Emergency Medical Services

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Emergency Medical Services
Pre-Hospital Care

• Bruce Goldfeder, MD
• University of Florida
• Medical Director
• PreHospital Care NASA

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1966 National Highway Safety Act

• Authorized the US Department of Transportation
  (DOT) for prehospital medical services to fund
• Ambulances
• Equipment
• Communications
• Training programs

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Emergency Medical Services Systems Act of 1973
(public law 93-154)

• Funded and authorized the Department of
  Health, Education and Welfare to develop EMS
  throughout the country.

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Public Law 93-154
15 components essential to an EMS system

• 9. Transfer of care
• 10. Consumer participation
• 11. Public education
• 12. Public safety agencies
• 13. Standard medical records
• 14. Independent review and evaluation
• 15. Disaster linkage

• Communications
• Training
• Manpower
• Mutual aid
• Transportation
• Accessibility
• Facilities
• Critical care units

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• 911 Emergency telephone number
• essential front door of the EMS system
• Enhanced 911 (E-911) equipment
• provides automatic number and location
  identification

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Emergency Medical Dispatch (EMD)

• Based on the principle that good information
  gathering during the dispatch phase of an
  emergency can better prepare responding EMS
  providers to deal with the situation at the
  scene.
• Deliver basic emergency care instruction to
  people on the scene.
• Prioritize request for emergency medical
  assistance.
• Ensure only appropriate agencies or prehospital
  providers are dispatched.

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Emergency Medical Dispatch (contd)

• May be carried out by a variety of agencies
• EMS agency
• Law enforcement agency (LEA)
• Separate public safety dispatch center

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Why is 911 better than dialing 0 ?

• 1st Additional call and routing process,
  which takes precious time.
• 2nd The caller may not be connected with the
  correct jurisdiction or service that he needs.

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TRAINING

• Community education
• First aid
• Child safety
• EMS system access
• Cardiopulmonary resuscitation (CPR)

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DUAL-RESPONSE SYSTEM

• (A) First responders (FRs)
• Individuals who may be the first to arrive at a
  medical emergency. Example - Firefighters,
  police, park rangers, or citizen volunteers.
• (B) Emergency Medical Technician (EMT)
• EMT basic (EMT-B) - CPR, AED, extrication,
  immobilization.
• EMT intermediate (EMT-I) - IV access, PASG
• EMT paramedic (EMT-P) - Intubation/RSI, EKG,
  synchronized cardioversion, manual
  defibrillation, drug therapy

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PUBLIC INTEREST PARTICIPATION Key ingredients
in any EMS system!

• Urban areas
• Paid public safety and ambulance personnel.
• Rural or wilderness areas
• Volunteers, park rangers, or ski patrols.

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MUTUAL AID AGREEMENTS

• EMS services have agreements with neighboring
  jurisdictions so that uninterrupted emergency
  care
• is available when local agencies are overwhelmed
  and/or unable to provide services.

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Mutual Aid Agreements
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Mutual Aid Agreements
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TRANSPORTATION

• Ground ambulances
• Provide most EMS transportation.
• The most important aspect of ambulance design is
  that the attendants must be able to provide
  airway and ventilatory support while safely
  transporting the patient.
• Air transport
• Helicopter (Rotor-wing)
• Airplane (Fixed-wing)

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ACCESS TO CARE

• A successful EMS system ensures that all
  individuals have access to emergency care
  regardless of their ability to pay or type of
  insurance coverage.
• Emergency physicians must serve
• as the patients advocate!!

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FACILITIES

• General
• Transport to the closest appropriate hospital.
• If multiple hospitals within the same transport
  time patients choice.
• Specialized receiving facilities
• Higher level of care warranted
• Transport to that institution (by passing closer
  hospitals).
• i.e. trauma, burn, stroke or angioplasty center

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Critical Care Units (CCUs)
Tertiary care facilities should be identified by
every EMS system to provide specialty care that
is not available in typical community
hospitals.Most common reasons for tertiary care
emergency transfer

• Trauma
• High-risk obstetrics
• Cardiac care
• Burns
• Neonatal intensive care
• Spinal cord injury
• Neurosurgery

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TRANSFER OF CARE

• Must be made with maximum safety for the patient!

