Emergency Medical Services: Overview and Ground Transport

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Chapter 190

Emergency Medical Services

Overview and Ground Transport

Perspective

Development of Emergency Medical Services

Before the advent of civilian ambulance services, the sick and injured were transported by any means available, including passerby motorists, wagons, farm machinery, delivery carts, buses, and taxicabs. Figure 190-1 depicts the early Larrey ambulance used during the Napoleonic Wars, the Rucker wagon used during the American Civil War, and a modern ambulance used today. In 1865, the Commercial Hospital in Cincinnati established the first hospital-based ambulance service. Four years later, the first city service began at New York’s Bellevue Hospital.1

In 1965, the President’s Commission on Highway Safety recommended a National Accident Response Program to decrease death and injury from highway accidents.2 Results from a second national survey by the National Academy of Sciences–National Research Council were used to draft a white paper entitled Accidental Death and Disability: The Neglected Disease of Modern Society.3 Published in 1966, this document described the hazardous conditions of emergency care provision at all levels and outlined the necessary building blocks for future maturation of emergency medical services (EMS). These national efforts were the impetus for congressional legislation that directed the U.S. Department of Transportation (DOT)–National Highway Traffic Safety Administration (NHTSA) to develop a program for improving emergency medical care.

During the mid-1960s, out-of-hospital cardiac care included field defibrillation programs in Belfast, Northern Ireland, and cardiac arrest research in several U.S. cities.4,5 In 1969, the first National Conference on EMS convened, resulting in the development of a curriculum, certification process, and national registry for the emergency medical technician–ambulance (EMT-A). By 1972, the U.S. Department of Labor recognized the EMT as an occupational specialty.6 Interested physicians and nurses later provided advanced educational courses and practical experiences for the EMTs, and thus began the paramedic providers.7,8

Additional programs prompted Congressional passage of the EMS Systems Act of 1973 (P.L. 93-154), which authorized funding that dramatically improved the development of comprehensive regional EMS delivery systems. Efforts to improve pediatric emergency care occurred in 1984 when Congress adopted the Emergency Medical Services for Children (EMS-C) initiative through the Health Services, Preventive Health Services, and Home Community Based Services Act of 1984 (P.L. 98-555).9 An Institute of Medicine (IOM) study, released in 1994, promoted the integration of EMS-C not just into existing EMS systems but into comprehensive systems of care provision, including injury prevention, primary and definitive care, and rehabilitation services.10

In 1996, the NHTSA published Emergency Medical Services Agenda for the Future, which broadly outlined the principles required for future EMS development.11 All components of an EMS system, both operational and clinical, were identified and discussed. This document has been used by many individuals and organizations as valuable reference material for planning, administration, and forecasting of the future of EMS delivery. More than 40 years since publishing the 1966 white paper, the IOM released a report on the status of emergency care entitled The Future of Emergency Care in United States Health System. The report focused on three separate yet related topics: (1) emergency care: at the breaking point, (2) emergency medical services at the crossroads, and (3) emergency care for children: growing pains.12–14

A major focus included the need to strengthen the integration of EMS into the entire health care system because lack of such coordination often results in patients being diverted from overcrowded to inappropriate or distant facilities. The recommendation was to ensure that the delivery of emergency medical and trauma care is organized into a coordinated, regional system such that patients receive care at the most appropriate facility on the basis of their injury or illness. Additional recommendations targeting EMS improvement included national accreditation for paramedic educational programs, adoption of a national certification system for individual state licensure, and recognition of common levels of EMS certification across the United States.

The concern for inadequate funding for EMS systems operations and disaster response was also addressed. Recommendations included development by Congress of regionally funded, multiyear demonstration projects that encourage states to identify and to test strategies for creation of seamless systems of care, workforce strengthening, evidence-based practices, and disaster preparedness. It was further recommended that an advisory committee be created to work with the Centers for Medicare and Medicaid Services to improve reimbursement and policies related to reimbursement.

