EMS

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EMS
PAST
PRESENT
FUTURE
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EMS PAST
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Pioneers of PrehospitalTrauma Care

• AMBROSE PARE
• French surgeon in 1500s
• Wrote first book on trauma care
• Condemned use of boiling oil for GSW and
  reintroduced use of ligatures for amputations
• No organized evacuation of wounded at this time

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History of PrehospitalTrauma Care

• No organized medical care for injured patients
  before 19th century
• On the battlefield no organized evacuation of the
  wounded and no field hospitals to treat them
• Generally women camp followers provided nursing
  care
• Organized prehospital care began with the efforts
  of military surgeons to treat battlefield
  casualties

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Pioneers of Prehospital CareEarly 1800s Baron
LarreySurgeon General, Napoleons Army
Baron Larreys Flying Ambulance
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Crimean War 1854-56

• Modern nursing care introduced by Florence
  Nightingale
• Casualties begin to be evacuated by railroad

FLORENCE NIGHTINGALE THE LADY WITH THE LAMP
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• Note a pattern developing the faster the injured
  arrived at a hospital, the better the survival.
  This principle has not changed

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Linda Richards

• Americas first trained nurse
• Traveled to England to learn from Florence
  Nightingale who had started a school for nurses
• On her return to the U.S Richards pioneered the
  founding of nursing training schools across the
  nation.
• In 1885 she helped to establish Japan's first
  nursing training program

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Air Evacuation

• First began in Paris in 1870 when hot-air
  balloons were used to evacuate 160 soldiers
• Did not become common until the second world war

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BEGINNINGS OF EMS IN THE U.S.
LOAD AND GO
ORIGINAL AMERICAN AMBULANCE AND ORIGIN OF THE
TERM HAUL ASS
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American Civil War
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Civil War

• Railroads continue to be used to evacuate
  casualties
• Army still used ambulances much like Napoleon
• Death rate very high because germs were unknown
  as the cause of infection barns used as
  hospitals
• U.S. Army set up the Medical Corps
• System-wide approach with ambulances on the
  battlefield transporting to system of hospitals
• Aid stations
• Field hospitals
• Rear general hospitals
• This model was used until the Vietnam war

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WORLD WAR I
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WORLD WAR I

• Poor planning (no field hospitals) caused
  excessive evacuation times of 12-18 hours
• High mortality rates gt20
• Most died of hemorrhagic shock
• No antibiotics so sepsis common
• Blood transfusions just beginning to be used
• Thomas half-ring femur splint was considered the
  greatest advancement in trauma care at this time

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WORLD WAR II

• Evacuation time for wounded decreased to 4-6
  hours
• Antibiotics developed
• Plasma and blood transfusions common
• Hospitals closer to the front to decrease time to
  surgery
• Fixed wing air transport
• Mortality rate 3.3

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KOREAN WAR

• Evacuation time averaged 2-4 hours
• Helicopter evacuation of wounded introduced
• More use of electrolyte solutions
• Better antibiotics
• Surgical hospitals closer to front lines
• Mortality rate 2.4

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VIETNAM WAR

• Casualties taken directly from front lines to
  surgical hospital by helicopter
• Average evacuation time 35 minutes
• Average time to surgery 1-2 hours
• Mortality 2.3
• Civilian systems have never matched this

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IRAQ WAR

• Rediscovered tourniquets
• Development of hemostatic agents
• Developed concept of CAB for patients with
  exsanguinating hemorrhage

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Civilian Prehospital Medical Care

• Before Vietnam War
• A few large hospitals provided ambulance services
  (transport only)
• Bellevue Hospital began horse drawn ambulances in
  1869
• No trained providers
• Rural areas used hearses for ambulances
• This went on until the 1970s

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ORIGINAL VOLUNTEER RESCUE

• Good Samaritan was much like volunteer rescue
  folks
• Considered 2nd class citizen
• Cared deeply for his fellowman and was willing to
  go out of his way and furnish his own ambulance
  to help him
• Set a standard we all have to live up to today

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Beginning of EMTs

• First prehospital training course taught to
  Chicago Fire Department in 1957
• Prehospital training did not catch on until the
  late 1960s and with few exceptions paramedic
  training did not begin until the 1970s

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PARAMEDICS WERE INVENTED TO REPLACE DOCTORS IN
TREATING PREHOSPITAL CARDIAC PATIENTS

• AT THAT TIME CARDIAC PATIENTS REQUIRED CAREFUL
  DELIBERATE CARE
• SPEED WAS NOT NEEDED
• THAT PRINICPLE IS NO LONGER TRUE

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Frank Pantridge, MD1916-2004
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Frank Pantridge, MD

• Called the grandfather of prehospital ALS
• In Belfast Ireland, in the 1950s he began using
  the new CPR system for cardiac resuscitation but
  realized he needed to get the treatment into the
  field
• Developed the first portable defibrillator and
  then the mobile intensive care ambulance

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Peter Safar, MD 1924-2003
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Peter Safar, M.D.

