EMERGENCY MEDICAL SERVICES LOCAL ROLE
Category: Emergency Medicine
Abstract : Local Role in Emergency Medical Services To be effective, an EMS system should be planned, organized, and operated at the local level. Local communities identify the needs and allocate resources to meet the demands for emergency care. The 15 elements of an EMS system defined by Public Law 93-154 can provide guidance in this process. Personnel In most urban areas, paid public safety an
Local Role in Emergency Medical Services
To be effective, an EMS system should be planned, organized, and operated at the local level. Local communities identify the needs and allocate resources to meet the demands for emergency care. The 15 elements of an EMS system defined by Public Law 93-154 can provide guidance in this process.
Personnel
In most urban areas, paid public safety and ambulance personnel provide prehospital medical care, but in rural or wilderness areas, citizen volunteers, park rangers, or ski patrols are commonly employed.
Training
Training begins with education of the private citizen in EMS system access, CPR, and other forms of first aid. Communications media can be used to reach large populations with the information necessary to educate citizens to respond to medical emergencies.
Currently, there are four DOT EMS training curriculum levels. These are first responder (FR), Emergency Medical Technician (EMT) basic (EMT-B), EMT intermediate (EMT-I), and EMT paramedic (EMT-P). The DOT FR course is designed primarily for individuals who may be the first to arrive at a medical emergency; typically police officers, firefighters, first aid teams, and/or other community EMS responders. This course provides instruction in CPR, spinal immobilization, bleeding control, and other basic emergency care procedures. The FR course is not designed for personnel working primarily on ambulances.
The three DOT EMT levels are designed for individuals who will function as members of an ambulance crew. Some states have additional EMT levels other than the three recognized by the DOT. The EMT-Bs have the necessary first aid skills to take care of immediately life-threatening prehospital emergency conditions. These skills include CPR, use of an automated external defibrillator (AED), and safe extrication, immobilization, and transportation of emergency victims. EMT-Bs are now being trained to assist patients in using their own nitroglycerin, epinephrine, and inhalers.
There is an optional module in the DOT EMT-B curriculum on advanced airway techniques: endotracheal intubation or an advanced airway adjunct, such as a pharyngeal-tracheal lumen airway or laryngeal-mask airway. The decision to teach the optional airway module generally is made by the state EMS agency. EMT-I training includes additional skills in patient assessment but also adds such skills as intravenous therapy, defibrillation, basic electrocardiogram (ECG) interpretation, and the ability to give some cardiac medications. The EMT-I curriculum was changed recently to add medications.
There are, however, some states that are still using the previous EMT-I curriculum that did not include delivery of medications. The highest level of EMT training, that of EMT-P, adds additional skills in patient assessment as well as additional background in basic medical physiology. Besides the skills of the EMT-I, the paramedics are trained in the ability to give additional medications and to have a better understanding of the pathophysiology and pharmacology needed for interventions in various medical conditions. Clearly, physicians need to be deeply involved in EMT training to ensure that knowledge and skills are being taught appropriately.
Communications
The universal emergency telephone number (e.g., 911 in the United States and Canada, 000 in Australia, 999 in the United Kingdom, and 112 in the European Union member countries) has greatly facilitated citizens' access to emergency medical care. In many systems, the answering centers have enhanced equipment (e.g., E-911) that provides automatic number and location identification as well as additional information to assist the responding personnel. However, the advent of cellular telephones has complicated this process. In some urban areas, up to 25 percent of all emergency calls are made from cellular phones. Technology is being developed to address this issue.
The emergency call is the essential front door of the EMS system; those answering the calls should have the knowledge and training to obtain initial medical information properly, dispatch appropriate personnel, and offer first aid information to the caller when appropriate. The training level for individuals answering emergency medical calls in dispatching ambulances is a curriculum called the Emergency Medical Dispatch (EMD) course. EMDs are trained to collect information in a structured manner in order to direct the most appropriate EMS response. This process is called priority dispatch. Information obtained by the EMD allows for the provision of basic instructions to help care for the patient prior to the arrival of EMS personnel. This process is called prearrival instruction.
Ambulance personnel should be able directly or indirectly to communicate with the hospital of destination. Most EMTs operate in the field under offline medical control, according to standing orders and patient care protocols developed by physicians. However, there are times when EMS personnel may require online medical control, in which they talk directly with a physician for specific direction or orders. The EMS communications system should function to provide public access, prompt dispatch of the appropriate vehicles and personnel, timely hospital notification, and online medical control. The public should be encouraged to use the universal emergency telephone number rather than call a hospital or physician when life-threatening symptoms (e.g., acute chest pain, dyspnea, loss of consciousness, or focal weakness) occur.
Transportation
Ground ambulances have evolved from transport vehicles into sophisticated and efficient mobile patient care areas where lifesaving maneuvers can be performed. The most important aspect of ambulance design is that the attendants must be able to provide airway and ventilatory support while transporting the patient safely. Basic life support (BLS) ambulances carry equipment appropriate for attendants trained at the EMT-B level. Advanced life support (ALS) ambulances are equipped for EMT-Ps or other health care personnel capable of providing drug therapy and performing other advanced medical procedures. Ground transportation is appropriate for the majority of ill or injured patients, especially in urban and suburban areas. Air transport should be considered if the time elapsed before definitive care is important and air transport would shorten that interval.
