Emergency Medical Services and Prehospital Care

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Chapter 69 Emergency Medical Services and Prehospital Care

Hazel Guinto-Ocampo, MD

1 Describe the American Heart Association’s pediatric chain of survival link

Prevention of injury or arrest → Early and effective cardiopulmonary resuscitation → Early emergency medical services (EMS) activation → Early advanced life support, including stabilization, transport, and rehabilitation.

The chain of survival and emergency medical services for children. In Hazinski MF (ed): PALS Provider Manual. Dallas, TX, American Heart Association, 2002, pp 1–16.

2 What is enhanced 911?

Enhanced 911 automatically provides computerized identification of the telephone number and location of the caller, regardless of the quality of information provided.

3 What is the role of an EMS dispatcher?

An EMS dispatcher is a specialized operator who gathers essential information regarding the nature and location of the emergency, and relays this information to the EMS system for dispatch of a first responder. The dispatcher’s responsibilities include calming the caller, learning the complaint, making a triage decision, and obtaining the location of the emergency.

4 What are dispatcher protocols?

These are written guidelines, often computerized, that are developed and utilized so that dispatchers can accurately instruct callers in pediatric cardiopulmonary resuscitation, relief of foreign-body airway obstruction, and essential first aid maneuvers, until EMS personnel arrive. Their use reduces the variability of the information provided by the dispatchers, and ensures that accurate emergency information is provided to every caller.

5 Name the three general categories of prehospital personnel

1 First responders

2 Basic life support (BLS) providers

3 Advanced life support (ALS) providers

The categories vary in levels of training and degrees of capabilities. At the federal level, the National Highway Traffic Safety Association (NHTSA) has developed the National Standard Curricula for certification for each category, but state or local requirements supersede these standards. Intermediate levels of providers with varied capabilities have evolved as many jurisdictions offer supplemental training modules.

Blackwell T: principles of emergency medical services systems. In Marx JA, Hockberger RS, Walls RM (eds): Rosen’s Emergency Medicine Concepts and Clinical Practice Vol. III, 5th ed. St. Louis, Mosby, 2002, pp 2616–2625.

6 What is a first responder?

First responders have limited but significant life-saving capabilities. By definition, first responders are typically the first to arrive at the scene of an incident. The Department of Transportation (DOT) recommends a 40-hour didactic curriculum for certification, and 16–36 hours for refresher training. Most are trained to administer BLS, help clear an obstructed airway, control hemorrhage, and splint an injured extremity. The use of an automated external defibrillator (AED) should be a mandatory procedure for first responders. Spinal immobilization is usually beyond the first responder’s capabilities. Except in some rural EMS systems, first responders usually do not provide ambulance transport.

Woodward GA, King BR, Garrett AL, Baker MD. Prehospital care and transport medicine. In Fleisher GR, Ludwig S, Henretig FM (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott, Williams & Wilkins, 2006, pp 93–134.

7 What are BLS providers?

BLS providers are usually called emergency medical technician–basic, or simply emergency medical technicians (EMTs). They have capabilities that exceed those of the first responders. In 1995, NHTSA developed a revised BLS provider curriculum, which requires 110 hours of didactic and clinical instruction. The DOT recommends a 24-hour refresher course, 48 hours of continuing education, and a BLS course every 2 years, for recertification. BLS providers are capable of patient assessment, spinal immobilization, noninvasive ventilatory assistance, and application of pneumatic antishock garment. They are trained to recognize respiratory distress, shock, altered mental status, mechanisms of injury, and death. As ambulance transport personnel, they perform initial triage and route patients to receiving medical facilities.

Woodward GA, King BR, Garrett AL, Baker MD. Prehospital care and transport medicine. In Fleisher GR, Ludwig S, Henretig FM (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott, Williams & Wilkins, 2006, pp 93–134.

8 What are ALS providers?

ALS providers are usually referred to as emergency medical technician–paramedic, or simply paramedics/medics. They are more extensively trained and more capable than BLS providers. A recently revised National Standard Curriculum for ALS providers requires approximately 1000 to 1200 hours of didactic, clinical, and field instruction on advanced resuscitation techniques, such as ventilatory support, vascular access, and drug administration. They are capable of general diagnostic skills, rhythm disturbance recognition and treatment, and advanced, including invasive, airway management. Many ALS provider educational programs have advanced to a 2-year associate or a 4-year baccalaureate degree. A 48-hour refresher course, 24 hours of yearly continuing education, BLS, and adult and pediatric ALS courses are required for recertification.

Woodward GA, King BR, Garrett AL, Baker MD. Prehospital care and transport medicine. In Fleisher GR, Ludwig S, Henretig FM (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott, Williams & Wilkins, 2006, pp 93–134.

