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Sabato Ems Studentlecture
1. Emergency Medical Services
Pre-Hospital Care
Joseph Sabato, Jr, MD
Assistant Professor of Emergency Medicine
Director of Special Operations
Mary Tang, MD, MPH, PGY-3
Robert Williams, MD, PGY-3
2. 1966 National Highway Safety Act
Authorized the US Department of Transportation
(DOT) for prehospital medical services to fund:
„ Ambulances
„ Equipment
„ Communications
„ Training programs
3. Emergency Medical Services
Systems Act of 1973
(public law 93-154)
„ Funded and authorized the Department of
Health, Education and Welfare to develop
EMS throughout the country.
4. Public Law 93-154
Identified the following 15 components as
essential to an EMS system:
„ Communications „ Transfer of care
„ Training „ Consumer participation
„ Manpower „ Public education
„ Mutual aid „ Public safety agencies
„ Transportation „ Standard medical
records
„ Accessibility
„ Independent review
„ Facilities
and evaluation
„ Critical care units
„ Disaster linkage
5. „ 911 Emergency telephone number
‚ essential front door of the EMS system
„ Enhanced 911 (E-911) equipment
‚ provides automatic number and location
identification
6. Emergency Medical Dispatch
(EMD)
„ Based on the principle that good information
gathering during the dispatch phase of an
emergency can better prepare responding EMS
providers to deal with the situation at the scene.
„ Deliver basic emergency care instruction to
people on the scene.
„ Prioritize request for emergency medical
assistance.
„ Ensure only appropriate agencies or prehospital
providers are dispatched.
7. Emergency Medical Dispatch (cont’d)
May be carried out by a variety of
agencies, including:
„ Law enforcement agency (LEA)
„ EMS agency
„ Separate public safety dispatch center
8. Why is 911 better than dialing “0” ?
1st: Additional call and routing process,
which takes precious time.
2nd: The caller may not be connected with
the correct jurisdiction or service that
he needs.
10. Dual-response System
„ First responders (FRs) followed by ambulance
personnel.
„ FRs: Firefighters, police, park rangers, or citizen
volunteers.
„ Emergency Medical Technician (EMT):
EMT basic (EMT-B) - CPR, AED, extrication, immobilization
EMT intermediate (EMT-I) - IV access, PASG
EMT paramedic (EMT-P) - Intubation/RSI, EKG,
synchronized cardioversion, manual defibrillation,
& drug therapy
11. Public interest and participation:
Key ingredients in any EMS system!
„ Urban areas:
Public safety and
ambulance personnel.
„ Rural or wilderness
areas:
Volunteers, park rangers,
or ski patrols.
12. Mutual Aid Agreements
EMS services have agreements with
neighboring jurisdictions so that
uninterrupted emergency care
is available when local agencies are
overwhelmed and/or unable to
provide services.
15. Transportation
„ Ground ambulances
„ Provide most EMS transportation.
„ The most important aspect of ambulance
design is that the attendants must be able to
provide airway and ventilatory support while
safely transporting the patient.
„ Air transport
Helicopter (Rotor-wing)
Airplane (Fixed-wing)
16. Access to Care
„ A successful EMS system ensures that all
individuals have access to emergency care
regardless of their ability to pay or type of
insurance coverage
„ Emergency physicians must serve as the
patients’ advocate!!
17. FACILITIES
General: Shandstastic!
„ Transport to the closest appropriate hospital.
‚ If multiple hospitals within the same transport time:
patient’s choice.
„ Specialized receiving facilities
„ Higher level of care warranted
ƒ Transport to that institution (by passing closer hospitals).
• i.e. trauma, burn, stroke or angioplasty center
18. Critical Care Units (CCU’s)
Tertiary care facilities should be identified by every
EMS system to provide specialty care that is not
available in typical community hospitals.
Most common reasons for tertiary care emergency
transfer: „ Trauma
„ High-risk obstetrics
„ Cardiac care
„ Burns
„ Neonatal intensive care
„ Spinal cord injury
„ Neurosurgery
„ Pediatric Specialty Hospitals
20. Consumer Participation
„ Laypersons should be represented on EMS
councils.
