Chapter 1 - EMS Systems
Clinical Care
- Clinical care describes the various pieces of equipment and scope of practice for using that equipment - Before going on duty, check all the equipment on the ambulance, ensure it is fully fueled, has sufficient oil and other key fluids, the tires are in good condition and properly inflated; test the driver's controls; test each built-in unit and controls in the patient compartment
Paramedic - In Depth
- Completes an extensive course of training that significantly increases knowledge and mastery of basic skills and covers a wide range of ALS skills - Course ranged from 1000-1300 hours divided between the classroom and internship training - This training is often offered within the context of an associates of bachelor degree
Certification
Used to ensure all health care providers have at least the same basic level of knowledge and skill
Continuous Quality Improvement
- A circular system of continuous internal and external reviews and audits of all aspects of an EMS system - To provide CQI, periodic run review meetings are help with those involved in patient care to review the run reports and then discuss any areas of care that appear to need change or improvement; positive feedback is also discussed - Designed to identify areas of improvement and if necessary assign remedial training or develop some other educational activity
Mobile Integrated Healthcare
- A new method of delivering health care that utilizes the prehospital spectrum that has evolved as a result of the Patient Protection and Affordable Care Act - Goal is to facilitate improved access to health care at an affordable price - Provided within the community, rather than at a physician's officer or hospital - an integrated team of health care professionals (Including EMS) delivers health care services in the community, and connects patients with other valuable resources, and leads to better service for those who are home bound or disabled - This new branch is causing the evolution of additional training levels for EMS providers (for example: community paramedicine)
NREMT - National Registry of Emergency Medical Technicians
- A nongovernmental agency that provides national standardized EMS testing and certification in much of the United States - Many states use the National Registry standards to certify their EMTs and grant licensing reciprocity to NREMT-certified EMS
Medical Director
- A physician in each EMS system who authorizes the EMTs in the service to provide medical care in the field - Providers are not required to consult medical direction before implementing standing orders - The ongoing working liaison between the medical community, hospitals, and the EMTs in the service - If treatment problems arise or different procedures should be considered, they are referred to the medical director for his or her decision and action - To ensure the proper training standards are met the medical director determines and approves the continuing education and training that are required of each EMT in the service
Self Confidence
- A state of being where you know what you know AND know what you not know; able to ask for help
Emergency Medical Dispatch
- A system developed to assist dispatchers in providing callers with vital instructions to help them deal with a medical emergency until EMS crews arrive - Dispatchers are trained/provided scripts to help relay relevant instructions to the callers - The system helps dispatchers select appropriate resource units to respond to a request for assistance - It is the dispatcher's duty to relay all relevant and available information to the responding crews in a timely manner
Chief Executive Officer
- EMS is usually administered by a senior EMS official - Daily operations and overall direction of the services are provided by an appointed chief executive officer - In charge of both the necessary administrative tasks and daily operations of the ambulance and crews
Self-Motivation
- Able to discover problems and solve them without someone directing you
Time Management
- Able to perform to delegate multiple tasks ensuring efficiency and safety
Communications
- Able to understand others and have them understand you
Teamwork and Diplomacy
- Able to work with others; to know your place within a team; able to communicate while giving respect to the listener
System Finance
- All EMS departments need a funding system that allows the to continue to provide care - Departments may have paid or volunteer personnel (or both) - Financial resources are available for EMS departments through taxation, fee for service, paid subscription, donations, federal/state/local grants, fund-raisers or a combination; which financial system is used depends on the needs and makeup of each EMS department
Information Systems
- An information system allows EMS providers to efficiently document the care that has been delivered; the information stored can be used to improve care - The information gathered is used for a variety of purposes: construct educational sessions for the department; used to justify hiring more personnel; examining the types of patients and their frequency can provide the foundation for the purchase of new equipment and guide continuing education session - The information can also be combined with other database resources to determine patient outcome