Finally, a small yet significant proportion of EMS transports involve the pediatric population; thus it is often difficult for prehospital providers to maintain the knowledge and skills necessary to care for critically ill or injured children. Many plans, including disaster preparedness, often neglect children. As such, the IOM report recommended several items, the most important of which is that the care of children be integrated into the overall EMS system and not separated from that of adults, with pediatric emergency care competencies being defined and training enhanced to maintain those competencies. Because it is difficult to ascertain whether systems have targeted the pediatric population, the IOM further recommended that a pediatric coordinator be included in all EMS systems to advocate for ensuring that equipment, medications, training, and protocols are appropriate for children.

Each of the three IOM reports supported the development by the federal government of national standards for emergency care performance indicators and evaluation and protocols for triage, treatment, and transport of patients. To accomplish this objective, a lead federal agency should be identified. Debate exists as to whether EMS at a national level should remain under the NHTSA or reside in other applicable agencies. Regardless, the parent organization should ensure that research is supported to improve the knowledge base and evidence for the practice of out-of-hospital medical care.

Emergency Medical Service Systems

Multiple EMS system designs exist, all predicated on the type of community served. Whereas this is a local decision, all states incorporate an administrative office that governs or oversees the provision of EMS activities. Typically the role is not to direct any individual service but to assist in planning, licensing services, and establishing or enforcing the scope and standards for practice. Other functions may include training, examining, certifying, and recertifying providers; record keeping; data collection; and auditing or investigating programs. A description of systems for the 200 most populous cities in the United States is periodically published in the Journal of Emergency Medical Services.15 For simplicity, the following categorization of systems is used: private and public agencies; basic life support (BLS) and advanced life support (ALS) services; and single-tiered, multitiered, and first responder systems.

Private and Public Agencies

Where local government has not assumed primary responsibility for EMS services, communities may depend on private providers. Financial responsibility varies but usually depends on federal reimbursement (Medicare or Medicaid) and user fees. A local government subsidy may or may not supplement the operation. If multiple providers are serving one jurisdiction, calls may be allocated by rotation or specified zone coverage. Dispatching varies by the system but may be by the provider or by a central agency. Medical direction is often provided by a contracted physician or physician oversight board.

Hospital-based EMS systems are few in number and may be managed by a single hospital or hospital corporation. Not all hospital-based EMS programs are considered private, in that the hospital may be a division under local or state government or operating under a public authority. As in private models, financial responsibility is usually in the form of user fees, with or without additional subsidy. Dispatching may be provided by a local public safety agency that may also be responsible for police and fire communications. An emergency physician from a sponsor or base hospital typically provides medical direction for these systems.

A public utility model is a hybrid between private and public design that allows local government to contract with a private or public provider. The successful bidder for service becomes a contracted entity that agrees to provide the specified services (ALS, BLS, or both) to the catchment area and, depending on the arrangement, may bill the patient directly or receive uniform reimbursement. Depending on local structure and interagency agreement, dispatching may be performed by an existing public safety organization or by the parent company. Medical direction is usually a specified individual subject to contractual terms.

When government officials were faced with planning and establishment of EMS systems during the early maturation periods, many decided that the fire department was the logical choice to incorporate EMS. Fire stations were strategically located throughout the community, and personnel were already used to providing emergency response. Firefighters could be cross-trained as a firefighter-paramedic or dedicated to either fire or EMS function with the opportunity for transfer. Public EMS systems that were not incorporated into fire departments evolved into their own separate entity, referred to as a municipal third-service system. Such agencies are operated by local municipalities and are endorsed and supported by local government. Many cities have been successful in combining police, fire, and EMS under a global public safety agency, with all department heads or chiefs reporting to one manager or administrator. Financially, public EMS systems may be supported by a tax base, which may or may not be supplemented by user fees. Regardless of design, medical oversight for a municipal EMS system may be provided by a physician appointed and contracted by a local hospital, an advisory council, or a medical oversight board.

