Comprehensive Study Notes on Emergency Medical Services Systems

The Emergency Medical Services System

• An Emergency Medical Services (EMS) system is a comprehensive network comprising three primary elements:

  • Personnel

  • Equipment

  • Resources

• EMS systems are established by a community to provide targeted transportation and essential pre-hospital medical care.

• The system consists of several integrated components:

  • Public: Members of the local community.

  • Communications System: Includes $9-1-1$ access and radio systems.

  • EMS Providers.

  • Fire Departments: Responsible for rescue and hazardous materials (haz-mat) response.

  • Public Utilities.

  • Hospitals:

    • Emergency Departments: Staffed by doctors, nurses, and technicians, with access to blood banks.

    • Surgery: Staffed by surgeons, nurses, and technicians.

    • Intensive Care and Rehabilitation: Staffed by doctors, nurses, and technicians.

Basic and Advanced Life Support

• Basic Life Support (BLS):

  • Involves simple life-saving procedures.

  • Often provided by lay rescuers.

  • Procedures include Cardiopulmonary Resuscitation (CPR), artificial ventilation, and bandaging.

  • Uses non-invasive procedures to control the airway and deliver oxygen.

  • Includes basic skills in "motion restriction" and patient transport.

• Advanced Life Support (ALS):

  • A wide and greatly variable term for invasive life-saving procedures.

  • Procedures include intravenous (IV) cannulation and advanced airway control.

  • Involves medication administration and electrical cardiac therapy.

  • Includes life-saving surgical procedures.

The Role of the Paramedic and Response Systems

• Paramedics are described as the "Special Forces" of medicine.

  • Their mandate is "Whatever, Whenever, Wherever."

  • They are specialists in the uncontrolled, pre-hospital setting.

  • They work in all weather conditions, including rain, snow, darkness, and extreme heat.

  • They care for all people and all medical conditions with only minutes of notice.

• Types of Response Systems:

  • BLS Response: No ALS is available in the system; typically found in rural or volunteer areas.

  • BLS / ALS Tiered System: BLS units respond first and call for ALS if indicated.

  • First Response System: Can be BLS or ALS; may be non-transport or transport-capable.

  • ALS Response: Uses paramedic first responders and paramedic transport units.

Historical Evolution of EMS

• Ancient Times: The first "protocols" were established in Mesopotamia, showing evidence of medications, patient assessment, and the use of bandages.

• $18^{\text{th}}$ and $19^{\text{th}}$ Centuries:

  • Field care was developed by one of Napoleon’s surgeons.

  • Triage was introduced to sort patients by the severity of their condition.

  • American Civil War: Clara Barton, a nurse, coordinated services for the wounded and founded the American Red Cross. Surgeons on the battlefield performed care that largely involved amputation.

• $20^{\text{th}}$ Century:

  • World War I: Introduction of the automated ambulance corps.

  • World War II: First use of surgical hospitals at the front lines.

  • Korea: Use of Mobile Army Surgical Hospital (MASH) units and the introduction of helicopters.

  • Vietnam: Use of evacuation (evac) hospitals where most patients arrived by helicopter, typically in under $1$ hour.

Modern EMS Legislation and Funding

• $1966$: "Accidental Death and Dismemberment: The Neglected Disease of Modern Society" (the White Paper) was published.

• $1966$: The National Highway Safety Act under the Department of Transportation (DOT) established rules to provide grants for EMS.

• $1969$: The EMT-Ambulance program was made public.

• $1969 - 1975$ (Texas Timeline):

  • $1969$: Miami Dade and Seattle established systems.

  • $1970$: Los Angeles County established a system.

  • $1973$: Houston, Texas.

  • $1974$: Dallas, Texas.

  • $1975$: Fort Worth, Texas.

• $1970$: The Wedworth-Townsend Paramedic Act was signed by Governor Ronald Reagan on July $15$, $1970$. This was the first legislation to define a paramedic under state law. This era also saw the TV show "Emergency!" which demonstrated EMS capabilities and created nationwide demand.

• $1973$: The EMS System Act allocated $300$ million to study EMS planning, operations, expansion, and research. Funding for regional systems continued until $1981$.

  • To be eligible for funding, a system had to address $15$ components: Manpower, Training, Communication, Critical Care Units, Public Safety Agencies, Consumer Participation, Transportation, Access to Care, Disaster Plans, Emergency facilities, Patient Transfer, Mutual Aid, Standardized Record Keeping, Public Information, and System Review.

  • Omitted from these requirements were system finance and medical direction.

• $1981$: The Consolidated Omnibus Budget Reconciliation Act (COBRA) wiped out federal EMS funding. Systems were left to fund themselves, and regulation moved to the states.

• $1990$s: Managed care introduced "Don’t call $9-1-1$," ambulance systems were corporatized and publicly traded, and Fire Departments were increasingly forced into EMS due to budget needs.