Facilities
In general, emergency patients should be transported to the closest appropriate hospital or, if there are multiple hospitals within the same transport time, to the hospital of the patient's choice. However, if the EMS system has identified a specific hospital with better resources to treat seriously ill or injured patients (e.g., trauma center, cardiac center), the patient should be transported to that institution, bypassing closer hospitals. Several systems of categorizing hospitals exist, and this process should precede or coincide with the development of the EMS system.
In a number of regions, the state has the statutory authority to designate certain specialty hospitals to receive a subset of patients (most commonly trauma patients) based on an objective review of the hospitals' capabilities. Some states and the American College of Surgeons also have developed a process to provide external verification of trauma centers. This process requires a review of hospital facilities, treatment processes, and patient outcomes to confirm that quality trauma care is in place. EMS systems are now also identifying hospitals as specialized receiving facilities that can provide emergency angioplasty for patients with acute myocardial infarction (AMI) or that have special expertise with thrombolytic therapy for acute stroke patients.
Decisions to divert patients to specialty centers have substantial health care and monetary implications. These decisions should be made in a collaborative manner for the EMS region based on clearly defined criteria.
Critical Care Units
Tertiary care facilities should be identified by every EMS system to provide specialty care that is not available in typical community hospitals. These facilities may be either within the EMS service area or, more commonly, outside the area. Usually, patients are transported initially to a local hospital for assessment and treatment and then transferred to a tertiary center. In some EMS regions, it may be possible to develop criteria for the transport of patients requiring tertiary specialty care directly from the scene to these centers. The most common reasons for tertiary care emergency transfer are trauma, neonatal intensive care, high-risk obstetrics, burns, spinal cord injury, and neurosurgical and cardiac care. It is not cost-effective or feasible for every community to support all these specialty services.
Public Safety Agencies
The EMS system should have strong ties with police and fire departments. Public safety agencies provide first-response services because their personnel are often the first on the scene of an emergency, and they are vital links in the delivery of emergency care. For example, police in some municipalities have begun carrying automatic defibrillators in order to improve outcomes for patients suffering cardiac arrest. Conversely, EMS personnel often require support from police and fire departments to provide medical care in hazardous circumstances.
Consumer Participation
Laypersons should be represented on EMS councils. Public support, both political and financial, is necessary for a good EMS system. Two important components of a successful EMS system are lay public first aid training and the implementation of a universal telephone number system.
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. Often the EMS system is a patient's only point of entry into the health care system. In an effort to control health care costs, patients may be discouraged from accessing the EMS system for perceived emergencies. An important principle of EMS is that all individuals deserve timely access to the system when necessary.
A more difficult problem exists when population densities or terrain dictate longer response times for some citizens than others. EMS councils should address such inequities by providing accurate information and advice to local political entities responsible for EMS service.
Transfer of Care
Patients sometimes are transferred from one medical care facility to another either within or outside of the EMS service area. Safe transfer is an important concept, and many problems can be avoided if both the transferring and receiving medical facilities develop transfer agreements in advance. For example, the prospective agreement to accept a trauma patient decreases the time spent arranging for transfer of a critical patient. The receiving physician should be assured of receiving all relevant information about the patient on arrival. Having appropriate medical personnel accompany the patient ensures medical support during transfer.
Standardization of Patients' Records
Patient care often depends on good medical records, and prehospital records are no exception. It is desirable that all ambulance services within a specific region use a similar reporting form that can be interpreted quickly and easily by receiving nurses and physicians. It is more difficult to standardize emergency department records. However, flow sheets that are easily interpretable by receiving physicians and nurses can be used. Uniform data elements for EMS care have been developed by the NHTSA and are coming into common use. Uniform data elements for emergency department care also have been developed by a cooperative effort among the NHTSA, the Centers for Disease Control and Prevention (CDC), and many emergency medical organizations. It is wise to design record systems that facilitate data extraction for trauma registries, severity scoring, and cardiac arrest outcome studies.
Public Information and Education
In designing a public information program, the local EMS council should consider that the public (1) understands how the community stands to benefit from an excellent EMS system, (2) is prepared to render first aid care, (3) knows how to quickly access the EMS system, and (4) understands that patients may not be delivered to the hospital of their choice under life-threatening conditions.
Independent Review and Evaluation
Governing agencies should be assured that there is ongoing review of the EMS system. Monitoring of radio communications, review of response times, and review of patient care records are relatively mechanical methods of quality control that are implemented easily. Outcome studies of such entities as cardiac arrest and multiple trauma require considerable physician input and cooperation. The system medical director should require that mechanisms be in place to ensure and improve the quality of EMS care. EMS system access to hospital charts should be a requirement for participating hospitals, with proper controls to ensure patient confidentiality.
Disaster Linkage
The EMS system is an integral part of disaster preparedness and should be involved in planning and practice drills along with public safety agencies and others. Public safety agencies should keep the EMS system informed of potential disaster situations or hazards that may be present temporarily. Also, hospitals should be prepared to keep the EMS system informed of their capacity to receive certain kinds of patients under disaster conditions.
Mutual Aid Agreements
EMS services should develop mutual aid agreements with neighboring jurisdictions so that uninterrupted emergency care is available when local agencies are overwhelmed or unable to provide services.
Research
While not one of the original 15 elements of an EMS system, research is needed to determine which therapeutic interventions are beneficial and which are not. Unfortunately, much of what has been done in prehospital emergency care has been based on assumptions, many of which have not been subjected to scientific investigation. An investment in research is the key to improved EMS practice.
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