Human Error
- Another function of the evaluation process is to determine ways to limit or eliminate human error; If the circumstances of the errors are understood, it may be possible to eliminate or at least minimize them - Three possible error sources: rules-based failure; knowledge-based failure; skills-based failure - The environment may also contribute to errors but can be managed using many approaches; to reduce these have the right people with the right equipment in the right place - Ways to help eliminate errors: Understand why you are doing something; ask for help, talk with partner, contact medical control or EMS supervisor; use cheat sheets of protocols in ambulance; discuss and learn from difficult calls
EMS Research
- Applying evidence-based practice is becoming an integral part of functioning as an EMS provider - Patient care should be focused on procedures that have proven useful in improving patient outcomes - As an EMT you will be involved in research typically through gathering data; carefully record all of the information about these patients - It is important to stay current on the latest advances in health care, including understanding what the results of a study mean/imply
Patient Confidentiality
- As a health care professional and an extension of physician care, you are bound by patient confidentiality - You should not discuss your findings or any disclosures made by the patient with anyone but those who are treating the patient or in limited situations, as required by law - When discussing a call with others, you should refrain from revealing any identifying information
History of EMT - Drawbacks
- As each state sought to create a system that would meet the needs of its citizens, the definitions of EMS providers began to vary from state to state -Example: In some states EMTs could provide medications whereas in other they could now
Empathy
- Aware of and thoughtful towards the needs of others
Licensure
- Can apply for licensure after passing a certification exam - The process by which states ensure applicant competency in an examination setting; allows state to manage who can function as a health care provider
Medical Control
- Can be provided either offline (indirect) or online (direct) - The service's protocols will identify an EMS physician, usually at a local hospital, who can be reached by radio or telephone for medical control during a call - On some calls, once the ambulance crews has initiated any immediate urgent care and gives their radio report, the online medical control physician may either confirm or modify the proposed treatment plan or prescribe additional special orders
Results of Accidental Death and Disability Publication of 1966
- Congress mandated two federal agencies to address the issues discussed in the paper 1. The NHTSA of the DOT through the Highway Safety Act of 1966 2. The Department of Health, Education and Welfare (now known as the Department of Health and Human Services) through the Emergency Medical Services Development Act of 1973 - These created funding sources and programs to develop improved systems of prehospital emergency care
Integrity
- Consistent actions, a firm adherence to a code of honest behavior
Define Emergency Medical Services Systems
- Consists of a team of health care professionals who, in each area of jurisdiction, are responsible for and provide emergency care and transportation to the sick and injured. - Each emergency medical service is part of a local or regional EMS system that provides the many pre-hospital and hospital components required for the delivery of proper emergency medical care.
Online Medical Control
- Consists of direction given over the phone or radio directly from the medical director or designated physician
Offline Medical Control
- Consists of standing orders, training, and supervision authorized by the medical director
Patient Advocacy
- Constantly keeping the needs of the patient at the center of care
Advanced Emergency Medical Technician - In Depth
- Course is designed to add knowledge and skills in specific aspects of ALS; delivers an expanded range of skills beyond the EMT - These additional skills include IV therapy, use of advanced airway adjuncts, and the knowledge and skills necessary to administer a limited number of medications - Courses range between 200-400 hours - In some areas of the United States the availability of paramedics is limited; AEMTs help to fill the gap by providing limited ALS care to regions paramedics are not available
National EMS Scope of Practice Model
- Created at the federal level by the NHTSA - This document provides the overarching guidelines for the minimum skills each level of EMS provider should be able to accomplish - Intended to ensure consistent delivery of EMS across the country
EMS Agenda fo the Future
- Created by the NHTSA to standardize the levels of EMS education and EMS providers in an effort to ensure a more seamless delivery of EMS care across the country - Multidisciplinary national review of all aspects of EMS delivery goal is to develop a more cohesive and consistent system across the country - In this document there are 14 components of an EMS system
