Introduction to EMS

From battlefield transport to hospital-quality care at the scene

The earliest documented emergency medical service appeared in France in the 1790s, and it did one thing: it carried the wounded off the battlefield. No care was given at the scene. During the American Civil War, Clara Barton organized care for the wounded and went on to found the American Red Cross, and by the First World War volunteer ambulance corps were an established part of military medicine. The wars in Korea and Vietnam brought the major advances in field care, and those advances carried over into the civilian trauma centers that followed.

Civilian service developed more slowly. Cities began ambulance services in the early 1900s, but they too were transport only. Smaller communities did not get service at all until after the Second World War, in the late 1940s, and where they did, it was often a funeral home's hearse or the fire department that provided it.

The defining shift in the history of EMS is the one from "just transport" to care of hospital quality that begins at the scene and continues without interruption until the patient reaches the hospital. Everything that follows in this book rests on that idea.

Timeline

The modern system took shape through a series of federal actions. In 1966 the National Highway Safety Act directed the Department of Transportation (DOT) to set standards for EMS. The National Registry of Emergency Medical Technicians (NREMT) was founded in 1970, and in 1973 the National EMS Systems Act became the cornerstone federal law for EMS systems. Since then control has largely passed to the states, which now run most of their own systems, although the National Highway Traffic Safety Administration (NHTSA) still provides guidance.

NHTSA's 10 EMS System Standards

NHTSA describes a complete EMS system in terms of 10 standards, each naming a component the system must have. They are:

• Regulation and policy
• Resource management
• Human resources and training
• Transportation
• Facilities
• Communications
• Public information and education
• Medical direction
• Trauma systems
• Evaluation, through quality improvement, quality assurance and total quality management (QI/QA/TQM)

Several of these, medical direction and evaluation among them, are taken up later in this chapter.

EMS system flow (patient's point of view)

Seen from the patient's side, the system is a chain of handoffs. The call is answered by an emergency medical dispatcher (EMD), who sends responders; depending on the system and the call, these may be EMRs, EMTs, AEMTs or paramedics. An ambulance then carries the patient to the emergency department (ED), and from the ED the patient moves on to the rest of the hospital.

The ED is the gateway to the hospital's services, including the operating room (OR) and its specialists. Some hospitals are also specialty centers: trauma centers, which keep surgical teams available 24/7, and burn, pediatric, cardiac and stroke centers. Choosing the right facility for a patient is a critical decision, because it weighs the patient's condition against the transport time, and on-line medical direction can help you make it.

911 and dispatch

The public reaches EMS by telephone, and the number is 911. The 911 system covers roughly 99% of the population and handles about 240 million calls a year, more than 80% of them from mobile devices. Enhanced 911 automatically identifies a landline caller's number and location, and some systems can locate wireless callers as well. For mobile devices this happens in two phases: Phase 1 identifies the caller's number, and Phase 2 identifies the physical location of the device. Calls placed over the internet (VoIP) are harder to locate, and this remains an ongoing technical challenge.

The call is answered by an emergency medical dispatcher (EMD). EMDs are specially trained and certified, and besides sending the right resources they give the caller pre-arrival instructions, such as how to perform CPR, provide ventilation or control bleeding until the crew arrives.

4 levels of training (low → high)

Prehospital providers are trained to one of four nationally recognized levels. From the least to the most training, they are:

• Emergency medical responder (EMR): often the first on scene; activates EMS, provides basic care for life threats and controls the scene.
• Emergency medical technician (EMT): the minimum certification for ambulance staff; basic medical and trauma care, and transport.
• Advanced EMT (AEMT): everything an EMT does, plus advanced airway devices, intravenous and intraosseous (IV/IO) fluids, and some medications.
• Paramedic: all of the EMT and AEMT skills plus advanced assessment and decision-making; the highest prehospital level.

In some states, specially trained nurses (RNs) and physicians also hold prehospital certifications.

"Think like an EMT" — critical decision making

Much of what makes an EMT effective is critical decision making: taking in information from the scene, from the assessment findings and from other sources, then synthesizing all of it to make the right call. When the information you have is not enough to decide, ask more questions or examine the patient further before you act. The choice of hospital is one example, because the closest hospital is not always the right destination when a specialty center is available. Giving a medication is another, because a drug that would help one patient may worsen another patient's condition.

EMT responsibilities

An EMT's responsibilities on a call follow a definite order of priority. Personal safety comes first, followed by the safety of the crew, the patient and bystanders. You work alongside other public safety professionals at the scene. Patient assessment always comes before patient care, because you cannot treat what you have not found. Care is followed by lifting and moving the patient safely, then by transport, and then by transfer of care at the hospital; a patient is never abandoned before that transfer is complete. Throughout, the EMT acts as the patient's advocate.