Basic Life Support and Advanced Life Support Service

BLS describes the provision of emergency care without the use of advanced therapeutic interventions. Skills include airway management (oral and nasal airways, bag-mask ventilation), cardiopulmonary resuscitation (CPR), hemorrhage control, fracture and spine immobilization, and childbirth assistance. Defibrillation with an automated external defibrillator (AED) is often included by many BLS systems. Services are provided by certified or medical first responders or emergency medical technicians (EMTs) certified at the basic level (EMT-B).

BLS systems may be associated with poor survival rates from out-of-hospital cardiac arrest, especially those not incorporating AED technology.16 Alternatively, there is debate on the effectiveness of ALS for medical and traumatic emergencies.17 Despite this evidence, few urban communities across the United States operate solely at the BLS level. Many rural and some suburban EMS services rely on volunteers who may not wish to become advanced-level providers. Because these services may have low call volumes, it becomes more difficult for personnel to maintain advanced skills and a proficient knowledge base. Also, such communities may not have access to medical supervision or hospital sponsorship for ALS care.18

Systems categorized as ALS offer a more comprehensive level of service by highly educated providers, usually certified at the intermediate or paramedic level (EMT-I or EMT-P, respectively) or equivalent levels, depending on individual state certifications. Provider skills include advanced airway interventions, intravenous line placement, medication administration, cardiac monitoring and manual defibrillation, and certain invasive procedures. Most EMS systems in urban cities operate at the ALS level of care.

The number of EMT-Ps in any jurisdiction has come under scrutiny, in that cities with more paramedics per capita tend to have lower survival rates.19 Although this may seem implausible, one explanation might be that the number of patient encounters per paramedic decreases and the sharpness of skills degrades when that community is saturated with paramedics.

Single-Tiered, Multitiered, and First Responder Systems

In a single-tiered system, every response regardless of the call type receives the same level of personnel expertise and equipment allocation (all BLS or ALS). Multiple-tiered systems use a combination of ALS and BLS levels, depending on the nature of the call. Differences in cost and effectiveness between a mixed ALS-BLS service and an all-ALS service have been debated. A single-tiered ALS response may prove to be cost-effective in specific locales, ensures the capability of providing a consistent advanced level of care to all patients regardless of illness or injury severity, and obviates the potential for undertriage or overtriage by 9-1-1 telecommunicators. Alternatively, a multitiered system may meet the needs of individual communities or agency infrastructure. This design often meets with employee satisfaction and has the potential to preserve ALS resources for higher priority calls in that BLS transport of nonurgent patients allows ALS ambulances to be available for potential critical responses.

Regardless of single- or multiple-tier design, EMS systems usually include first responder services as part of their structure. The first responder, usually a police officer or firefighter, is the nontransport BLS or ALS provider who responds to the scene of an emergency to provide initial care before definitive medical care and transportation assets arrive. The first responder quickly assesses the situation and patients, determines whether additional resources are required, initiates patient care, and provides advance information to responding personnel.

The design of an EMS system is targeted toward providing quality patient care in the briefest time after unexpected injury or illness. A desirable and cost-effective design might include BLS nontransport first responders with short response times (average 2-4 minutes), having the capability of providing early defibrillation and airway support, coupled with ensuing ALS care and transport services.20

Levels of Provider and Scope of Practice

At the federal level, the NHTSA is responsible for development of the education standards and scope of practice for the different certification levels. The National EMS Education Agenda21 and the National EMS Scope of Practice Model22 now define the curriculum, education content, and core competencies for each level of provider. Individual state legislation is responsible for provider levels recognized, initial and continuing medical education requirements at each level, testing, and time intervals for course completion and recertification. The following sections outline the new suggested levels of provider and incorporated skills. Suggested hours of training are listed in Table 190-1.

Emergency Medical Responder

The emergency medical responder, formerly referred to as first responder, is typically the first to arrive on the scene of an incident. Initial scene and patient assessment along with limited lifesaving interventions is the primary function. Along with CPR and basic airway management skills, the emergency medical responder should be able to control hemorrhage and initiate spinal immobilization.