Star of Life
- Created by the National Highway Transportation Safety Administration (NHTSA) - Symbol that represents EMS as a critical public service; Represents medicine and healing - Each bar represents an EMS function: Detection, Reporting, Response, On-Scene Care, Care in Transit, Transfer to Definitive Care - Serpent & Staff - Portrays the staff of Asclepius; ancient Greek physician deified as the god of medicine -The Star of Life has become synonymous with EMS and can be seen as a means of identification of EMS services
Protocols
- Described in a comprehensive guide delineating the EMT's scope of practice
Automated External Defibrillator
- Detect life-threatening cardiac dysrhythmias (ventricular fibrillation and ventricular tachycardia) and deliver the appropriate electrical shock to the patient - Included at every level of prehospital emergency training
Human Resources
- EMS is examined as a profession with the overarching concept being to encourage the creation of EMS systems that provide an environment where people want to work and can turn their passion into a career - To do this... 1. Efforts are being made to ensure EMS providers can move from one state to another more seamlessly - The National Scope of Practice Model helps create stable foundations on which each level of EMS provider is grounded; encourages a more consistent definition of "what is an EMT" - EMS Agenda for the Future encourages the creation of systems that help to protect the well-being of EMS providers; also encourages systems to develop career ladders
EMT's Role in Finance:
- EMTs may be asked to gather insurance information from patients, secure signatures on certain documents, or obtain written permission from patients to bill their health insurance company - EMTs are also involved with fundraising, stuffing envelopes, or making calls to potential subscribers of the service
Public Access
- Easy access to help in an emergency is essential - An emergency communication center that dispatched fire, police, rescue and EMS units can be reached by calling 911 - Training the public how to summons an EMS unit is an important part of the public education responsibility of each EMS service - Advanced tech can identify not only the cell number from which the call is placed, but also the GPS coordinates at the time the call was made - Emergency Medical Dispatch Systems aid in the dispatchers
EMT History - 1960's/Early 1970's
- Emergency ambulance services and care varied widely across the United States; many communities did not have formal provisions for prehospital emergency care or transportation - Ranged from well-trained advanced first aid personnel with modern ambulances; hospital based ambulance services that were staffed with interns and early forms of prehospital care providers; local funeral homes using a hearse that could carry a cot; police and fire departments using a station wagon that carried a cot and first aid kit - Many were staffed with a driver and an attendant who had some basic first aid training
EMT History - Korean Conflict
- Evolved into the field medic and rapid helicopter evacuation to nearby Mobile Army Surgical Hospital units where immediate surgical interventions could be performed - Many advances in the immediate care of trauma patients resulted from the casualty experiences in the Korean and Vietnam conflicts
Public Health
- Examines the heath needs of entire populations with the goal of preventing health problems - What needs to be addressed is the concept of prevention (primary focus); the concept applies to both the patient and the EMS provider - The goal of education should be to create an environment where the need for EMS is decreased - EMTs are also involved in the surveillance of illnesses and injuries; EMT personnel can be used to determine if a serious, widespread condition exists - One of the important effects of public education is an increase in public respect for EMS; they are more likely to consider EMS a vital part of the public health care systme
Emergency Medical Responder - In Depth
- Examples: Law enforcement officers, firefighters, park rangers, ski patrollers, other organized rescuers - Provide immediate emergency care at the scene before the ambulance and EMTs arrive - Provides the skills necessary to initiate immediate care and assist the EMTs on their arrival - Focuses on providing immediate BLS and urgent care with limited equipment; familiarizes students with the additional procedures, equipment and packaging techniques that EMTs may use and the EMR may be called on to assist
Community Paramedicine
- Experienced paramedics receive advanced training to equip them to provide services within a community - In addition to patient care services the paramedic would usually provide, community paramedics may include performing health evaluations, monitoring chronic illness or conditions, obtaining laboratory samples, administering immunizations and serving as a patient advocate
EMS System - Federal to Local
