EMT Chapter 1: EMS Systems

Certification

A certification exam ensures all health care providers have the same basic level of knowledge and skill.

EMS Agenda for the Future

A multidisciplinary, national review of all aspects of EMS delivery. 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

Scene Size-up

Involves: - Awareness of scene safety - Awareness of the overall situation During scene size-up you must: - Get a big-picture overview of the call - Determine whether it is safe to proceed - Determine if additional resources are needed - Identify the initial approach to mitigate the emergency

EMS as a career

Job stressors and coping mechanisms

Licensure

Licensure is the process by which states ensure an applicant's competency in an examination setting.

Packaging

Most patients will need to be transported to a hospital, clinic, or other medical care facility.

World War II

The military trained special corpsmen to provide care in the field and bring casualties to aid stations staffed by nurses and physicians.

World War I

Volunteer ambulances were organized and personnel went overseas to provide care for the wounded.

Refresher Training and Continuing Education

When you have not used a particular procedure for some time, skill decay may occur. Your medical director may establish a training program to correct the deficit.

Licensure Requirements

(Differ from state to state) The criteria to be licensed and employed as an EMT include: - High school diploma or equivalent - Proof of immunization against certain communicable diseases - Successful completion of a background check and drug screening - Valid driver's license - Successful completion of a recognized health care provider basic life support (BLS)/cardiopulmonary resuscitation (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 - Demonstration of 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

Medical Director

- A medical director authorizes EMTs to provide medical care in the field. - The medical director: - Determines appropriate care in a set of written standing orders and protocols - Is the ongoing working liaison among the medical community, hospitals, and the EMTs in the service - Determines and approves the continuing education and training required of each EMT in the service

Advanced Emergency Medical Technician

- AEMT training is designed to add knowledge and skills in specific aspects of ALS to providers who have been trained and have experience in providing emergency care. - Additional skills include: - IV therapy - Use of advanced airway adjuncts - The knowledge and skills necessary to administer a limited number of medications - The AEMT course ranges between 200 and 400 hours. - The purpose is to deliver an expanded range of skills beyond the EMT. In some parts of the United States, the availability of paramedics is limited and AEMTs help to fill the gap by providing limited ALS care to regions where paramedics are not available.

ALS

- ALS-level instructors and directors must hold a four-year degree. - Training is provided either in a college, adult career center, or hospital setting. In most states, ALS training must be approved by the state and have a medical director. - Many lectures and small-group sessions are presented by the medical director or other physicians, nurses, and EMS instructors. - In supervised practice or other in-hospital settings, students are supervised directly by physicians and nurses.

1980s

- Advanced levels of training were introduced to provide key components of advanced life support (ALS) care and advanced lifesaving procedures. - With the evolution in training and technology, the EMT and advanced emergency medical technician (AEMT) can now perform important advanced skills in the field that were formerly reserved for only the paramedic.

Information Systems

- An information system allows EMS providers to document the care delivered. - Information is used for constructing educational sessions for the department. - Data from ambulance activity logs are 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 sessions.

Personal attributes include:

- Appearance - Attitude and behavior - Ability to perform under pressure - Composure - Self-confidence

Eliminating Environmental Error

- Are there ways to limit distractions? - How do we improve lighting so EMTs can see well? - How organized is the equipment? Can the EMT find what he or she needs in a timely manner? - Trying to reduce environmental factors regarding errors means having the people with the right equipment in place.

Clinical Care

- As an EMT, you will use a wide range of different emergency equipment. - Familiarize yourself with the roads in your primary service area (PSA) or sector. - Check all the equipment and supplies and communication equipment that the ambulance carries. - It is your responsibility to ensure the ambulance is fully fueled, has sufficient fluids, and that the tires are in good condition.

Domestic Emergency Care - Pre-1970

- As recently as the 1960s and early 1970s, emergency ambulance service and care varied widely across the United States. - In most cases, emergency vehicles were staffed with a driver and an attendant who had some basic first aid training.