The role also extends to community health and injury prevention, such as noticing fall hazards or poisoning risks in a patient's home.

Good EMT traits

The job makes physical demands. A good EMT is in good health and physically fit, and is able to lift and carry 125 lb (57 kg). Good near and distance vision is needed, along with functional color vision, because color changes in the skin, lips and nail beds are diagnostic cues. Clear speech and good hearing matter as well.

The personal traits matter just as much. The EMT should be pleasant, sincere and cooperative; resourceful and a self-starter; emotionally stable; able to lead; and neat and clean in appearance. Good moral character and controlled personal habits are expected, which means no alcohol within 8 hours of duty and no smoking on duty. Finally, the EMT is a good listener who is nonjudgmental and fair with every patient.

Education & the NREMT

Certification is not permanent. Refresher training is required periodically, roughly every 2–4 years, in order to recertify. Continuing education supplements the original training rather than replacing it, and it comes in many forms: conferences, classes and videos. Both are necessary because EMS knowledge and procedures change constantly, so much so that some of what you learn will change during your own course.

The NREMT sets and maintains national standards and registers EMRs, EMTs, AEMTs and paramedics. Registration is earned by passing the NREMT practical examination and its computer-based knowledge examination. Holding national registration helps with reciprocity, the transfer of certification from one state to another, and is looked on favorably by employers. Most states use the NREMT examination as their own certification examination.

Quality improvement (QI)

Quality improvement (QI) is the continuous self-review of an EMS system to identify and fix problems, with the aim of ensuring the highest quality of prehospital care. EMTs support QI in several ways: by writing accurate and complete reports, by serving on QI committees, by critiquing their own performance after each call, by gathering feedback from patients and hospitals, by maintaining their equipment, and by continuing their education.

Medical direction

Every EMS system operates under the authority of a physician. The Medical Director is the physician with ultimate responsibility for the patient-care side of the system: the protocols, oversight of training, and a central role in QI. Medical direction reaches the EMT in two forms, set out in the table below.

Table 1.1Medical direction

Off-line direction takes the form of standing orders, which let you act without contacting a physician. On-line direction is a real-time order from an on-duty physician, given over the phone or radio.

EMS role in public health

Public health is the system that oversees the health of a population as a whole: clean water, vaccination, prenatal care and the like. EMS contributes to it in a number of ways. Geriatric injury prevention includes identifying fall hazards, running blood pressure (BP) clinics and promoting the File of Life. Youth injury prevention includes car-seat clinics and bicycle helmet programs. Many EMS agencies take part in public vaccination programs, giving flu shots and, in some regions, routine childhood vaccines. EMS also contributes to disease surveillance, because trends in call volume are an early warning of influenza, opioid overdoses and mass-casualty events.

The umbrella term for this expanded role is Mobile Integrated Health Care, also called community paramedicine. EMS is uniquely placed for it because it operates directly in patients' homes and communities rather than only in hospitals and offices.

Research & evidence-based EMS

Evidence-based techniques are those supported by scientific evidence rather than by tradition alone. The measure that matters is patient outcomes, meaning long-term results and not simply survival to the hospital. Oxygen is the classic example: O2 is not a "wonder drug," and excess O2 can worsen the outcome of a myocardial infarction (MI) or a stroke.

Adopting an evidence-based practice follows a process. A hypothesis is formed, the literature is reviewed, the evidence is evaluated together with the Medical Director, and the practice is adopted only if the evidence supports it. This is the scientific method, in use for roughly 400 years since Galileo: a general observation leads to a hypothesis, the hypothesis to a prediction, and the prediction to testing that proves or disproves it.

Research that is peer reviewed has been vetted by other experts before it is published in a journal, which makes it more reliable than EMS magazines; those are informative, but they do not publish original, peer-reviewed research. Research in EMS is hard for several reasons: the environment is unstable, patient encounters are brief, data collection is disjointed, and there are ethical issues in obtaining consent from critically ill patients.

Street Scenes — professionalism case study

Two EMTs on the same kind of call illustrate what professionalism looks like in practice. Chuck is the poor example. His uniform is unkempt, he does not introduce himself, and he is dismissive of the patient, calling the patient "hon," cutting the patient off and criticizing his partner in front of the patient. This is unprofessional behavior and poor people skills.

Susan Miller is the good example. Her uniform is neat. She introduces herself and her crew, and she has checked the equipment and reviewed procedures before the call. She reassures the patient, and when correction is needed she gives it privately and constructively, never in front of the patient. After the call she debriefs with her crew.