- Federal Level: the NHTSA creates the National EMS Scope of Practice Model - State: licensure is a state function; state laws are enacted to regulate how EMS providers will operate and are then executed by the state level EMS administrative offices that control licensure - Local: Medical directors provides daily oversight and support to EMS personnel; day-to-day operational concerns that medical director will have direct input on -EMT: The only way a medical director can allow an EMT to perform a skill is if the state has already approved that skill; the medical director can limit scope of practice but cannot expand it beyond state law
Emergency Care and Transportation of the Sick and Injured
- First EMT Textbook created in 1971 (often referred to as the Orange Book) in response to the DOT creating the first EMT curriculum - Created by the American Academy of Orthopedic Surgeons
Primary Prevention
- Focuses on strategies that will prevent the event from ever happening - Example: Vaccinations; knowing the dangers of drinking and driving, knowing the harmful effects of tobacco and other drugs - EMTs contribution to primary prevention efforts: become involved in programs that educate the community about safety; teaching first aid and CPR to various groups
Medical Direction
- Given by the medical director - The appropriate care for each injury, condition or illness is determined by the medical director and is described in a set of written standing orders and protocols
Paramedic - Brief
- Has extensive training in advanced life support (ALS) - Includes endotracheal intubation, emergency pharmacology, cardiac monitoring, and other advanced assessment and treatment skills
Emergency Medical Technician - Brief
- Has training in basic life support (BLS) - Includes automated external defibrillation, use of airway adjuncts, as assisting patients with certain medication
Emergency Medical Responder - Brief
- Has very basic training and provides care before the ambulance arrives - May also perform in an assistant role within the ambulance
HIPPA
- Health Insurance Portability and Accountability Act - National level protection on patient privacy
Licensure Requirements
- High school diploma or equivalent - Proof of immunizations against certain communicable diseases - Successful completion of a background check and drug screening - Valid driver's license - Successful completion of a BLS/CPR course - Successful completion of a state-approved EMT course - Successful completion of a state recognized written certification examination - Successful completion of a state recognized practical certification examination - Demonstrate the mental and physical ability necessary to safely and properly perform all the tasks and functions described in the defined role of an EMT - Compliance with other state, local and employer provisions
Integration of Health Services
- Integration of health services means that the prehospital care you administered is coordinated with the care administered at the hospital - When you deliver a patient to the ED you are transferring that patient to another care provider - This helps to decrease errors, increase efficiencies and ensure the patient receives comprehensive continuity of care - Some EMS systems collaborate with local hospitals to improve patient outcomes associated with time sensitive treatment (Ex: Heart attack --> the cardiac catheterization team is notified and mobilized for when the patient arrives at the ED)
Professional Attributes of EMTs
- Integrity - Empathy - Self Motivation - Appearance and Hygiene - Self Confidence - Time Management - Communications - Teamwork and Diplomacy - Respect - Patient Advocacy - Careful Delivery of Care
Scene Size Up
- Involves both awareness of scene safety and big-picture awareness of the overall situation at hand. - You must gain a big-picture perspective of the call, determine whether it is safe to proceed, determine whether additional resources are needed, and identify the initial approach to mitigate the emergency
Roles and Responsibilities of the EMT
- Keep vehicles and equipment ready for an emergency - Ensure the safety of yourself, your partner, the patient, and bystanders - Emergency vehicle operation - Be on on-scene leader - Perform an evaluation of the scene - Call for additional resources as needed - Gain patient access - Perform a patient assessment - Give emergency medical care to the patient while awaiting the arrival of additional medical resources - Give emotional support to the patient, the patient's family and other responders - Maintain continuity of care by working with other medical professionals - Resolve emergency incidents - Uphold medical and legal standards - Ensure and protect patient privacy - Give administrative support - Constantly continue your professional development - Cultivate and sustain community relations - Give back to the profession
EMT History - 1980s
- Many areas enhanced the EMT National Standard Curriculum by adding EMTs with advanced levels of training who could provide ALS care and advanced life-saving procedures - With the evolution of training and technology, the EMT and AEMT can now perform a number of important advanced skills in the field that were previously reserved for paramedics
Packaging
- Most patients need to be transported to a facility such as a hospital, clinic, etc.
