Transcript Emergency Medical Services Patient Care from Scene to Hospital

Emergency Medical
Services
What it is and how we got there
Jeffrey Linzer Sr., MD, MICP
Pre-hospital Care Coordinator
Emergency Pediatric Group
Children’s Healthcare of Atlanta
Emergency Medicine
Department of Pediatrics
Emory University School of Medicine
It’s not rocket science
What is Emergency Medical
Services (EMS)?
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A system of coordinated response and
emergency medical care, involving multiple
personnel and agencies that provides
emergency medical care
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activated by a call for help after an incident of
serious illness or injury
While the focus of EMS is emergency
medical care it is much more than a ride to
the hospital
What is EMS?
What are the components of
an EMS system?
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Pre-response
Prehospital
Emergency Department/Hospital
Critical Care
Rehabilitation
EMS System
9-1-1
Dispatch
First Responders
EMS System
Advanced Life Support
Medical Control
EMS System
Stabilization
Transport
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System Objectives
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Tired response
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Closer “first responder” (EMT-Basic, EMT-D)
begins stabilization while more distant,
advanced trained provider responds
Response time
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“First responder” arrival within a few minutes
Advance responder arrival in less than 10
minutes
System Objectives
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Advanced life support
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Brings the emergency department to the scene
Mutual-aid
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Links providers from different areas to provide
closest EMS unit
History of EMS
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More then just the story of the Good
Samaritans who would bound the injured
traveler’s wounds with oil and wine at the
side of the road
History of EMS
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1797 - Napoleon’s chief physician Baron
Dominique-Jean Larrey, is credited with the
institution of the first prehospital system
designed to triage and transport the injured
from the field to aid stations
1870 - First documented aeromedical
transportation occurred during the Prussian
siege of Paris when hot air balloons were
used to transported wounded soldiers
History of EMS
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In the US, the first ambulance services were
provided by hospitals in Cincinnati (1865) and
New York City (1869)
Grady provided first ambulance for Atlanta in
1891
History of EMS
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1928 - First volunteer rescue squads
organized in Roanoke, Virginia
Physicians usually staffed hospital based
ambulances until World War 2
In urban areas municipal hospitals or fire
departments would run “inhalator calls”
Advances in Emergency
Medical Care – 1950’s
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Nurses required a physician’s order to take a
temperature
Nurses could be fired for questioning physicians
An ambubag could only be used by a physician
CPR was experimentally only used in a few
hospitals
Defibrillators were investigational
If your heart stopped you were pronounced dead
Ambulances were fast taxi rides often without
bandages or oxygen
History of Emergency Medical
Care
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1732 - The first recorded use of mouth-tomouth ventilation involving a coal miner in
Dublin
1896 - First major publication describing the
resuscitation of near drowning victims
History of Emergency Medical
Care
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1947 - Beck reported the first successful case of AC
defibrillation in a human
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common household current (110 V) was applied directly to
the heart using a stripped lamp cord of a 14 y/o who
arrested during thoracic surgery
1958 - Safar demonstrated mouth-to-mouth
ventilation to be superior to other methods of
manual ventilation
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used Baltimore firefighters in his studies to perform
ventilation of anesthetized surgical residents
Birth of Modern Pre-hospital
Care
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1959 – First hospital AC external defibrillators
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these heavy (~100 lbs) units were moved around on top of
a cart which had a tendency to tip over, thus the name
"Crash Cart“
DC defibrillator developed in 1960
1960 – Article by Kouwenhoven, Jude, and
Knickerbocker's the technique of "Closed Chest
Cardiac Massage" is published in JAMA
1962 - Cardiopulmonary resuscitation (CPR), closed
chest cardiac massage combined with mouth-tomouth, shown to be efficacious
Birth of Modern Pre-hospital
Care
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Until the late 1960’s and early ‘70’s ambulance
service was usually provided by the local funeral
home
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at best, the ambulance attendants had a ‘first-aid’ card
1967 - First textbook for pre-hospital care
“Emergency Care and Transportation of the Sick
and Injured” is published by the American Academy
of Orthopedic Surgeons
1968 - AT&T reserves the digits 9-1-1 for emergency
use
1966 - Turning point for EMS
1966 - Turning point for EMS
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The National Research Council of the National
Academy of Sciences publishes a White Paper
“Accidental Death & Disability: The Neglected
Disease of Modern Society”, bringing the harsh
reality of the poor quality of EMS to the attention of
the public
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“Expert consultants returning from both Korea and Vietnam
have publicly asserted that, if seriously wounded, their
chances for survival would be better in the zone of combat
than on the average city street.”
Accidental Death and Disability: The Neglected Disease of
Modern Society (1966)
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...(regarding ambulance service) a diversity of
standards... ill-designed equipment and generally
inadequate supplies.
