Emergency Medical Service History Levels Of Care Prehospital

Although not commonly understood, EMS systems in U.S. provide emergency care that is almost on par with that of an emergency room. Equipment and procedures are obviously limited, due to the nature of the environment that EMS personnel must work in. EMS providers work under the license and indirect supervision of a medical director or board-certified physician who oversees the policies and protocols of a particular EMS system or organization.

EMS professionals are trained to follow a formal and carefully designed decision tree, more commonly referred to as a protocol or standard of care, which has been created and approved by physicians. The emphasis in emergency services is on following correct procedure quickly and accurately rather than on making in-depth diagnosis which requires much professional experience. The use of a decision tree allows EMS workers to be trained in a much shorter time than physicians.

National EMS standards are drawn up by the U.S. Department of Transportation and modified from state to state by the state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Comittees (usually in rural areas) or by other committees or even individual EMS providers. Also see emergency medical technician.

1 History

The origins of EMS date back to the days of Napoleon, when the French army utilized horse drawn " ambulances" to transport the injured soldier from the battlefield. One of the first civilian EMS services can be traced back to 1869, when Dr. Edward L. Dalton at Bellevue Hospital, then known as the Free Hospital of New York, in New York City started a basic transportation service for the sick and injured. The component of care on scene began in 1928, when Julien Stanley Wise started the Roanoke Life Saving Crew, the first land-based rescue squad in the nation. Over the years EMS continued to evolve into much more than a "ride to the hospital."

In particular in the US state of California and in Seattle, Washington state (see Medic One), projects began to include paramedics in the EMS responses in the late 1960s. Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the television series, Emergency! which in part followed the adventures of two Los Angeles County Fire Department paramedics as they responded to various types of medical emergency. James O. PagePage JD ( August 7, 1936 September 4, 2004), was recognized as a leading authority on emergency medical services ( EMS). Page served in the Los Angeles County Fire Department for 16 years rising to the rank of Battalion Chief. In 1973 he was appointed as served as the series technical advisor and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.

In a return to the military roots of EMS, the United States ArmyThe Army is the branch of the United States armed forces which has primary responsibility for land-based military operations. As of fiscal year 2002 (FY02), it consisted of 480,000 soldiers on active duty and 555,000 in reserve (350,000 in Army National G has developed the combat lifesaverA combat lifesaver is a soldier who has received rudimentary training in advanced first aid skills. These advanced skills include wilderness first aid but also some paramedic skills such as intubation and advanced airway management. Combat lifesavers are program to instruct soldiers in advanced first aidFirst aid is a series of simple, life-saving medical techniques that a non-doctor or layman can be trained to perform in medical emergencies, before the intervention of emergency medical technicians or doctors. It is best to obtain training in first aid b and limited paramedic skills including intubation. The combat lifesaver is intended to bridge the gap between self-aid / buddy-aid and the platoon medic on the 21st century decentralized battlefield.

2 Levels of Care

Two levels of care are provided by EMS systems: BLS and ALS (Basic Life Support and Advanced Life Support). BLS providers are CFRs (Certified First Responders) and EMTs (Emergency Medical Technicians) and provide all care outlined in the EMS standard of care, except for invasive procedures and (to a certain extent) giving medications. ALS providers are principally paramedics and EMT-Intermediates (EMT-I), who are certified to perform invasive procedures and to give a wide variety of drugs. The biggest difference between EMT-I's and Paramedics is that while EMT-I's handle advanced airway management like Paramedics, they do not have as in-depth cardiac training and usually administer fewer medications.

In times of economic crisis and in poorer areas, much normal medical care is provided through emergency services to patients who do not have regular physicians or regular medical attention.

3 Prehospital Care Strategies: "Scoop and run", "stay and play" or "play and run"?

The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" is best exemplified by the MEDEVAC aeromedical evacuation helicopter, where the "stay and play" is best exemplified by the French SMUR emergency mobile resuscitation unit.

