medic 2. Paramedic Davis. I am enroute
with a driver of high speed MVC with
massive damage to the vehicle. The patient
is c/o CP and leg pain, Vitals are stable.
The patient is requesting transport to St.
Joseph’s hospital and refuses transport to
the trauma center… What do you advise?
Medical Control Scenario - 5
• Medical Control this is Horizon Medic 6. I
am on the scene with a 14 y/o female.
Bystanders witnessed a GTC seizure and
called EMS. The patient is now alert,
oriented and following commands but
refuses treatment and transport. We have
attempted to contact the parents without
success. What do you advise ?
Medical Control Scenarios - 6
• Medical Control this is Rural Metro 413. I
am on the scene with a 48 y/o female. EMS
was called by a friend whom the patient told
in a phone conversation that she wanted to
commit suicide. On our arrival the patient
admits to the statement, but states that she is
not “really suicidal” Bottles of medications
including TCA’s are in the home. What do
you advise?