1970s

- DOT developed and published the first curriculum to serve as the guideline for EMT training. - The American Academy of Orthopaedic Surgeons prepared and published the first EMT textbook—Emergency Care and Transportation of the Sick and Injured—in 1971 (often called the Orange Book for its original trademark orange cover). - Each state developed legislation, and the EMS system expanded throughout the United States. - Emergency medicine became a recognized medical specialty, and fully staffed EDs became the accepted standard of care. - 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.

HIPAA

- Do not discuss findings or disclosures made by the patient with anyone but those who are treating the patient or, in limited situations as required by law, the police or other social agencies. - Avoid revealing any information that might disclose the name or identity of patients you've treated. - The protection of patient privacy has drawn national attention with the passage of the Health Insurance Portability and Accountability Act (HIPAA).

Origins of modern EMS

- EMS as we know it today had its origins in 1966 with the publication of Accidental Death and Disability: The Neglected Disease of Modern Society (known more commonly as The White Paper), which revealed the serious inadequacy of prehospital emergency care and transportation in many areas. - Congress mandated two federal agencies to create funding sources and programs to develop improved systems of prehospital emergency care: - The NHTSA of the DOT, through the Highway Safety Act of 1966 - 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

System Finance

- EMS departments may have: - Paid personnel - Volunteer personnel - A mix of both - Financial resources are available through: - Taxation - Fee for service - Paid subscription - Donations - Federal/state/local grants - Fund-raisers - Combinations of these - The financial system used depends on the needs and makeup of each EMS department. EMTs may be asked to: - Gather insurance information - Secure signatures on documents such as HIPAA notifications - Obtain written permission from patients to bill their health insurance company - Regardless of the type of system in which you work, you will help the department secure its financial resources.

Education Systems:

- EMT instructors are approved and licensed by the state EMS office or agency. - EMS training programs must adhere to national standards established by: - CoAEMSP (Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions) - CAAHEP (Commission on Accreditation of Allied Health Education Programs) - To be licensed in some states, an instructor must have extensive medical and educational training and teach for a designated period while being observed and supervised by an experienced instructor.

Public Education

- EMTs are also involved with: - Surveillance of illnesses and injuries - The PCRs generated by EMS personnel can be used to determine if a serious, widespread condition exists. - Educating the public on: - Injury prevention - Services EMS provides - Performing CPR - Helping a choking victim - Assisting in delivery

Continuing Education

- EMTs are required to attend a certain number of hours of continuing education each year. - The required hours are provided by the training officer and medical director. - Most EMS education programs and hospitals offer a number of regular continuing education opportunities in each region. - You may also attend state and national EMS conferences to help keep current about local, state, and national issues affecting EMS. - Because there are many levels of licensing, you should ensure that the continuing education you receive is approved for the EMT.

Public Access

- Emergency communication centers (or public safety access points) can be reached by dialing 9-1-1. - Enhanced 9-1-1 systems identify the cell phone number and the exact geographic coordinates through global positioning system (GPS) technology. - Emergency medical dispatch (EMD) was developed to assist dispatchers in providing callers with instructions to help them deal with a medical emergency until EMS crews arrive.

Eliminating human error

- Errors occur from: - A rules-based failure - A knowledge-based failure - A skills-based failure - Limiting errors requires the efforts of both the EMS agency and EMS personnel. - Agencies need to have clear protocols, which need to be understood by all EMTs within the service.

EMS Research

- Evidence-based practice focuses patient care on procedures that have proven useful in improving outcomes. - All aspects of the EMT role are currently being researched within the academic community and in the practitioner community. - EMTs gather data. - High-quality patient care should focus on procedures useful in improving patient outcomes through sound research. - The International Liaison Committee on Resuscitation (ILCOR), along with its member the American Heart Association, documents guidelines based on large amounts of evidence. These guidelines are an excellent example of evidence-based medical decision making in progress. - Stay current on the latest advances in health care.