The strategy developed for prehospital care in North America is called scoop and run. It is based on the golden hour concept, i.e. a victim's best chance for survival is in an operating room , with the goal of having the patient in surgery within an hour of the traumatic event. This is especially true in case of internal bleeding. Thus, the minimal prehospital care are performed (A.B.C., stop the external bleeding, cover the injuries, spine immobilization, endotracheal intubation) and the victim is transported as fast as possible to a trauma center. This philosophy is aptly summarized by the following quotation from "The Rules of EMS": "Trauma is treated with diesel first."

The stay and play strategy was designed in France with the SMUR (Service mobile d'urgence de réanimation, emergency mobile resuscitation unit) and SAMU (Service d'aide médicale d'urgence, i.e. EMS), as they noted that much of the time, the victim died during transportation. They developed a strategy based on maximum care before transportation. Prehospital medical care is provided by a medical doctor MD, a nurse and an ambulance technician, with almost all the equipment and drugs that can be found in an emergency department. The priority here is the stabilization of the patient prior to transport, including intravenous drip to rise the blood pressure (one of the causes of death during transportation is the drop of the pressure perfusion of the brain and heart due to the accelerations, see shock).

In case of a severe myocardial infarction (or heart attack), all cares are performed onsite (including possibly thrombolysis), and the victim is transported only if the heart starts again or is declared dead. Defibrilation is performed by a firefighter rescue team with an automated external defibrillator if it arrives before the medical team.

Both strategies have their advantages and drawbacks.

The confrontation of these two opposite strategies has led recently to a new concept: the play and run. The time that cannot be reduced (e.g. while extracting a victim trapped in a car) is used to perform medical care. The treatment aim is no longer to recover a "normal" blood pressure, but a minimal blood pressure, using not only intravenous drip but also vasocompressing drugs and antishock pants (to compress the legs and push the blood into the rest of the body). The aim is to reduce the risk of death due to transportation trauma while respecting the golden hour. The difficulty with play and run lies in the difficulty of getting a good IV stick in a moving vehicle and controlling the volume of IV fluids given to the patient. Too little fluid will cause inadequate circulation and heart failure, while too much fluid will cause excessive loss of oxygen-bearing blood.

4 Organization and Funding

EMS in the US is delivered through various models. These include;

Third Service stand alone
Third Service hospital based
Fire Service fully integrated and cross trained
Fire Service based, non-integrated

(Police and Fire Services being the first two emergency services)

Funding and manpower models include:

Volunteer Public, non-billing, subsidized by property taxes
Volunteer Public, calls billed, partially subsidized through property taxes
Full time paid Private Enterprise, calls billed, partially subsidized through property taxes
Full time paid Private Enterprise, calls billed, no subsidy
Full time paid Public Utility Model, calls billed, usually no subsidy

Although the Fire Service in the US is rated through ISO classes and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. On the contrary it may be financially advantages for a person to die rather than accumulate large medical bills in rehabilitation. (depending on the size or existence of a life insurance policy) This relegates EMS funding to an emotional plea for funds during difficult financial times. Can you put a value on a human life? Apparently you can since juries and actuaries do it on a daily basis.

Fire Service based EMS may also face funding crisis's due to rapid increases in EMS calls in a department still devoted to and funded primarily for fire suppression. Compounding these financial difficulties are third party payers such as Medicare which view EMS as a transportion service and not a medical care service. Much of the public has been aware of EMS's medical capabilities since the early 1970s but many third party payers still seem clueless after over 30 years of EMS successes. The US Armed Services seem to be the only federal entity that seems to understand and value good EMS.

5 The future of EMS

The future development of an artificial blood substitute that will carry oxygen will greatly enhance the provision of emergency medical services, as natural blood is rarely available for field transfusions outside military medicine due to scarcity and fragility.

An interim life-saving technique being pioneered by the US military is the use of blood clotting powders such as QuikClot which make it easier to stop previously uncontrollable bleeding from major wounds.

Pioneering advances in telemedicine, including the use of videocameras, now make it possible for advanced medical direction and advice to be supplied to emergency medical technicians, military medics, and nurses or other community health care providers in remote or isolated areas or even aboard cruise ships. One future possibility is the use of robotics to permit a surgeon thousands of miles away to provide life-saving surgery from the comfort of their own office, without requiring emergency travel or exposing themselves to hazards.

6 See also

7 External links

System of Emergency Medical Assistance in France

First aid

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