Emergency medical services

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Three ambulances and a specialist response vehicle (right) in New Jersey. Ambulances and a Response Truck.jpg
Three ambulances and a specialist response vehicle (right) in New Jersey.
An ambulance in Lausanne (Switzerland) marked with multiple Stars of Life (representing emergency medical services). Ambulance Lausanne.jpg
An ambulance in Lausanne (Switzerland) marked with multiple Stars of Life (representing emergency medical services).
Emergency medical services prepare to airlift the victim of a car accident to hospital, in Ontario, Canada. Medical evacuation after car accident Kawartha Lakes Ontario.jpg
Emergency medical services prepare to airlift the victim of a car accident to hospital, in Ontario, Canada.

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services which treat illnesses and injuries that require an urgent medical response, providing out-of-hospital treatment and transport to definitive care. [1] They may also be known as a first aid squad, [2] FAST squad, [3] emergency squad, [4] rescue squad, [5] ambulance squad, [6] ambulance corps, [7] life squad [8] or by other initialisms such as EMAS or EMARS.

Emergency service Organizations that ensure public safety and health by addressing different emergencies

Emergency services and rescue services are organizations which ensure public safety and health by addressing different emergencies. Some of these agencies exist solely for addressing certain types of emergencies whilst others deal with ad hoc emergencies as part of their normal responsibilities. Many of these agencies engage in community awareness and prevention programs to help the public avoid, detect, and report emergencies effectively.

Rescue squad

Rescue squad is a term used in the United States to refer to emergency units that provide emergency medical services and may perform technical rescues and firefighting operations.

An acronym is a word or name formed as a type of abbreviation from the initial components of a phrase or a word, usually individual letters, as in NATO or scuba, sometimes syllables, as in Benelux, or a mixture of the two, as in radar.

Contents

In most places, the EMS can be summoned by members of the public (as well as medical facilities, other emergency services, businesses and authorities) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation. [9] Ambulances are the primary vehicles for delivering EMS, though some also use cars, motorcycles, aircraft or boats. EMS agencies may also operate the non-emergency patient transport service, and some have units for technical rescue operations such as extrication, water rescue, and search and rescue. [10]

Emergency telephone number telephone number that allows caller to contact local emergency services for assistance

In many countries the public switched telephone network has a single emergency telephone number that allows a caller to contact local emergency services for assistance. The emergency number differs from country to country; it is typically a three-digit number so that it can be easily remembered and dialed quickly. Some countries have a different emergency number for each of the different emergency services; these often differ only by the last digit. See List of emergency telephone numbers.

Ambulance Vehicle equipped for transporting and care for ill and wounded people

An ambulance is a medically equipped vehicle which transports patients to treatment facilities, such as hospitals. In some instances, out-of-hospital medical care is provided to the patient.

Nontransporting EMS vehicle

A nontransporting EMS vehicle,, is an emergency medical service (EMS) vehicle that responds to emergencies, but is not designed to transport a patient. For patients whose condition requires transport, an ambulance is necessary.

As a first resort, the EMS provide treatment on the scene to those in need of urgent medical care. If it is deemed necessary, they are tasked with transferring the patient to the next point of care. This is most likely an emergency department of a hospital. Historically, ambulances only transported patients to care, and this remains the case in parts of the developing world. [11] The term "emergency medical service" was popularised when these services began to emphasise diagnosis and treatment at the scene. In some countries, a substantial portion of EMS calls do not result in a patient being taken to hospital. [12]

A patient is any recipient of health care services. The patient is most often ill or injured and in need of treatment by a physician, nurse, psychologist, dentist, veterinarian, or other health care provider.

Clinical point of care is the point in time when clinicians deliver healthcare products and services to patients at the time of care.

Emergency department Medical treatment facility specializing in emergency medicine

An emergency department (ED), also known as an accident & emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.

Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive ambulances, with no medical training. [11] In contrast, most systems have personnel who retain at least basic first aid certifications, such as basic life support (BLS). In English-speaking countries, they are known as emergency medical technicians (EMTs) and paramedics, with the latter having additional training such as advanced life support (ALS) skills. Physicians and nurses also provide pre-hospital care to varying degrees in different countries.

Professional certification, trade certification, or professional designation, often called simply certification or qualification, is a designation earned by a person to assure qualification to perform a job or task. Not all certifications that use post-nominal letters are an acknowledgement of educational achievement, or an agency appointed to safeguard the public interest.

First aid Emergency first response medical treatment

First aid is the first and immediate assistance given to any person suffering from either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial intervention in a serious condition prior to professional medical help being available, such as performing cardiopulmonary resuscitation (CPR) while waiting for an ambulance, as well as the complete treatment of minor conditions, such as applying a plaster to a cut. First aid is generally performed by someone with basic medical training. Mental health first aid is an extension of the concept of first aid to cover mental health, while psychological first aid is used as early treatment of people at risk for developing PTSD.

Basic life support (BLS) is a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by qualified bystanders.

History

Precursors

Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, in which a man who has been beaten is cared for by a passing Samaritan. Luke 10:34 (NIV) – "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." During the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield. [13]

New Testament Second division of the Christian biblical canon

The New Testament is the second part of the Christian biblical canon, the first being the Old Testament. The New Testament discusses the teachings and person of Jesus, as well as events in first-century Christianity. Christians regard both the Old and New Testaments together as sacred scripture.

Parable of the Good Samaritan didactic story told by Jesus in Luke 10:25–37

The parable of the Good Samaritan is a parable told by Jesus in the Gospel of Luke. It is about a traveller who is stripped of clothing, beaten, and left half dead alongside the road. First a priest and then a Levite comes by, but both avoid the man. Finally, a Samaritan happens upon the traveller. Samaritans and Jews despised each other, but the Samaritan helps the injured man. Jesus is described as telling the parable in response to the question from a lawyer, "And who is my neighbour?". In response, Jesus tells the parable, the conclusion of which is that the neighbour figure in the parable is the man who shows mercy to the injured man—that is, the Samaritan.

Knights Hospitaller Western Christian military order

The Order of Knights of the Hospital of Saint John of Jerusalem, also known as the Order of Saint John, Order of Hospitallers, Knights Hospitaller, Order of Malta, Knights Hospitalier or Hospitallers, was a medieval and early modern Catholic military order. It was headquartered in the Kingdom of Jerusalem, on the island of Rhodes, in Malta and Saint Petersburg.

A drawing of one of Larrey's ambulances volantes. Larrey's Flying Ambulance.jpg
A drawing of one of Larrey's ambulances volantes.

The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte's chief surgeon. [14] [15] Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. [14] [15] [16] Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. [15] Larrey's projects for 'flying ambulances' were first approved by the Committee of Public Safety in 1794. Larrey subsequently entered Napoleon's service during the Italian campaigns in 1796, where his ambulances were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even developing a litter which could be carried by a camel for a campaign in Egypt. [15]

Dominique Jean Larrey

Baron Dominique Jean Larrey was a French surgeon in Napoleon's Grande Armée and an important innovator in battlefield medicine and triage. He is often considered the first modern military surgeon.

France Republic with majority of territory in Europe and numerous oversea territories around the world

France, officially the French Republic, is a sovereign state whose territory consists of metropolitan France in Western Europe and several overseas regions and territories. The metropolitan area of France extends from the Mediterranean Sea to the English Channel and the North Sea, and from the Rhine to the Atlantic Ocean. It is bordered by Belgium, Luxembourg and Germany to the northeast, Switzerland and Italy to the east, and Andorra and Spain to the south. The overseas territories include French Guiana in South America and several islands in the Atlantic, Pacific and Indian oceans. The country's 18 integral regions span a combined area of 643,801 square kilometres (248,573 sq mi) and a total population of 67.02 million. France is a unitary semi-presidential republic with its capital in Paris, the country's largest city and main cultural and commercial centre. Other major urban areas include Lyon, Marseille, Toulouse, Bordeaux, Lille and Nice.