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CONSUMER PARTCIPATION

• Laypersons should be represented on EMS councils.
• Two important components of a successful EMS
  system
• Lay public first aid training
• Implementation of a 911 system

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Public Information and Education

• In designing a public information program, the
  EMS councils goal should be for the public
• Understand how the community stands to
  benefit from an excellent EMS system.
• Be prepared to render first aid care.
• Know how to access the EMS system quickly.
• Understand that patients may not be delivered to
  the hospital of their choice under
  life-threatening conditions.

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PUBLIC SAFETY AGENCIES

• Strong ties with police and fire departments
• Often provide first-response service because
  their personnel are often the first on the scene
  of an emergency.
• I.e., police carrying oxygen and automatic
  defibrillators

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Standardization of Patients Records

• All ambulance services within a specific region
  should use a similar reporting form that can be
  quickly and easily be interpreted by receiving
  nurses and physicians.

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Independent Review Evaluation

• Continuous quality improvement (CQI) is the sum
  of all quantities undertaken to assess and
  improve the products and services provided
  throughout the entire EMS system.
• monitoring radio communications
• response times
• patients care records
• outcome studies, i.e. cardiac arrest and multiple
  trauma.
• protocol review

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DISASTER PLANNING

• The EMS system is an integral element of
  disaster preparedness and planning.
• Important role in initial response and
  transportation
• Establish a regional disaster preparedness plan
  in coordination with public safety agencies,
  government medical community
• Periodic disaster drills

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Short Break
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Medical Direction

• The process by which a dedicated physician(s)
  guides and oversees the patient care that is
  provided by an EMS system.

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MEDICAL DIRECTION

• Why do paramedics, who are licensed by the state,
  need a medical director or physician advisor?

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ON-LINE MEDICAL DIRECTION (OLMD)

• a.k.a. direct medical control,
• on-line medical command, or
• real-time medical control.
• Direct medical communication to personnel in the
  field.
• in person
• radio
• phone communication
• landline (traditional telephone)
• cellular

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OFF-LINE MEDICAL CONTROL

• Responsibility of the service medical director
• Development protocols and standing orders
• Development of medical accountability (QA)
• Development of ongoing education
• Physicians must remember that they have the
  ultimate responsibility for the overall quality
  of PreHospital medical care.

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Qualifications of an EMS Medical Director

• Licensed physician with interest, experience, and
  knowledge in emergency medicine and PreHospital
  care.
• Preferable if full-time, practicing, emergency
  physician at the lead hospital for the EMS
  system, with additional training and experience
  in EMS.

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Medical Basis for EMS
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Emergency Cardiac Care

• ALS saves lives after sudden cardiac arrest.
• The number of lives saved and the cost are
  debated.
• Without treatment at the scene, the survival
  rate of out-of-hospital cardiac arrest is
  virtually zero.
• Seattle and King Count, Washington
• 26 patients successfully resuscitated from
  out-of-hospital cardiac arrest.
• New York City
• 1.4 overall survival
• Outcome of out-of-hospital cardiac arrest in New
  York City. The Pre-Hospital Arrest Survival
  Evaluation (PHASE) study.
• JAMA 1994 Mar (Lombardi, Gallagher, and Gennis)

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Universal Precautions

• Blood and body fluids
• Masks
• Goggles
• Gloves

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Improve Survival

• Shorten interval between collapse and
  defibrillation.
• Local system must optimize the chain of
  survival
• early access
• early CPR
• early defibrillation
• early ALS
• First responders
• AEDs

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Pilot programs
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Pilot programs
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Trauma Care

• Delivery of critically injured trauma patients to
  trauma centers saves lives.
• Controversial PASG
• IV on scene (field) vs. en route
• Houston no IVF in Prehospital or
  E.R. for hypotensive
  victims of penetrating truncal trauma.