The four elements referred to as the chain of survival by the American Heart Association, which decrease mortality from out-of-hospital cardiac arrest, are early access to care, CPR, defibrillation, and advanced airway management and medications.23 Because early defibrillation may improve the odds of survival of out-of-hospital cardiac arrest, the use of an AED should be a mandatory procedure for the emergency medical responder.24

Emergency Medical Technician

The EMT, formerly referred to as the EMT-Basic, is the minimum level required to staff a BLS ambulance and is commonly used for nonemergency and convalescent transport services. In addition to the skills of the first responder, the EMT is also involved with triage, more detailed patient assessment, and transportation. Like first responders, EMTs should have the capability of providing early defibrillation.

In 1995, the NHTSA released the revised EMT curriculum to include 46 lessons, each with cognitive, effective, and psychomotor objectives.25 Many states expanded the course to include more skills, such as AED use, epinephrine autoinjections, albuterol administration by hand-held nebulizer or metered-dose inhaler, and use of adjunctive airway devices such as the extraglottic airway.

Emergency Medical Technician–Paramedic

The EMT-P is the most advanced provider. Paramedics have the capability to address most prehospital emergencies. The scope of practice includes a wide variety of therapeutics and procedures including cardiac rhythm recognition, expanded pharmacologic treatments, and advanced airway interventions. Other important invasive procedures include needle decompression of a tension pneumothorax, needle or surgical cricothyrotomy, and transthoracic cardiac pacing.

The initial training course for the EMT-P includes didactic, clinical, and field education. All course content focuses on technical and professional competencies. Additional modules are included that allow programs to incorporate an expanded scope of practice.26 With the expansion of EMS technology and management career options, many paramedic educational programs have advanced from 1-year certificate curriculums to 2-year associate or 4-year baccalaureate degrees. The National EMS Education Standards document recommends that all paramedic education programs be accredited in the future by the Commission on Accreditation of Allied Health Education Programs.

Future

To complement many of the educational issues addressed in the EMS Agenda for the Future document and at the request of the National Association of State EMS Officials (NASEMSO), the NHTSA along with the Health Resources and Services Administration under the Department of Health and Human Services published the Emergency Medical Services Education Agenda for the Future: A Systems Approach in 2000.27 This document sets forth the processes required to improve EMS education delivery similar to what is realized with other allied health care professions, provides a means of ensuring more instructor flexibility and EMS adaptation to community needs and resources, and moves toward standardization of all levels of certification across the United States. From this document, multiple activities have been completed and published, including the National EMS Core Content, a National EMS Scope of Practice Model of minimum competencies, and the 2009 National EMS Education Standards, which would ultimately replace the current National Standard Curricula for each level of provider. The NASEMSO has been collaborating with multiple EMS stakeholders and the federal partner organizations to assist states in implementing this agenda. The National Registry of Emergency Medical Technicians is in the process of revising their examination, with a new paramedic examination being finalized by January 2013. Future goals include the establishment of a national EMS certification program, consistent levels of provider that build off of each advancing level (emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic), the requirement for educational programs to be nationally accredited, and the limitation of examinations only to those graduates who completed these accredited programs.

Material Resources

Before the mid-1960s, few if any regulations governed system design, operations, and equipment. As EMS development progressed, guidelines for emergency vehicle specifications were adopted by the DOT and equipment lists were proposed. Today, collaborative efforts from multiple professional medical colleges and organizations continue to publish documents that recommend design, equipment, and medications for ambulances.28

Medications

During the 1980s, many believed that prehospital drug administration was unjustified and simply delayed hospital transport.29,30 Moreover, although there was a profound paucity of outcomes-based research into the use of various medications and practices in the prehospital environment, this has been improved in recent years.31 There is significant evidence for early defibrillation and certain advanced cardiac life support medications, which are carried by most ALS services.24,32

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