Prussia state in Central Europe between 1525–1947

Prussia was a historically prominent German state that originated in 1525 with a duchy centred on the region of Prussia on the southeast coast of the Baltic Sea. It was de facto dissolved by an emergency decree transferring powers of the Prussian government to German Chancellor Franz von Papen in 1932 and de jure by an Allied decree in 1947. For centuries, the House of Hohenzollern ruled Prussia, successfully expanding its size by way of an unusually well-organised and effective army. Prussia, with its capital first in Königsberg and then, in 1701, in Berlin, decisively shaped the history of Germany.

Early civilian ambulances

A major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832. [17] The statement on the carriage, as printed in The Times , said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other". [16] This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.

A horse-drawn Bellevue Hospital ambulance in New York City, 1895. Bellevue Hospital Ambulance, New York Times, 1895.JPG
A horse-drawn Bellevue Hospital ambulance in New York City, 1895.

The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865. [16] This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine.

Another early ambulance service was founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ringtheater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide. [18]

In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. [19] It was modelled on a military-style command and discipline structure.

Motorization

A Royal Navy ambulance during World War I. Royal Naval World War I ambulance truck, KT9793, c 1919 Wellcome L0034479.jpg
A Royal Navy ambulance during World War I.

Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. [16] This was followed in 1900 by New York City, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2 hp motors on the rear axle. [16]

American historians claim that the world's first component of civilian pre-hospital care on scene began in 1928, when "Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad in the nation." [20] Canadian historians dispute this with the city of Toronto claiming "The first formal training for ambulance attendants was conducted in 1892."[ citation needed ]

During World War One, further advances were made in providing care before and during transport – traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. [21] Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Prior to World War II, there were some areas where a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses – the only available vehicle that could carry a recumbent patient – and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars. [22] [23]

Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.

Rise of modern EMS

A 1973 Cadillac Miller-Meteor ambulance. Note the raised roof, with more room for the attendants and patients DFVAC 1970s Cadillac Miller Meteor color.jpg
A 1973 Cadillac Miller-Meteor ambulance. Note the raised roof, with more room for the attendants and patients

Advances in the 1960s, especially the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. [24] In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the US during that time was Accidental Death and Disability: The Neglected Disease of Modern Society , also known as The White Paper. The report concluded that ambulance services in the US varied widely in quality and were often unregulated and unsatisfactory. [25] These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. The government reports resulted in the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.

In 1971 a progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a "superb white paper" that "jolted and wakened the entire structure of organized medicine. This report is created as a "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services". Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting. [26] Such advancements included Dr. R Adams Cowley creating the country's first statewide EMS program, in Maryland. [27]

The developments were paralleled in other countries. In the United Kingdom, a 1973 law merged the municipal ambulance services into larger agencies and set national standards. [28] In France, the first official SAMU agencies were founded in the 1970s. [29]

Organization

Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization. This variation may lead to large differences in levels of care and expected scope of practice. Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.

Government ambulance service

A government-owned ambulance in Kiev, Ukraine An ambulance in Kiev.jpg
A government-owned ambulance in Kiev, Ukraine

Operating separately from (although alongside) the fire and police services of the area, these ambulances are funded by local, provincial or national governments. In some countries, these only tend to be found in big cities, whereas in countries such as the United Kingdom, almost all emergency ambulances are part of a national health system. [30]

In the United States, ambulance services provided by a local government are often referred to as "third service" EMS (the fire department, police department, and separate EMS forming an emergency services trio) by the employees of said service, as well as other city officials and residents. Government ambulance services also have to take civil service exams just like government fire departments and police. In the United States, certain federal government agencies employ emergency medical technicians at the basic and advanced life support levels, such as the National Park Service and the Federal Bureau of Prisons.