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The Chain of Survival
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The Chain of Survival

• Early Access Someone suspects or determines the
  victim is in sudden cardiac arrest and calls for
  help
• Early CPR Someone trained in CPR keeps the
  victims blood flowing until defibrillation can
  begin
• Early Defibrillation Someone trained in
  defibrillation shocks the victim as quickly as
  possible
• Early Advanced Care Medical personnel provide
  advanced cardiac care which can include airway
  support, medications, and hospital services

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Vehicles

• First-response units do not transport patients
• fire engines
• police cruisers
• rescue vehicles
• Ground ambulances
• Transport ambulances
• Type 1 standard pick-up chassis with a modular
  box to carry personnel, patient, and equipment
• Type 2 enlarged van-type vehicle
• Type 3 van chassis with a modular box in the
  back.

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Defibrillators

• Automated external defibrillators (AEDs)
• analyze the patients rhythm, determine whether a
  defibrillatory shock is indicated, charge the
  capacitors, and then inform the operator that a
  shock is advised.
• defibrillate only for ventricular fibrillation
  and very fast wide QRS
  complex tachycardias (usually
  over 180/bpm)
• used only in pulses and apneic patients.

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Defibrillators
Physio Control Life Pack 12
Zoll M Series
HP CodeMaster 100
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Automated External Defibrillators
Physio-Control LIFEPAK 500
Laerdal HeartStart
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Prehospital Airway Devices

• The establishment and maintenance of a patient
  airway is the primary task of the prehospital
  emergency care provider.
• Think ABCs!!!

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Basic Airway Devices

• Oropharyngeal airways (OPA)
• Nasopharyngeal airways (NPA)
• Bag-valve-mask ventilation (BVM).
• Pulmonary Resuscitator

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Advanced Airway Devices

• Endotracheal tubes and blades
• End-tidal CO2 detectors (ETCO2)
• Pulse-Oximeter
• Laryngeal Mask Airway (LMA)
• Esophageal Gastric Tube Airway (EGTA)
• Esophageal Intubation Detector
• Esophageal Obturator Airway (EOA)
• Blind insertion
• Pharyngeotracheal Lumen Airway (PTL)
• Esophageal-Trachea Combitube (ETC)
• McGill forceps
• Melker Cricothyrotomy equipment

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Vascular Access Equipment

• Paramedics are very adept at placing IVs
• IV access should not prolong scene times in a
  trauma patient, especially when Load and Go
  criteria are present

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Spinal Immobilization ABCs

• The preservation of integrity of the spinal
  column is of paramount importance in the field.
• C-S stabilization and airway assessment are
  performed simultaneously.
• Manual stabilization of the neck is not released
  until the patient has been transferred and
  securely strapped to a board.

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Spinal Immobilization ABCs
Odontoid fracture Atlantoaxial dislocation
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Air Medical Transport

• Helicopter
• inventor - Igor Sikorsky
• Burma, 1945
• first rotor-wing medical evacuation
• Korean War
• 20,000 transported patients
• Vietnam War
• 370,000 transported patients
• Denver, 1972
• first hospital-based civilian program

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Air Medical Transport

• Association of Air Medical Services (AAMS)
• Domestic 362 air medical providers
• International 23 air medical providers
• Hospital(s) based
• Helicopter cost 1-5 million
• annual operating cost 2 million
• Patients transported
• 827 per program
• 1997 - survey of 126 United States air medical
  programs

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Clinical Use of Helicopters

• Fast ambulances
• 125-175 mph
• 150-200 mile range
• Two major types of helicopter missions
• (1) Trauma/medical scene responses (30)
• (2) Interfacility transfers
  (70)

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Rotor-wing aircraft

• Advantages
• Can be based at a hospital or another location
  near your service area.
• Do not require a runway for takeoff and landing.
• Capable of landing in relatively small and
  secluded areas.
• Usually ready for takeoff in a matter of minutes.

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Fixed-wing Aircraft

• Great range - can fly thousands of miles (rotor
  maximum range of 350 miles)
• Able to transport a heavier load
• Faster
• More economical for most flight distances
  (helicopter more expensive than ground
  transport).
• When pressurized, preferable for conditions
  affected by altitude.

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Alachua County Emergency Services