Emergency Medical Services What it is and how we got there

1. Emergency Medical ServicesWhat 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

2. It’s not rocket science

3. What is Emergency Medical Services (EMS)? • A system of coordinated response and emergency medical care, involving multiple personnel and agencies that provides emergency medical care • 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

4. What is EMS?

5. What are the components of an EMS system? • Pre-response • Prehospital • Emergency Department/Hospital • Critical Care • Rehabilitation

6. EMS System 9-1-1 Dispatch First Responders

7. Advanced Life Support Medical Control EMS System

8. E G L E S T O N Stabilization Transport EMS System

9. System Objectives • Tired response • Closer “first responder” (EMT-Basic, EMT-D) begins stabilization while more distant, advanced trained provider responds • Response time • “First responder” arrival within a few minutes • Advance responder arrival in less than 10 minutes

10. System Objectives • Advanced life support • Brings the emergency department to the scene • Mutual-aid • Links providers from different areas to provide closest EMS unit

11. History of EMS • 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

12. History of EMS • 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

13. History of EMS • 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

14. History of EMS • 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”

15. Advances in Emergency Medical Care – 1950’s • 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

16. History of Emergency Medical Care • 1732 - The first recorded use of mouth-to-mouth ventilation involving a coal miner in Dublin • 1896 - First major publication describing the resuscitation of near drowning victims

17. History of Emergency Medical Care • 1947 - Beck reported the first successful case of AC defibrillation in a human • 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 • used Baltimore firefighters in his studies to perform ventilation of anesthetized surgical residents

18. Birth of Modern Pre-hospital Care • 1959 – First hospital AC external defibrillators • 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-to-mouth, shown to be efficacious

19. Birth of Modern Pre-hospital Care • Until the late 1960’s and early ‘70’s ambulance service was usually provided by the local funeral home • 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

20. 1966 - Turning point for EMS

21. 1966 - Turning point for EMS • 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 • “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.”

22. Accidental Death and Disability: The Neglected Disease of Modern Society (1966) • ...(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...

23. Results of the White Paper • National Highway Traffic Safety Act of 1966 • established national standards for training emergency medical technicians, and minimum equipment required on an ambulance • EMS Systems Act of 1973 • assisted system planners in establishing area wide or regional EMS programs • Emergency Medical Services for Children (EMS-C) Program (1984) • provide support for development of programs for emergency medical care for injured children and adolescents

24. First Mobile Cardiac Care Units • 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 • 1970 programs start in Seattle and Los Angeles, first volunteer paramedic program in Charlottesville, VA

25. What is an Emergency Medical Technician (EMT)? • Person who receives training to provide pre-hospital emergency medical care • Services provided depends on the level of training • First responder • EMT-Basic (EMT-1) • EMT-D • EMT-Intermediate (EMT-2) • EMT-P (Paramedic)

26. First responder and basic EMT • First responder - provides basic first aid and CPR • EMT-D - may provide defibrillation • EMT-Basic - training emphasizes patient assessment skills and managing • respiratory conditions (using suction devices, oxygen delivery systems) • trauma (splints and immobilization) • cardiac emergencies (CPR)

27. EMT-Intermediate • 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

28. Paramedic • Receives training in anatomy and physiology as well as advanced medical skills • provide advanced airways including endotracheal intubation and cricothyrotomy • needle chest decompression • obtain intraosseous access • may administer a large variety of medications • Programs commonly conducted in community colleges and technical schools • 1200-1800 hours of coursework (1 to 2 years) • Extensive classroom, clinical and field experience is required

29. Star of Life • Designed in 1973, represents the six systems functions of EMS • trademarked by NHTSA to control its use

30. Working in a hostile environment • 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

31. Medical Control • The process insuring pre-hospital procedures and providers follow accepted medical standards

32. Medical Control • Medical control may be prospective, immediate or retrospective • Prospective: developing practice standards, policies and protocols • Immediate: medical direction at the scene of an emergency • Retrospective: quality control and improvement

33. Medical Control • “On-line” • Immediate • “Off-line” • Prospective • Retrospective

34. Georgia • 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 • EMS Advisory Council • EMS Medical Director’s Advisory Council

35. Safe transport • 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

36. 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. • 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.

37. 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. • 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.

38. Safe transport • 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 • NAEMSP and NASEMSD policy statement Prehospital and Disaster Medicine, April-June 1994

39. Safe transport • A patient should never be transported with lights and siren just because it’s a child

40. Your responsibility • Provide on-line medical control • 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

41. And so…

42. Bye-bye!