Emergency medical services

An ambulance in the United Kingdom, part of the national emergency medical service provision

The Traumahawk Air Ambulance of Palm Beach County, Florida.

Emergency medical services (abbreviated to initialism "EMS" in many countries), and also known as a first aid squad, emergency squad, rescue squad, ambulance squad, ambulance service, ambulance corps or life squad, are systems providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or their clinician, believes constitutes a medical emergency.

The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the malady, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital or another place where physicians are available. In some developing regions, the emergency medical service does not provide treatment to the patients, but only the provision of transport to the point of care.

In most places in the world, the EMS is summoned by members of the public (or other emergency services, businesses or authority) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.

EMS also encompass services developed to move patients from one medical facility to an alternative which usually includes transferring the patient to a higher level of care. These specilized hospitals that provide higher level of care included services such as neonatal intensive care (NICU), state regional burn centers , specilized care for spinal injury and/or neurosurgery, regional stroke centers , specialized cardiac care (cardiac catherization ), and specialized/regional trauma care.

In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue. Training and qualification levels for members and employees of emergency medical services varies widely throughout the world. EMS in many systems provide members that are qualified to to drive only with no medical training. In contrast, most systems have personnel that retain, at a minimum, a basic first aid certificate (Basic Life Support (BLS)), additionally most EMS systems are staffed with Advanced Life Support (ALS) personnel including fully qualified paramedic's, nurse's, or rarely physician's.

History

Main article: Ambulance § History

Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaritan. Luke 10:34 (NIV) - "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." Also during the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield.

The first record of ambulances being used for emergency purposes was the use by Queen Isabella of Spain, in 1487. The Spanish army of the time was treated extremely well and attracted volunteers from across the continent, and part of this was the first military hospitals or 'ambulancias', although injured soldiers were not picked up for treatment until after the cessation of the battle, resulting in many dying on the field.

A 1973 Cadillac Miller-Meteor ambulance. Note the higher roof, with more room for the attendants and patient

A major change in usage of ambulances in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte’s chief physician. Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. These 'flying ambulances' were first used by Napoleon's Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon's other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt.

In civilian ambulances, a major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832. The statement on the carriage, as printed in The Times, said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other". This tenet of ambulances providing instant care, allowing hospitals to spaced further apart, displays itself in modern emergency medical planning.

The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine.

A 1948 Cadillac A. J. Miller ambulance. The A. J. Miller company purchased this car from Cadillac, then modified it to turn it into an ambulance. The resemblance to a hearse is obvious. (see text)

Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. This was followed in 1900 by New York city, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2hp motors on the rear axle.

During World War One, further advances were made in providing care before and during transport – traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses - the only available vehicle that could carry a recumbent patient - and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.

Advances in the 1960s, especially the development of CPR & defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. In Ireland, a mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper. These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), in the equipment (and thus weight) that an ambulance had to carry, and several other factors.

The purpose of EMS

6 points on the Star of Life

6 points on the Star of Life

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery.

This common theme in medicine is demonstrated by the star of life. The Star of Life shown here, where each of the 'arms' to the star represent one of the 6 points. These 6 points are used to represent the six stages of high quality pre-hospital care, which are:

1. Early Detection - Members of the public, or another agency, find the incident and understand the problem
2. Early Reporting - The first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted
3. Early Response - The first professional (EMS) rescuers arrive on scene as quickly as possible, enabling care to begin
4. Good On Scene Care - The emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident
5. Care in Transit - the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
6. Transfer to Definitive Care - the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Levels of care in EMS

Dependent on the country and area in which the EMS operates, and what type of provider it is, there may be any one of several levels of EMS crew. They can broadly be divided in to Basic Life Support (BLS) qualifications (responders, ambulance technicians) which usually involves non-invasive procedures and Advanced Life Support (ALS) qualifications (higher level technicians and paramedics) which includes more invasive procedures (such as intubation and intravenous medication administration).

Based on what scope of practice or qualifications a person might obtain determines the level or "title" a person will retain. These titles and levels of qualifications are discribed below;

Police vehicle from New Zealand

Basic Life Support

First Responder

A first responder person who arrives first at the scene of an incident, and whose job is to provide early critical care such as CPR or using an AED. First responders may be dispatched by the ambulance service, may be passers-by, or may be dispatched to the scene from other agencies, such as the police, fire department, or search and rescue.

Ambulance Driver

Some services employ ambulance driving staff with no medical qualification (or just a first aid certificate) whose job is to drive the ambulance. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.

Ambulance Care Assistant (ACA)

Ambulance Care Assistants have varying levels of training across the world, but these staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. Dependent on provider, they may be trained in first aid or extended skills such as use of an AED, oxygen therapy and other live saving or palliative skills. In some services, they may provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.

File:Emtsloadingpatient.jpg

EMT's loading a patient

Emergency Medical Technician (EMT)

Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United States. Technicians are usually able to perform a wide range of emergency care skills, such as defibrillation, spinal care and oxygen therapy.