Korean Conflict

- Evolution of the field medic and rapid helicopter evacuation to Mobile Army Surgical Hospital units where immediate surgical intervention could be performed. - Advances made in the immediate care of trauma patients.

Quality Control

- To provide the necessary quality control, the medical director and other involved staff: - Review patient care reports (PCRs) - Audit administrative records - Survey patients

Secondary Prevention

- In a secondary prevention strategy, the event has already happened. The question is, how can we decrease the effects of the event? - Example: There have been significant changes in guardrail construction over the years as more information has become available on what happens during a vehicle collision.

Other Means of Eliminating Errors

- Knowing the reason for your actions gives you time to reflect and make a more informed decision. - If you cannot come up with a solution, ask for help. Talk with your partner, contact medical control, or call your EMS supervisor. - Use "cheat sheets." - Discussing the events of a call provides an excellent avenue for learning. Such discussions can help lead to changes in: - Protocol - How equipment is stocked - The purchase of new equipment

Levels of Training

- Licensure of EMTs is a state function subject to the laws and regulations of the state in which the EMT practices. - At the federal level, NHTSA brings in experts to create the National EMS Scope of Practice Model. - The local medical director provides daily oversight and support to EMS personnel. - National guidelines are intended to ensure consistent delivery of EMS across the country. - The only way a medical director can allow an EMT to perform a skill is if the state has already approved that skill.

Medical Direction

- Medical control is provided either off-line (indirect) or online (direct). - Online medical control consists of direction given over the phone or radio directly from the medical director or designated physician. - Off-line medical control consists of standing orders, training, and supervision authorized by the medical director. - Protocols identify an EMS physician, usually at a local hospital, who can be reached for medical control during a call. - Once the ambulance crew initiates any immediate urgent care and gives its radio report, the online medical control physician may either confirm or modify the proposed treatment plan or prescribe additional special orders that the EMTs are to follow.

Public basic support and immediate aid

- Millions of laypeople have been trained in BLS/CPR. - Many people take first aid courses that include bleeding control and other simple skills that may be required to provide immediate essential care. - Many people who regularly accompany groups in situations where the arrival of EMS may be delayed are trained in advanced first aid. - One of the most dramatic recent developments in prehospital emergency care is the use of an automated external defibrillator (AED). - These devices detect treatable life-threatening cardiac arrhythmias and deliver the appropriate electrical shock to the patient.

Mobile Integrated Health Care

- Mobile integrated health care (MIH) evolved to facilitate improved access to health care at an affordable price. - Health care is provided within the community. - An integrated team of health care professionals delivers health care services and connects patients with other resources. - In community paramedicine, experienced paramedics receive advanced training, including: - Performing health evaluations - Monitoring chronic illnesses or conditions - Obtaining laboratory samples - Administering immunizations - Serving as a patient advocate

1990s

- NHTSA created the EMS Agenda for the Future, a plan to standardize the levels of EMS education and EMS providers to ensure a more seamless delivery of EMS care across the country.

Primary Prevention

- Primary prevention focuses on strategies that will prevent the event from ever happening. - Example: Polio was a devastating disease that caused death and disability for thousands of Americans in the early 1900s. A vaccine was developed to prevent the disease. In the span of one generation, the disease was virtually eliminated. Vaccinations are a good example of primary prevention within public health. - If a major outbreak were to occur in the United States, EMTs may be called on to assist in the administration of vaccinations. - EMTs can contribute to primary prevention efforts by: - Becoming involved in programs that educate the community - Teaching first aid and CPR

Levels of training include:

- Public basic support and immediate aid - Emergency medical responder - Emergency medical technician - Advanced emergency medical technician - Paramedic

Prevention and Public Education

- Public health examines the health needs of entire populations with the goal of preventing health problems. - Health care in the United States: - Is expensive - In the United States, more than 17.9% of the gross domestic product is accounted for by health care. - May not deliver the better product - People born in the United States have an average life expectancy of 79 years. - There are 35 other countries where people are living longer. - The focus of the public health arm of health care is prevention.