Fire- or police-linked service

In countries such as the United States, Japan, France, and parts of India; ambulances can be operated by the local fire or police services. Fire-based EMS is the most common model in the United States, where nearly all urban fire departments provide EMS [31] and a majority of emergency transport ambulance services in large cities are part of fire departments. It is somewhat rare for a police department in the United States to provide EMS or ambulance services, although many police officers have basic medical training.

Charity ambulance service

A volunteer ambulance crew in Modena, Italy Modena ambulance.jpg
A volunteer ambulance crew in Modena, Italy

Charities or non-profit companies operate some emergency medical services. They are primarily staffed by volunteers, though some have paid employees. These may be linked to a volunteer fire service, and some volunteers may provide both services. Some ambulance charities specialize in providing cover at public gatherings and events (e.g. sporting events), while others provide care to the wider community.

The International Red Cross and Red Crescent Movement is the largest charity in the world that provides emergency medicine. [32] (in some countries, it operates as a private ambulance service). Other organisations include St John Ambulance, [32] the Order of Malta Ambulance Corps and Hatzalah, [33] as well as small local volunteer agencies. In the United States, volunteer ambulances are rarer, but can still be seen in both metropolitan and rural areas (e.g. Hatzalah).

A few charities provide ambulances for taking patients on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the UK's Jumbulance project. [34]

Private ambulance service

Some ambulances are operated by commercial companies with paid employees, usually on a contract to the local or national government, Hospital Networks, Health Care Facilities and Insurance Companies.

In the USA private ambulance companies provide 911 emergency services in large cities as well as most rural areas by contracting with local governments. In areas that the local County or City provide their own 911 service, private companies provide discharges and transfers from hospitals and to/from other health related facilities and homes. In most areas private companies are part of the local government Emergency Disaster plan, and are relied upon heavily for the overall EMS response, treatment and recovery.

In some areas, private companies may provide only the patient transport elements of ambulance care (i.e. non-urgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility-impaired if they have for example fallen and simply need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available at all times for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events. [35] In Latin America, private ambulance companies are often the only readily available EMS service

Combined emergency service

These are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where demand or budget is too low to support separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.

Hospital-based service

Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital.

Internal ambulances

Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion.

Purpose

Six points on the Star of Life Star of life parts.svg
Six points on the Star of Life

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the six points, are used to represent the six stages of high quality pre-hospital care, which are: [36]

  1. Early detection members of the public, or another agency, find the incident and understand the problem
  2. Early reporting the first persons on scene make a call to the emergency medical services (911) and provide details to enable a response to be mounted
  3. Early response the first professional (EMS) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin
  4. Good on-scene/ field care the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.
  5. Care in transit - the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
  6. Transfer to definitive care the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Strategies for delivering care

Training for EMS in Estonia. Haige esmavaatlus kopteril.jpg
Training for EMS in Estonia.

Although a variety of differing philosophical approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician-led and the other led by pre-hospital allied health staff such as emergency medical technicians or paramedics. These models are commonly referred to as the Franco-German model and Anglo-American model. [37] [38]

Studies have been inconclusive as to whether one model delivers better results than the other. [37] [38] [39] A 2010 study in the Oman Medical Journal suggested that rapid transport was a better strategy for trauma cases, while stabilization at the scene was a better strategy for cardiac arrests. [38]

Levels of care

Many systems have tiers of response for medical emergencies. For example, a common arrangement in the United States is that fire engines or volunteers are sent to provide a rapid initial response to a medical emergency, while an ambulance is sent to provide advanced treatment and transport the patient. In France, fire service and private company ambulances provide basic care, while hospital-based ambulances with physicians on board provide advanced care. In many countries, an air ambulance provides a higher level of care than a regular ambulance.

Examples of level of care include:

Transport-only

A motorcycle ambulance in South Sudan. ERanger-Sudan09.JPG
A motorcycle ambulance in South Sudan.