„ Two important components of a successful
EMS system:
Lay public first aid training
Implementation of a 911 system
21. Public Information and
Education
„ In designing a public information program, the
EMS council’s goal should be for the public:
3. Understand how the community stands to
benefit from an excellent EMS system.
4. Be prepared to render first aid care.
5. Know how to access the EMS system quickly.
6. Understand that patients may not be delivered
to the hospital of their choice under life-
threatening conditions.
22. Public Safety Agencies
„ Strong ties with police and fire departments
„ Often provide first-response service because
their personnel are often the first on the
scene of an emergency.
I.e., police carrying oxygen and automatic defibrillators
23. Standardization of
Patients’ Records
„ All ambulance services within a specific
region should use a similar reporting form
that can be quickly and easily be
interpreted by receiving nurses and
physicians.
„ flow sheets
„ uniform data
„ NEMSIS/EMSTARS
24. Disaster Planning
The EMS system is an integral element of disaster
preparedness and planning.
„ Important role in initial response and transportation
„ Establish a regional disaster preparedness plan in coordination
with public safety agencies, government and medical
community
‚ Disaster management, communication, treatment and
destination of casualties
„ Periodic disaster drills
„ MCIs
„ Hazmat
25. Medical Direction
The process by which a dedicated physician(s) guides and
oversees the patient care that is provided by an EMS system.
Why do paramedics, who are licensed by the state,
need a medical director or physician advisor?
26. On-line Medical Direction (OLMD)
a.k.a. direct medical control,
on-line medical command, or
real-time medical control.
„ Direct medical communication to personnel in
the field.
‚ in person
‚ radio
‚ phone communication
• landline (traditional telephone)
• cellular
27. Off-line Medical Control
„ Responsibility of the service medical director
2. Development and implementation of
protocols and standing orders
3. Development of medical accountability (QA)
4. Development of ongoing education
‚ initial and recertifying training programs.
„ Physicians must remember that they have the
ultimate responsibility for the overall quality of
prehospital medical care.
28. Qualifications of an EMS
Medical Director
„ Licensed physician with interest, experience,
and knowledge in emergency medicine and
prehospital care.
„ Preferable if full-time, practicing, emergency
physician at the lead hospital for the EMS
system, with additional training and experience
in EMS.
30. Emergency Cardiac Care
ALS saves lives after sudden cardiac arrest.
„ The number of lives saved and the cost are debated.
Without treatment at the scene, the survival rate of out-of-
hospital cardiac arrest is virtually zero.
Seattle and King Count, Washington
ƒ 26% patients successfully resuscitated from out-of-hospital cardiac
arrest.
New York City
ƒ 1.4% overall survival
Outcome of out-of-hospital cardiac arrest in New York City. The
Pre-Hospital Arrest Survival Evaluation (PHASE) study.
JAMA 1994 Mar (Lombardi, Gallagher, and Gennis)
31. Hypothermia
„ Recommended for witnessed cardiac arrest
(Vtach, Vfib) with spontaneous return of
circulation
„ Administer as soon as possible, i.e, pre-hospital
with ice packs to groin, axillae, and neck
Howes et al. "Evidence for the use of hypothermia after cardiac arrest." CJEM
2006;8(2):109-15
32. Minimal Interruption of CPR
„ MICR = initial series of 200 uninterrupted
chest compressions, rhythm analysis with
single shock, then 200 post-shock
compressions before pulse check or
rhythm-reanalysis; also done before
admin of epi, intubation
„ Shown to improve survival in out-of-
hospital cardiac arrest
Bobrow et al. “Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital
Cardiac Arrest.” JAMA 299(10)1158-1165.
33. Improve Survival
Shorten interval between collapse and defibrillation.
Local system must optimize the “chain of survival”
‚ early access
‚ early CPR
‚ early defibrillation
‚ early ALS
„ First responders
„ AEDs
34. Pilot programs
Jim Alexander - Security officer
Las Vegas security officer saves two lives in less than
one year
U.S. Air Force retiree Jim Alexander works as a security
officer at Stardust Resort and Casino in Las Vegas. In less
than one year, Alexander saved the lives of two casino
guests: one in September 1997 and another in August 1998.