• Important Scientific Milestones:

  • No Emergency Physicians until $1972$.

  • No national Curricula until $1977$.

  • Advanced Cardiovascular Life Support (ACLS) did not exist until $1979$.

Medical Oversight and Protocols

• Medical Director: A physician legally responsible for clinical aspects. They oversee patient care, approve medications and equipment, develop protocols, and determine standing orders. Paramedics operate under "delegated practice."

  • Roles include educating and training personnel, assisting in selection, and serving as the "medical conscience" and advocate for patients and paramedics.

• Protocols: Written guidelines that establish the local standard of care and identify the local "Scope of Practice," including treatment algorithms and standing orders.

• On-line Medical Direction: Direct orders given by a physician to a paramedic via radio or telephone. Requires the paramedic to provide a detailed physical examination and a descriptive patient report.

• Off-line Medical Direction: Paramedics operate under written standing orders and manage patients without direct physician interaction. Responsibility includes detailed physical examination, diagnosis of condition, and patient management.

Texas Regional Advisory Councils (TSA Units)

• Established throughout Texas as consensus organizations to improve trauma care, managed by the Bureau of Emergency Management.

• Trauma Service Areas (TSA):

  • TSA-A: Amarillo

  • TSA-B: Brownfield

  • TSA-C: Wichita Falls

  • TSA-D: Abilene

  • TSA-E: Irving

  • TSA-F: Mount Pleasant

  • TSA-G: Tyler

  • TSA-H: Nacogdoches

  • TSA-I: El Paso

  • TSA-J: Midland

  • TSA-K: San Angelo

  • TSA-L: Temple

  • TSA-M: Waco

  • TSA-N: Bryan

  • TSA-O: Lockhart

  • TSA-P: San Antonio

  • TSA-Q: Houston

  • TSA-R: Fulshear

  • TSA-S: Victoria

  • TSA-T: Laredo

  • TSA-U: Corpus Christi

  • TSA-V: Harlingen

Communications and Dispatch

• A coordinated communications plan includes citizen access, a single control center, and operational and medical communication capabilities across hardware and software.

• Emergency Medical Dispatcher (EMD): Medically trained specialists who dispatch ambulances, assure service area coverage, and provide pre-arrival instructions to callers.

Education and Practice Standards

• Initial Education: Based on the EMT-Paramedic: National Standard Curriculum. It establishes minimum content and is divided into three learning domains:

  • Cognitive

  • Psychomotor

  • Affective

• Continuing Education: Post-graduate maintenance and growth to maintain readiness for current and future demands.

• Levels of EMS Training in Texas:

  • Emergency Care Attendant (ECA): Lowest certification level; exceeds national First Responder. Allows two ECAs to operate a BLS ambulance in very rural areas.

  • Emergency Medical Technician (EMT): Standard care level; minimum requirement in $49$ states.

  • Advanced EMT (EMT-Intermediate): Includes IV access, advanced airway, and increased assessment skills.

  • Paramedic: Capable of all skills provided in an emergency department within the first $15$ minutes.

  • Licensed Paramedic: Requires an Associate’s degree in EMS or any Bachelor’s degree.

• National Registry of EMTs (NREMT): Prepares and administers standardized tests for First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic levels to establish minimal standards of competency.

Patient Transportation and Logistics

• Transportation must be to appropriate facilities, such as:

  • Trauma centers, Pediatric centers, Burn centers, Cardiac cath centers, Stroke centers, and Hyperbaric centers.

• Ambulance Types:

  • Type I: Pick-up chassis with a modular box.

  • Type II: Modified van, primarily for transfer services and long-distance transport.

  • Type III: Van front chassis with a modular box; commonly used in large fleets.

  • Medium-duty: Truck chassis with a modular box; often used in urban fire departments.

  • Rotor-winged: Helicopters used to add speed; must be used appropriately as they can sometimes delay arrival to the ED.

• Mass-Casualty Preparation: Requires mutual aid agreements developed before a need arises. Plans for multi-vehicle accidents or extreme situations involve table-top exercises and active responder practice.

Quality Management and Research

• Definitions:

  • Quality Assurance (QA): The process of measuring quality within a system.

  • Quality Improvement (QI): Actions taken to correct system weaknesses.

  • Quality Management (QM): The collective process of QA and QI.

  • Continuous Quality Improvement (CQI): A system for continually evaluating and improving care, focusing on the system rather than individuals.

• The CQI dynamic process includes: Identify problems → Identify cause → Develop remedy → Plan correction → Enforce correction → Reexamine.

• EMS Research Principles:

  • Essential for changes in professional standards, training, and equipment based on empirical data.

  • Funding depends on proving value through outcome studies.

  • Research Types: Prospective and Retrospective.

  • Design: Use of samples, randomization, controls, placebos, and blinding (unblinded, single-blinded, double-blinded).

  • Statistics used include mean, median, mode, and standard deviation.