• Intensive care specialist who pioneered the
  ABCs of CPR including mouth-to-mouth
  resuscitation
• Worked with Laerdal to develop the Resusci Anne
• Helped develop the first ALS ambulances
• In 1966 trained some of the first paramedics by
  taking 44 unemployed African-American men and
  giving them 3000 hours of training (doctors got
  3500)

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Nancy Caroline, MD1944-2002
THE MOTHER OF PARAMEDICS
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Nancy Caroline, MD

• She was influenced by Dr. Safar to believe that
  nonphysicians could be trained to perform
  physician skills
• She worked in the field with Dr. Safars original
  paramedics
• Was the original author of the DOT national
  standard curriculum for paramedics in 1974
• There were no paramedic textbooks so in 1975 she
  wrote the original textbook Emergency Care in the
  Streets
• Now in its 6th edition

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Milestones

• In 1968 the American College of Emergency
  Physicians was formed. This led to the
  development of residency training programs and
  eventually to the recognition of emergency
  medicine as a specialty in 1979..

In the House of Medicine, the light that is never
turned off
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R Adams Cowley 1917-1991
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R Adams Cowley, MD

• In the 1960s Dr. R Adams Cowley, a cardiovascular
  surgeon, did pioneer work in trauma care and
  helped bring about special training in trauma
  care for surgeons.
• Developed the concept of the Golden Hour
• He was responsible for the development of the
  Maryland Institute for EMS Systems (MIEMSS), the
  first statewide EMS system

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EMERGENCY 1972-1977
RAMPARTS
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Milestones

• 1968 St. Vincents Hospital in New York City
  began first mobile coronary care unit
• 1969 Miami, FL Fire Department began the nations
  first paramedic program under Dr. Eugene Nagel
• 1972 The television show Emergency! Began
• Soon every town wanted their own Ramparts
• There were 12 medic units in the country at the
  time
• Four years later at least 50 of the population
  was within 10 minutes of a medic unit
• 1973 St. Anthonys Hospital in Denver starts the
  nations first civilian aeromedical transport
  service (Flight for Life)

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Rocco Morando
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Rocco Morando

• Was instrumental in establishing the National
  Registry of EMTs in 1970 and became its first
  executive director in 1971
• He retired in 1981 and the headquarters building
  was named after him
• Was also instrumental in establishing the
  National Association of EMTs in 1975
• He and Dr. McSwain helped keep NAEMT afloat
  during the early years when support (and funds)
  was sparse

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Milestones

• 1975
• First paramedic textbook written by Nancy
  Caroline
• National Association of EMTs is formed
• 1978 American Heart Association begins the
  Alphabet Courses with ACLS
• 1980 American College of Surgeons begins the ATLS
  course for physicians
• 1982 Alabama Chapter of ACEP begins BTLS course
• 1983 NAEMT and ACS begin PHTLS

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James O. Page1936-2004
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James O. Page

• Probably best known of all those mentioned so far
• Untiring speaker who was always ready to tell
  people about EMS
• A man of many parts, Fire chief, lawyer,
  technical consultant for Emergency!, first EMS
  director for North Carolina, prolific writer and
  speaker, founder of JEMS, most recognized
  spokesman for EMS until his death in 2004

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Norman McSwain, MD
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Norman McSwain, MD

• Dedicated trauma surgeon and educator
• Supporter of EMS for over 30 years
• Founding father of NAEMT
• Founding father of PHTLS and continues to serve
  as medical director
• Gentleman and scholar
• But dont ever let him drive

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EMS PRESENT
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WE ARE AT THE END OF THE BEGINNING IN EMS
Ray Fowler, MD
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EMS at Present