Some countries split this term in to several levels (such as in the US, where there is EMT-B and EMT-I, and EMT-P. the title of EMT is not protected in all countries, such as in Great Britain, where anyone can legally call themselves an EMT, even without any training.

In some jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more advanced airway procedures, CPAP, Analgesic Administration, and limited cardiac monitoring and manual defibrillator capabilities. Most advanced procedures and skills are not within the national scope of practice for a EMT-B. As such most states require additional training and certifications to perform above the national curriculum standards.

Paramedic (EMT-P)

A paramedic has a high level of prehospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs such as morphine), cardiac monitoring, intubation and other skills such as performing a cricothyrotomy. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification (FP-C), and Critical Care EMT-Paramedic.

Paramedic Practitioner

In the United Kingdom, some serving paramedics receive additional univeristy education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics.

Critical Care Paramedic (CCEMTP)

File:CCEMTP.gif

CCEMTP's in the United States

A critical care paramedic, also called an advanced practice Paramedic in some US States, represents a higher level of licensure above that of the DOT and NREMT-Paramedic curriculum. These Paramedics receive at least six months of additional training beyond normal EMS medicine in a Critical Care Emergency Medical Transport Program, including critical care use of devices and life support systems normally restricted to the ICU or critical care hospital setting, placement and use of UVCs, UACs, surgical airways, Rapid Sequence Intubation (RSI) intubation, blood administration, and chest tube insertion. CCEMT-P represent the highest level of care in the United States, however few states have implemented the program as an official level of licensure. These are New York, Tennessee, and New Jersey. Iowa has a Critical Care Paramedic level,but these paramedics are trained only to the DOT Paramedic Curriculum as entry-level paramedics.

Emergency Care Practitioner (ECP)

An emergency care practitioner is a position sometimes called a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques. This is a level that is not common in the United States where the highest levels of care is usually the Paramedic or Critical Care Paramedic levels.

Registered Nurse (RN)

Some services use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician or paramedic or physician. They may bring specialized in-hospital skills to the mobile patient care environment, which is especially beneficial to those who may be ill or injured in remote locations that do not enjoy close proximity to definitive hospital intervention and who may require extended care. Registered nurses are more common in countries that have a limited EMS infastructure in place, or in European countries such as France or in Australia and New Zealand. In the United States, the most common uses of ambulance-based Registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. These nurses are required in the US to seek additional certifications beyond basic RN by their employers, such as ACLS, PHTLS, CCRN, and CEN

Physician (MD or DO)

Some ambulance services - most notably air ambulances will employ physicians to take the clinical lead in the ambulance; bringing a full range of additional skills such as use of prescription medicines. This is less common in the United States for cost and historical reasons. Adult or pediatric critical care transports often use physicians since they may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, Paramedic or RN. Physicians are leaders of medical retrieval teams in many western countries such as the UK, South Africa, Australia and New Zealand{fact}} to take the highest level of skill, equipment and therapy to a rural or district hospital to transport a critically ill or injured patient to a tertiary hospital.

A typical Rescue Unit for a fire department

Cross-Trained EMS

Depending on the service provider, but most commonly in the Fire and Police linked or combined services, the EMS crew members may also be certified or trained in skills such as water rescue or motor vehicle extrication using the jaws of life in medically directed rescue. Some EMS providers offer different kinds of rescue service including rope rescue, cave rescue, water rescue, extrication, search and rescue and more. Some EMS organizations may have a whole variety of vehicles including boats, response cars and ambulances to deal with the demands of their particular service. In some places, the law requires that all rescue team members be medically certified and in others the main rescue service (such as a Fire Department) do not have medical staff and leave all rescue up to an EMS department.

Prehospital Delivery of care

Depending on country, area within in country, or clinical need, emergency medical services may be provided by one or more different types of organisation. This variation may lead to large differences in levels of care and expected scope of practice.

The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was often the case in a historical context, and is still true in the developing world, where operators as diverse as taxi drivers and undertakers may operate this service.

Most developed countries now provide a government funded emergency medical service, which can be run on a national level, as is the case in the United Kingdom, where a national network of ambulance trusts operate an emergency service, paid for through central taxation, and available to anyone in need, or can be run on a more regional model, as is the case in the United States, where individual authorities have the responsibility for providing these services.

Typical scene at a local emergency room

Ambulance services can be stand alone organisations, but in some cases, the emergency medical service is operated by the local fire or police service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance, such as fire truck. In some locales, firefighters are the first responders to calls for emergency medical aid, with separate ambulance services providing transportation to hospitals when necessary.

Some charities or non-profit companies also operate emergency medical services, often alongside a patient transport function. These often focus on providing ambulances for the community, or for cover at private events, such as sports matches. The Red Cross provides this service in many countries across the world on a volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organizations such as St John Ambulance. and the Order of Malta Ambulance Corps. In some countries, these volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency, or simply to help cover busy periods.