Evaluation includes:

- Quality control - Continuous quality improvement (CQI) Refresher training and continuing education - Eliminating human error - Eliminating environmental error - Other means of eliminating errors.

Emergency medical responder

- The EMS system includes immediate care by EMRs, such as law enforcement officers, firefighters, park rangers, ski patrollers, or other organized rescuers who often arrive at the scene before the EMTs. - EMR training provides 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 additional procedures, equipment, and packaging techniques that EMTs may use, and with which the EMR may be called on to assist.

Emergency medical technician

- The EMT course requires approximately 150 hours (more in some states) and provides the essential knowledge and skills required to provide basic emergency care in the field. - On arrival at the scene, you and any other EMTs who have responded should assume responsibility for the assessment and care of the patient and follow the proper packaging and transport of the patient to the emergency department (ED) if appropriate.

Continuous Quality Improvement (CQI)

- The continuous quality control (CQI) process is designed to identify areas of improvement and, if necessary, assign remedial training or develop some other educational activity. - The medical director is also responsible for ensuring that appropriate continuing education and training are available.

Human Resources

- The obligation of providing for and protecting citizens has led to the creation of EMS levels that are unique to a particular state. - EMS levels can make movement from one state to another complicated. - A key function of the National EMS Scope of Practice Model is to encourage a more consistent definition of "what is an EMT" so providers can move more freely about the country. - The EMS Agenda for the Future encourages the creation of systems that help to protect the well-being of EMS providers. - It also encourages systems to develop career ladders.

Paramedic

- The paramedic completes an extensive course of training that significantly increases knowledge and mastery of basic skills and covers a wide range of ALS skills. - This course ranges from 1,000 to more than 1,300 hours, divided between classroom and internship training. - This training is often offered within the context of an associate's degree or bachelor's degree college program.

Integration of Health Services

- The prehospital care you administer is coordinated with the care administered at the hospital. - Some EMS systems collaborate with local hospitals to improve patient outcomes associated with time-sensitive treatment like heart attacks, trauma, and stroke. - Key personnel are ready to begin critical treatments as soon as the patient arrives at the hospital.

Legislation and Regulation

- The state EMS office is responsible for authorizing, auditing, and regulating all emergency medical services, training institutions, courses, instructors, and providers within the state. - In most states, the state EMS office obtains input from an advisory committee made up of: - Representatives of the services - Service medical directors - Medical associations - Hospitals - Training programs - Instructors' associations - EMT associations - The public - Daily operations and overall direction are provided by an appointed chief executive officer and several other officers. - When EMS is a part of a fire or police department, the department chief delegates the responsibility for directing EMS to an assistant chief or other officer whose sole responsibility is to manage the EMS activities of the department. - The chief executive is in charge of: - Administrative tasks (e.g., scheduling, personnel, budgets, purchasing, vehicle maintenance) - Daily operations of the ambulances and crews

Communication Systems

- Using the information provided by the caller, the dispatcher selects the appropriate parts of the emergency system that need to be activated. - Over half of EMS support is provided by a governmental entity such as a fire agency (about 45%) or other nonfire governmental agency (20%). - Private services deliver about one-fourth of EMS support. - New technologies include: - Cell phones linked to GPS - Moving digital maps - Medical databases

Treatment

As an emergency medical technician (EMT), you will: - Provide oxygenation - Provide medication therapy - Control bleeding - Manage patients in emotional crisis

Emergency Medical Services (EMS)

The emergency medical services (EMS) system consists of a team of health care professionals who are responsible for and provide emergency care and transportation to the sick and injured.

Patient Assessment

You need to determine: - What is wrong with the patient - Which complaints are life threatening