EMT History - 1990s
- NHTSA began examining EMS from a national perspective with a counsel of various medical professionals - Created the EMS agenda for the Future
ILCOR Guidelines
- On a regular basis, the International Liaison Committee on Resuscitation along with the American Heart Association updates guidelines based on current medical evidence
Standing Orders
- Part of protocols and designate what the EMT is required to do for a specific complaint of condition
Careful Delivery of Care
- Pays attention to detail; makes sure what is being done for the patient is done as safely as possible
Respect
- Places others in high regard or importance; understands others are more important than self
Prevention and Public Education
- Prevention and public education are aspects of EMS where the focus is on public health
Title I of the ADA
- Protects EMT's with disabilities seeking gainful employment under many circumstances - Employers with a certain number of employees are required to adjust processes so that a candidate with a disability can be considered for the position, and when possible modify the work environment or how the job is normally performed - This ensures EMT's who can perform the functional job skills the opportunity to pursue a career in EMS
Americans with Disabilities Act of 1990 (ADA)
- Protects people who have a disability from being denied access to programs and services that are provided by state or local governments and prohibits employers from failing to provide full and equal employment to the disabled
Treatment
- Provide oxygenation, medication therapies, control bleeding, assist in childbirth, manage patients in emotional crisis, calm patients, help relieve anxiety
Emergency Medical Technician - In Depth
- Requires approximately 150 hours of training - Provides the essential knowledge and skills required to provide basic emergency care in the field; serves as a foundation - Upon scene arrival you should (and any other EMTs) should assume responsibility for the assessment and care of the patient and follow the proper packaging and transport of the patient to the ED if appropriate
EMT History - Late 1970s
- The DOT developed a recommended National Standard Curriculum for the training of paramedics and identified a part of the course to serve as training for EMTs
EMT History - Early 1970's
- The DOT developed and published the first curriculum to serve as the guideline for EMT training
Secondary Prevention
- The event has already happened, and the question becomes how can be decrease the effects of the event - Example: Helmets and seatbelts; road guardrails
Patient Assessment
- The foundation of any EMS call - Must determine what is wrong with the patient
Healthcare in the United States
- The high-tech, on demand style of care that is prevalent has two drawbacks 1. It is very expensive; 17.9% of GDP is on healthcare 2. It may not deliver a better product; the average life expectancy is higher in 35 countries (79 in United States) - What needs to be addressed is prevention
Primary Service Area
- The main area in which an EMS agency operates
Continuing Education
- The medical director is also responsible for ensuring that appropriate continuing education and training are available - Information and skills in emergency medical care change constantly so refresher training or continuing education as new modalities or care, equipment, and understanding of critical illnesses and trauma develop - When you have not used a particular procedure, skill decay may occur; the medical director may establish a training program to correct the deficit - Ensuring your skills and knowledge are current us one of the ongoing commitments of being an EMT
Evaluation
- The medical director is responsible for maintaining quality control, ensuring that all staff members who are involved in caring for patients meet appropriate medical care standards - To provide the necessary quality control, the medical director and other involved staff review patient care reports (PCR), audit administrative records and survey patients - Helps function to determine ways to limit or eliminate human error
EMT History - World War II
- The military trained special corpsmen to provide care in the field and bring the casualties to aid station staffed by nurses and physicians
History of EMT - Origins in 1966
- The publication of Accidental Death and Disability - The Neglected Disease of Modern Society (The White Paper) revealed to the public and Congress the serious inadequacy of prehospital emergency care and transportation in many areas
Education Systems