There are also private ambulance companies, with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care (i.e. non urgent), although in some places these private services are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy or to respond to non-emergency home calls. Private companies are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews.

Rural EMS

The face of rural/frontier EMS has changed dramatically since the 1966 National Academy of Sciences, National Research Council (NAS-NRC) white paper “Accidental Death and Disability: the Neglected Disease of Modern Society” marked the conception of modern EMS. Ambulance service of that era was more about a fast ride than medical care. It was provided as a low-investment by-product service of funeral homes and others whose primary business already had the requisite type of vehicle.

The NAS-NRC white paper revealed the ill-equipped, ill-trained nature of these services, as well as the potential to do more harm than good. Subsequent reforms led to the birth of modern EMS with the Emergency Medical Services Systems Act of 1973. As standards for training, equipment and care changed, so did the providers of rural/frontier EMS. Dedicated ambulance vehicles staffed by trained EMT's operated by independent volunteer organizations, volunteer fire departments, local hospitals, and others replaced hearses.

In the past three decades, the EMS field, with its capabilities and role as a unique discipline at the crossroads of medicine, public health and public safety, has matured dramatically. At a rural car crash, the gold standard medical response has gone from hearse to helicopter. The pressure to provide advanced life support (ALS), created at first by enthusiastic EMTs within EMS agencies themselves, has become compounded by media-generated public expectation. The drive to provide ALS has had an effect similar to that experienced by funeral home ambulance operators pressed to provide safe, basic care in the early 1970s. More workplace issues arose. The 1950s brought much needed emphasis on the physical and mental health of EMS providers.

File:ACTAS Paramedics.jpg

Paramedics of the A.C.T. Ambulance Service

EMS agencies dependent on volunteers for staffing and fund-raising for revenue, have found advancement difficult. Indeed, it is often a challenge to continue to assure the timely response of a basic life support ambulance in these settings. In the current era of preparing public safety for effective response to manage terrorist and other events, the reality of rural/frontier EMS is that the infrastructure upon which to build such a response is itself in jeopardy. The 1996 NHTSA “EMS Agenda for the Future,”41 the visionary guide upon which this document is based, states that “EMS of the future will be community-based health management which is fully integrated with the overall health care system.” A theme running through the Rural/Frontier EMS Agenda for the Future is that such EMS integration is not only a reasonable approach to making community health care more seamless and to meeting community health care needs that might not otherwise be met, but that providing a variety of EMS-based community health services may be crucial to the survival and advancement of many rural/frontier EMS agencies.

Another related theme is that EMS should not only weave itself into the local health care system but into the fabric of the community itself. Communities can objectively assess and publicly discuss the level and type of EMS care available, consider other options and accompanying costs, and then select a model to subsidize. Where this happens through a well-orchestrated and timely process of informed self-determination, community EMS can be preserved and advanced levels of care can be attained.

The National Rural Health Association National Rural and Frontier Emergency Medical Services Agenda for the Future document suggests other means of maintaining an effective EMS presence as well such as alternative methods of delivering advanced life support back-up, and the formation of regional cooperatives for medical oversight, quality improvement, data collection and processing.

Strategies for delivering care

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" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, where the "stay and play" is exemplified by the French SMUR emergency mobile resuscitation unit.

The strategy developed for prehospital care in North America is called load and go. It is based on the Golden Hour theory, i.e., that 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 appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care ("ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; spine immobilization; endotracheal intubation) and the victim is transported as fast as possible to a trauma center.

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies).

Clinical governance

In most areas, the EMS crews will work under the auspices of a medical director, usually a medical doctor, who will set and enforce the standards of clinical care expected of them. In some areas, such as the United Kingdom, the ambulance crew will be independent clinicians with their own clinical discretion and liability for their own actions.

Organization in different countries

• Emergency Medical Services in the United States
• Emergency Medical Services in Canada
• Emergency Medical Services in France
• Emergency Medical Services in the United Kingdom
• Emergency Medical Services in Germany
• Emergency Medical Services in Italy
• Emergency Medical Services in Norway
• Emergency medical services in Australia
• Emergency medical services in South Africa‎
• Magen David Adom the Israeli ambulance service

See also

• 9-1-1
• Emergency Medical Technician
• Paramedic
• First Aid
• Battlefield medicine
• Rescue squad
• Extrication
• Trauma center
• Hospital
• Air Ambulance
• Prehospital Medicine
• Advanced life support
• Basic life support
• Emergency medicine
• Emergency physician
• The White Paper
• Good Samaritan law
• Cardiopulmonary resuscitation

Further reading

• Planning Emergency Medical Communications: Volume 2, Local/Regional Level Planning Guide, (Washington, D.C.: National Highway Traffic Safety Administration, US Department of Transportation, 1995).

External links

• National Association of Emergency Medical Technicians Homepage
• National Collegiate Emergency Medical Services Foundation Homepage
• National EMS Memorial Service Webpage
• National Registry of Emergency Medical Technicians
• Emergency Medical Services at Curlie
• National Rural and Frontier Emergency Medical Services Agenda for the Future