35. Trauma Care
Delivery of critically injured trauma patients to
trauma centers saves lives.
Controversial: IV on scene (field) vs. en route
Houston: no IVF in Prehospital or E.R.
for hypotensive victims of
penetrating truncal trauma.
36. EMS For Children
„ Leadership in the area of injury and illness prevention
„ Leadership in local, regional, and state EMS and EMSC systems by
involvement in the provision of medical direction (oversight),
education of providers, quality improvement, and legislative
advocacy
„ Collaboration with other physicians and health care professionals to
enhance the medical home for children, including referral to
primary care, specialized care, and rehabilitation services
„ Research in the design and function of EMS systems, education of
providers, out-of-hospital and emergency care interventions, and
outcomes of emergency care
„ Expertise for and collaboration with the National EMSC Program
(Maternal and Child Health Bureau in collaboration with the
National Highway Traffic Safety Administration)
37. “The Chain of Survival”
In 1990, the American Heart Association introduced a
treatment model for victims of sudden cardiac arrest called
the Chain of Survival. It outlines the specific sequence of
events that need to happen for a victim to survive and
recover from sudden cardiac arrest.
38. The Chain of Survival
„ Early Access: Someone suspects or determines the victim
is in sudden cardiac arrest and calls for help
„ Early CPR: Someone trained in CPR keeps the victim’s
blood flowing until defibrillation can begin
„ Early Defibrillation: Someone trained in defibrillation
shocks the victim as quickly as possible
„ Early Advanced Care: Medical personnel provide
advanced cardiac care which can include airway support,
medications, and hospital services
39. Defibrillators
Automated external defibrillators (AEDs)
„ analyze the patient’s rhythm, determine whether a defibrillatory
shock is indicated, charge the capacitors, and then inform the
operator that a shock is advised.
„ defibrillate only for ventricular fibrillation
and very fast wide QRS complex tachycardias
(usually over 180/bpm)
„ used only in pulses and apneic patients.
42. New CPR Guidelines
„ Current AHA/ACC ACLS guidelines for
chest compression to breath ratio for
single provider = 30:2 (vs. 15:2)
„ No pulse checks for layperson
45. Vascular Access
Equipment
„ Paramedics are very adept
at placing IV’s
„ IV access should not
prolong scene times in a
trauma patient, especially
when “Load and Go”
criteria are present
46. Spinal Immobilization ABC’s
The preservation of integrity of the spinal column
is of paramount importance in the field.
„ C-Spine stabilization and airway assessment are
performed simultaneously.
„ Manual stabilization of the neck is not released until
the patient has been transferred and securely
strapped to a board.
48. Air Medical Transport
Association of Air Medical Services (AAMS)
Domestic: 362 air medical providers
International 23 air medical providers
Hospital(s) based
„ Helicopter cost: $1-5 million
• annual operating cost: $2 million
Patients transported
„ 827 per program
1997 - survey of 126 United States air medical
programs
49. Clinical Use of Helicopters
Fast ambulances
125-175 mph
150-200 mile range
Two major types of helicopter missions
(1) Trauma/medical scene responses (30%)
(2) Interfacility transfers (70%)
50. Rotor-wing aircraft
Advantages
„ Can be based at a hospital or another
location near your service area.
„ Do not require a runway for takeoff and
landing.
„ Capable of landing in relatively small and
secluded areas.
„ Usually ready for takeoff in a matter of
minutes.
52. Future of EMS
„ EMS will represent the intersection of public safety, public health, and
health care systems.
„ EMS will continue to be diverse at the local level.
„ As a component of health care systems, EMS will be influenced significantly
by their continuing evolution.
„ There will be increasing need for information regarding EMS systems and
outcomes.
„ It will be necessary to continue to make some EMS system-related
decisions on the basis of limited information.
„ The media will continue to influence the public’s perception of EMS.
„ Federal funding/financial resources will be decreasing.
„ To make good decisions, public policy makers will need to be well-informed
about EMS issues.
NHTSA agenda guidelines: www.nhtsa.dot.gov/people/injury/ems/agenda/emsbro.html