...(no) standard for the competence or training of
ambulance attendants.
...(though) it is possible to converse with the
astronauts... communication is seldom possible
between an ambulance and the emergency
department...
... “emergency facilities”... (are) poorly equipped,
inadequately manned...
Results of the White Paper
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National Highway Traffic Safety Act of 1966
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EMS Systems Act of 1973
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established national standards for training emergency
medical technicians, and minimum equipment required on
an ambulance
assisted system planners in establishing area wide or
regional EMS programs
Emergency Medical Services for Children (EMS-C)
Program (1984)
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provide support for development of programs for
emergency medical care for injured children and
adolescents
First Mobile Cardiac Care Units
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1966 - Pantridge develops the first MCCU in
Belfast
1968 – First MCCU in the US is started by St.
Vincent's Hospital (New York City); the
program first used physicians
1968 - First paramedic program in the US is
Miami-Dade County Florida
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1970 programs start in Seattle and Los Angeles,
first volunteer paramedic program in
Charlottesville, VA
What is an Emergency Medical
Technician (EMT)?
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Person who receives training to provide prehospital emergency medical care
Services provided depends on the level of
training
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First responder
EMT-Basic (EMT-1)
EMT-D
EMT-Intermediate (EMT-2)
EMT-P (Paramedic)
First responder and basic EMT
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First responder - provides basic first aid and
CPR
EMT-D - may provide defibrillation
EMT-Basic - training emphasizes patient
assessment skills and managing
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respiratory conditions (using suction devices,
oxygen delivery systems)
trauma (splints and immobilization)
cardiac emergencies (CPR)
EMT-Intermediate
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Foundation is Basic EMT training
Skills include the use of advanced airway
devices, intravenous fluids, and some
medications
Classroom and practical coursework up to
350 hours based on scope of practice
Paramedic
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Receives training in anatomy and physiology as well
as advanced medical skills
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Programs commonly conducted in community
colleges and technical schools
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provide advanced airways including endotracheal
intubation and cricothyrotomy
needle chest decompression
obtain intraosseous access
may administer a large variety of medications
1200-1800 hours of coursework (1 to 2 years)
Extensive classroom, clinical and field experience is
required
Star of Life
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Designed in 1973, represents the six systems
functions of EMS
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trademarked by NHTSA to control its use
Working in a hostile
environment
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Paramedics and EMT’s are extension of the
emergency department
By using the ‘ABC’s they can stabilize and
prevent deterioration of the patient
They provide conditions to help ensure the
survival of the patient during transport from
the scene to the hospital
Medical Control
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The process insuring pre-hospital procedures
and providers follow accepted medical
standards
Medical Control
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Medical control may be prospective,
immediate or retrospective
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Prospective: developing practice standards,
policies and protocols
Immediate: medical direction at the scene of an
emergency
Retrospective: quality control and improvement
Medical Control
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“On-line”
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Immediate
“Off-line”
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Prospective
Retrospective
Georgia
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EMTs may perform any service or procedure
authorized by the local medical director within
the state-set scope of practice
Oversight is by the Office of EMS & Trauma
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EMS Advisory Council
EMS Medical Director’s Advisory Council
Safe transport
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Most children with respiratory problems do
not need emergent transport to the ED
Place child in position of comfort
Never place child on top of another person
laying on the gurney
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Recommended method for restraining children up to about 18
kg who can tolerate a semi-upright seated position, showing
belt attachment to the cot and routing through the convertible
child restraint.
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Bull MJ, Weber K, Talty J, Miriam M. Crash protection for children in ambulances: recommendations and
procedures. 45th Annual Proceedings Association for the Advancement of Automotive Medicine.
2001:353-367.
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Recommended method for restraining infants who cannot
tolerate a semi-upright seated position, showing belt
attachment to the cot and routing through the car bed loops.
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Bull MJ, Weber K, Talty J, Miriam M. Crash protection for children in ambulances: recommendations and
procedures. 45th Annual Proceedings Association for the Advancement of Automotive Medicine.
2001:353-367.
Safe transport
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Use of lights and siren for patient transport
should be limited to emergency transport
settings
Local medical directors should take the lead
on developing emergency transport
guidelines
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NAEMSP and NASEMSD policy statement Prehospital and Disaster Medicine, April-June 1994
Safe transport
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A patient should never be transported with
lights and siren just because it’s a child
Your responsibility
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Provide on-line medical control
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direct or approve treatment provided at the scene
direct ambulance to appropriate facility
provide guidance and education to EMS staff after
arrival at hospital
In Georgia, signing the “PCR” report form is
giving approval for care provided in the field
And so…
Byebye!