• Except for isolated instances, the whole country
  is within a reasonable distance of an ALS
  ambulance
• EMS systems continue to vary widely with few
  states having centralized management of the
  system
• Some states dont even have a State EMS Medical
  Director
• Many states do not require that their EMS
  training programs be accredited

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Standardization of the Profession

• In process of finally standardizing levels of
  prehospital EMS providers
• EMT
• BLS including AED and CPAP
• Only a committee could have come up with the
  brilliant idea to take a generic term (EMT) that
  applied to all levels of providers and make it
  refer to only one level, thus rendering all
  previous references confusing
• Advanced EMT
• Above Rescue airway, IV fluids limited
  medications
• Paramedic
• Above intubation Monitor Defibrillator more
  meds

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Have Yet to Prove to Everyone that Paramedics
Make a Difference

• EMS is the largest hoax ever foisted on the
  American people. There is no data, not one
  study, which shows that anything beyond the
  intermediate level basic EMT with a
  defibrillator capabilities does anything in the
  long run to change the health care of the United
  States
• Gregory Henry, MD
• Dr. Henry is an expert in risk management, not
  EMS, but he strikes a nerve

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EMS
FUTURE
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WHERE DO WE GO FROM HERE?WE FACE SOME
CHALLENGES
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Must Recruit More EMTs

• There is a critical need for competent,
  professional EMTs
• Prehospital EMS is an exciting career that should
  be emotionally and financially rewarding
• Somewhere we got the idea that only older
  men/women should be EMTs
• Students just out of high school are too
  immature to be EMTs
• Bill Brown, National Registry
• Tell that to the nursing profession
• We must begin recruiting students while they are
  in high school

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Paramedics Must Change How They Define Themselves

• At present too many define themselves by what
  procedures they can do
• Too many dishonor the profession by being more
  interested in doing invasive procedures than
  caring for the patient
• The worth of a prehospital provider is not in
  what procedures they do but how many people they
  save
• Less may be more
• Patient care must come first
• In most instances this means Load and Go with
  most interventions done in the ambulance
• ALS is almost impossible when there is only one
  EMT in the back of the ambulance

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Critical Care Systems (STEMI, Stroke, Trauma)
will allow Paramedics to prove their worth
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Volunteers will Continue to be Needed

• They are critical in many rural areas
• Local, state, or federal funding is not likely to
  provide enough funding to replace them
• They are capable of providing the same level of
  care as the best municipal or private services

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Must Introduce Science to Prehospital Care

• Must scientifically prove what saves lives in the
  prehospital environment
• Should do only those things that are proven to
  help
• If there is no scientific data that a procedure
  helps people, we should stop doing it
• This reflects positively not negatively on our
  worth
• If the data shows a procedure decreases survival
  it MUST be stopped or changed to make it safer
• At present the data shows rapid transport to the
  appropriate hospital is the most important role
  of prehospital medicine
• Scientific studies are difficult in the
  prehospital arena but must be pursued if we are
  to be accepted as a profession

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Quantitative Capnography Must Become a
Requirement for Intubation

• Has been standard of care for anesthesiologists
  for over 10 years
• Became standard of care because it essentially
  eliminated unrecognized esophageal intubations
• If Doctors who specialize in intubating patients
  cant always recognize an esophageal intubation
  without capnography, why do we think we can?
• Scientific studies show we have too many
  unrecognized esophageal intubations in the field
• Quantitative CO2 devices are now under 1000

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(No Transcript)
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Device that Reads Out Rate of Ventilation and CO2
levelSOMETHING LIKE THIS MUST BE USED IF WE DO
INTUBATION IN THE FIELD (OR THE E.D.)
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CPAP WILL ELIMINATE MOST INTUBATIONS EXCEPT
FORTRAUMA CASES

• It is non-invasive and can be used for many
  medical causes of dyspnea

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Must Better Define the Roleof Helicopter EMS

• Helicopter EMS is a critical service but is
  frequently being misused
• It should be reserved for critical cases in which
  the use of the helicopter will SIGNIFICANTLY
  reduce the transport time
• In Alabama the average response time is 22
  minutes and the average transport time is 17
  minutes
• On average the patient is not delivered for one
  hour after the initial call to the helicopter

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FINAL THOUGHTFUTURE EMS WILL BE BETTER OR WORSE
DEPENDING ON WHAT WE DO, BUT IT IS NOT GOING
AWAYTHE AMERICAN PEOPLE LOVE EMS, WARTS AND ALL
AND RIGHTLY SO