- The quality of care you provide depends on your ability and quality of your training; therefore, your instructor and others who help develop the training program are key members of the emergency care team - As an EMT you are required to attend a certain number of hours of continuing education approved for EMTs each year to maintain, update, and expand your knowledge and skills
EMT History - 1970's
- Through the 1970s following the recommended guidelines, each state developed the necessary legislation, and the EMS system expanded throughout the United States - During this period, emergency medicine became a recognized medical speciality and fully staffed ED's became the accepted standard of care
Legislation and Regulation
- Training protocols and practices must conform to the EMS legislation, rules, regulations and guidelines adopted by each state - The state EMS office is responsible for authorizing, auditing and regulating all emergency medical services, training institutions, courses, instructors, and providers within the state - At the local level each EMS system operates in a designated PSA in which it is responsible for the provision of prehospital emergency care and the transportation
Advanced Emergency Medical Technician - Brief
- Trains in specific aspects of advanced life support (ALS) - Includes intravenous therapy and the administration of certain emergency medication
Appearance and Hygiene
- Uses persona to project a sense of trust, professionalism, knowledge and compassion
Communication Systems
- Using the information provided by the caller the dispatcher will select the appropriate parts of the emergency system that need to be activated - Over half of EMS support is provided by a governmental agency (fire agency: 45%; non-fire agency: 20%); Private services deliver about 25% of EMS support - Other EMS models seen less frequently included hospital-based programs and Native American tribal services - Responding units can transmit their position to a dispatcher who can transmit the location of a call to a moving digital map in the unit, complete with turn-by-turn directions - Medical databases can be queried and patient information can be directly downloaded to the EMTs computer or uploaded from the EMTs laptop to the database
Good Samaritans
- Variety of people on the scene eager to help - Can be trained in first aid and CPR, physicians and nurses, other well-meaning people with no previous training - Identified and used properly these people can provide valuable assistance when you are shorthanded; other times they can interfere with operations or even create problems or danger for themselves or others - In the initial scene size-up identify the various people on the scene and orchestrate well-meaning attempts to assist
EMT History - World War I
- With the early use of motor vehicles in warfare, volunteer ambulances were organized and personnel went overseas to provide care for the wounded
Professional Attributes
- You are a health care professional - Your attitude and behavior must reflect that you are knowledgeable and sincerely dedicated to serving anyone who is injured or in an acute medical emergency - You must be nonjudgmental and overcome your instinct to reach poorly to uncooperative, demanding, unpleasant, ungrateful and verbally abusive behavior (people in emergency situations will often react with inappropriate behavior) - Every patient, regardless of his or her attitude is entitled to compassion, respect and the best care that you can provide
Four Training and Licensure Levels of EMS
1. Emergency Medical Responder (EMR) 2. Emergency Medical Technician (EMT) 3. Advanced EMT (AEMT) 4. Paramedic
EMS Agenda for the Future - Components of an EMS System
1. Public Access 2. Clinical Care 3. Medical Direction 4. Integration of Health Services 5. Information Systems 6. Prevention 7. EMS Research 8. Communication Systems 9. Human Resources 10. Legislation and Regulation 11. Evaluation 12. System Finance 13. Public Education 14. Education Systems
Interaction of the Components of the NHTSA Emergency Services System
Right Side: - Someone recognizes an emergency - 911 is activated - An ambulance is dispatched - Emergency care and transportation are administered Center: The essential aspects needed to allow the primary 911 components to function (finances, radios, computers and people) Left: Demonstrates the continuum of care from the prehospital environment to the ED and beyond; as patients leave the health care system, there are strategies of prevention and education to help ensure people live long and healthy lives
Public Access Safety Point
The communication center where trained dispatchers obtain the necessary information from the caller, and following dispatch protocols, dispatch the ambulance crew and other equipment and responders that may be needed