Emergency Medical Services

1. Emergency Medical Services Bruce Goldfeder, MD University of Florida Medical Director – PreHospital Care & NASA ‘Pre-Hospital Care’

2. 1966 National Highway Safety Act Authorized the US Department of Transportation (DOT) for prehospital medical services to fund: • Ambulances • Equipment • Communications • Training programs

3. Emergency Medical ServicesSystems Act of 1973 (public law 93-154) Funded and authorized the Department of Health, Education and Welfare to develop EMS throughout the country.

4. Communications Training Manpower Mutual aid Transportation Accessibility Facilities Critical care units 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 Public Law 93-154 15 components essential to an EMS system

5. 911 Emergency telephone number essential front door of the EMS system • Enhanced 911 (E-911) equipment provides automatic number and location identification

6. 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.

7. Emergency Medical Dispatch (cont’d) May be carried out by a variety of agencies: • EMS agency • Law enforcement agency (LEA) • Separate public safety dispatch center

8. 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.

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

10. 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

11. 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.

12. 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.

13. Mutual Aid Agreements

14. Mutual Aid Agreements

15. 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)

16. 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!!

17. FACILITIES General: • Transport to the closest appropriate hospital. If multiple hospitals within the same transport time: patient’s 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

18. Trauma High-risk obstetrics Cardiac care Burns Neonatal intensive care Spinal cord injury Neurosurgery Critical Care Units (CCU’s) 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:

19. TRANSFER OF CARE • Must be made with maximum safety for the patient!

20. 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

21. Public Information and Education • In designing a public information program, the EMS council’s 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.

22. 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

23. 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.

24. 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

25. 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

26. Short Break

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

28. MEDICAL DIRECTION Why do paramedics, who are licensed by the state, need a medical director or physician advisor?

29. 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

30. 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.

31. 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.

32. Medical Basis for EMS

33. 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)

34. Universal Precautions Blood and body fluids • Masks • Goggles • Gloves

35. 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

36. Jim Alexander - Security officerLas Vegas security officer saves two lives in less than one year U.S. Air Force retiree Jim Alexander works as a security officer at Stardust Resort and Casino in Las Vegas. In less than one year, Alexander saved the lives of two casino guests: one in September 1997 and another in August 1998. Pilot programs

37. Richard BransonPassenger safety is paramount with Virgin AtlanticFlamboyant millionaire Richard Branson has long been known for his brilliance in business. So, perhaps it’s no surprise that Virgin Atlantic Airways was the first airline in the world to carry automated external defibrillators on board. This commitment to safety paid off in December 1997 when the crew on a Virgin flight from London to Miami saved the life of a passenger in sudden cardiac arrest. It was the first successful defibrillation in U.S. airspace history. Pilot programs

38. 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.

39. In 1990, the American Heart Association introduced a treatment model for victims of sudden cardiac arrest called the Chain of Survival. It outlines the specific sequence of events that need to happen for a victim to survive and recover from sudden cardiac arrest. “The Chain of Survival”

40. 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 victim’s 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

41. 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.

42. Automated external defibrillators (AEDs) analyze the patient’s 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. Defibrillators

43. Defibrillators Physio Control Life Pack 12 Zoll “M” Series HP CodeMaster 100

44. Automated External Defibrillators Physio-Control LIFEPAK 500 Laerdal HeartStart

45. Prehospital Airway Devices The establishment and maintenance of a patient airway is the primary task of the prehospital emergency care provider. Think ABC’s!!!

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

47. 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

48. Vascular Access Equipment • Paramedics are very adept at placing IV’s • IV access should not prolong scene times in a trauma patient, especially when “Load and Go” criteria are present

49. Spinal Immobilization ABC’s 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.

50. Spinal Immobilization ABC’s Odontoid fracture & Atlantoaxial dislocation