9 How can one become an intermediate provider?

Intermediate providers have met EMT-basic certification and undergo supplemental training. For example, some EMTs acquire additional training in defibrillation and are designated EMT-D.

KEY POINTS: CATEGORIES OF PREHOSPITAL PERSONNEL

1 First responders

2 BLS providers or EMT–B (basic)

3 ALS providers or EMT–P (paramedic)

10 Where can I find the list of minimum pediatric equipment and supplies for BLS and ALS units?

The most recent lists of recommended pediatric BLS and ALS ambulance equipment were published simultaneously in the following journals:

image Committee on Ambulance Equipment and Supplies, National EMSC Resource Alliance. Guidelines for pediatric equipment and supplies for basic and advanced life support ambulances. Ann Emerg Med 28:699–701, 1996.

image Committee on Ambulance Equipment and Supplies, National EMSC Resource Alliance. Guidelines for pediatric equipment and supplies for basic and advanced life support ambulances. Pediatr Emerg Care 12:452–453, 1996.

11 What is medical command?

Medical command is the entity responsible for the supervision of the emergency medical services of the community. In general, paramedics are assigned to a specific operational base or base station, and these base stations are responsible to medical command. Medical control provides medical direction to prehospital personnel. Medical control can be off-line/indirect, or on-line/direct.

12 Differentiate off-line and on-line medical control

image Off-line medical control consists of patient care protocol development, personnel education and training, prospective and retrospective patient care review, and other process improvement activities.

image On-line medical control involves real-time interaction between a physician or designee, and a field provider. On-line medical control can be centralized or decentralized. In a centralized system, a designated hospital is responsible for all direct medical control orders and notification, regardless of the receiving facility. In a decentralized system, each receiving hospital provides direction to EMTs transporting patients to their facility.

13 Where can I find examples of pediatric EMS protocols?

National Association of EMS Physicians: Model Pediatric Protocols, 2003:www.naemsp.org/protocols.asp

14 Describe the difference between single-tiered and multitiered EMS systems

image In a single-tiered system, every response, regardless of the call type, receives the same level of personnel expertise and equipment (all BLS or ALS). The advantage of this design is the provision of advanced level of care to all calls, and overcomes under- or overtriaging by EMS dispatchers.

image Multitiered systems respond with an ALS- or BLS-level unit depending on the nature of the call. This design reserves ALS units for higher-priority calls, and aims to ensure that an ALS unit is always available for potential critical responses.

The ideal EMS system design provides quality patient care in the briefest possible period of time. Therefore, the efficiency of adopting a single-tiered versus multitiered response is affected by the availability of BLS and ALS providers in the community, and the distance from the scene of the incident to the nearest receiving hospital. Regardless of the response design, EMS systems usually include first responder services, often provided by the police or fire department, as part of the response.

15 What is EMS-C?

Emergency Medical Services for Children (EMS-C) is a federally funded program administered by the Health Resources and Services Administration’s Maternal and Child Health Bureau and NHTSA, which provides grant funding to states or medical schools in all 50 states, the District of Columbia, and five territories, to support pediatric emergency care initiatives at the state and local level. Funding supports all the components of the program, namely, education and training, systems development, data analysis and research, and public policy and future planning. EMS-C partners with numerous national organizations involved in the care of acutely ill or injured children.

Emergency Medical Services for Children: www.ems-c.org

16 What resources are available through EMS-C?

Numerous education and training resources regarding emergency care are available through EMS-C. These resources are geared toward various users, such as children, parents and families, school and child care professionals, prehospital care providers, and physicians and nurses. These resources are available, mostly for free, through the EMS-C website, which won the 1999 Gold Award for best government health care website.

Emergency Medical Services for Children: www.ems-c.org

17 What is family-centered prehospital care?

Family-centered prehospital care is a systematic approach to building collaborative relationships between prehospital personnel and the patients’ families during on-site treatment, transport, and transition of care. The goal is to provide the best outcome for the patient through collaboration with his or her family members.

Emergency Medical Services for Children. Available at www.ems-c.org

18 What is an AED?

An AED is a device that recognizes rhythms amenable to shock, and directs the user to deliver the shock.

19 In which pediatric age groups is it appropriate to use an AED?

AEDs may be used for children 1 year of age or older. Ideally, the device should be equipped with pediatric pad/cable systems that reduce the energy delivered for patients younger than 8 years of age.

Samson RA, Berg RA, Bingham R: Use of automated external defibrillators for children: An update—an advisory statement from the Pediatric Advanced Life Support Task Force, International Liaison Committee on Resuscitation. Pediatrics 112:163–168, 2003.

20 What is the doctrine of implied consent?

This doctrine permits the treatment of minors without parental consent when an emergency exists. A minor with a condition that threatens either life or limb is viewed as an emergency and must be treated and transported.

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