The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was historically the case in all countries. It remains the case in much of the developing world, where operators as diverse as taxi drivers [11] and undertakers may transport people to hospital.

Transport-centered EMS

Ambulances parked outside a local emergency room. BFDandUVES.JPG
Ambulances parked outside a local emergency room.

The Anglo-American model is also known as "load and go" or "scoop and run". [38] In this model, ambulances are staffed by paramedics and/or emergency medical technicians. They have specialized medical training, but not to the same level as a physician. In this model it is rare to find a physician actually working routinely in ambulances, although they may be deployed to major or complex cases. The physicians who work in EMS provide oversight for the work of the ambulance crews. This may include off-line medical control, where they devise protocols or 'standing orders' (procedures for treatment). This may also include on-line medical control, in which the physician is contacted to provide advice and authorization for various medical interventions.

In some cases, such as in the UK, South Africa and Australia, a paramedic may be an autonomous health care professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient. [40] Recently "Telemedicine" has been making an appearance in ambulances. Similar to online medical control, this practice allows paramedics to remotely transmit data such as vital signs and 12 and 15 lead ECGs to the hospital from the field. This allows the emergency department to prepare to treat patients prior to their arrival. [41] This is allowing lower level providers (Such as EMT-B) in the United States to utilize these advanced technologies and have the doctor interpret them, thus bringing rapid identification of rhythms to areas where paramedics are stretched thin. [42]

Major trauma

The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit or the German "Notarzt"-System (preclinical emergency physician).

The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and the victim is transported as fast as possible to a trauma centre. [43]

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient. [44] Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab. [45] The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent. [46] In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals. [47]

Physician-led EMS

Ambulance in the Czech Republic Rallye Rejviz 2012, ZZS ZK, VW T5 Strobel (01).jpg
Ambulance in the Czech Republic

Physician-led EMS is also known as the Franco-German model, "stay and play", "stay and stabilize" or "delay and treat". [38] In a physician-led system, doctors respond directly to all major emergencies requiring more than simple first aid. The physicians will attempt to treat casualties at the scene and will only transport them to hospital if it is deemed necessary. If patients are transported to hospital, they are more likely to go straight to a ward rather than to an emergency department. [38] Countries that use this model include France, Belgium, Luxembourg, Italy, Spain, Brazil and Chile.

In some cases in this model, such as France, there is no direct equivalent to a paramedic. [48] Physicians and (in some cases) nurses provide all medical interventions for the patient. Other ambulance personnel are not non-medically trained and only provide driving and heavy lifting. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is an assistant to the physician with a restricted scope of practice. They are only permitted to perform Advanced Life Support (ALS) procedures if authorized by the physician, or in cases of immediate life-threatening conditions. [49] Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.

Personnel

EMT staff at an emergency call in New York City Woman collapses in the East Village of New York.jpg
EMT staff at an emergency call in New York City
A patient arriving at hospital MS1 on stretcher.jpg
A patient arriving at hospital

Ambulance caregivers are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.[ citation needed ]

A unique aspect of EMS is that there are two hierarchies of authority, as the chain of command is separate to medical authority. [50]

Basic life support (BLS)

First responder

First responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, cardio-pulmonary resuscitation (CPR), and automated external defibrillator (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an emergency call. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before an ambulance can arrive and to then assist the ambulance crew. [51]

Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include Community First Responder schemes run by ambulance services the UK and similar volunteer schemes operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as rescue squads. Police officers and firefighters who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level.

Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The International Red Cross and Red Crescent Movement and St John Ambulance both provide first aiders in these roles.

Driver

Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid certificate), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills. [52]

Non-emergency driver/attendant

Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom. [53] [54]

Emergency medical technician

EMTs loading a patient into an ambulance EMTs loading a patient.jpg
EMTs loading a patient into an ambulance

Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I (EMT-A in some states) and EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. EMTs are usually able to perform a wide range of emergency care skills, such as automated defibrillation, care of spinal injuries and oxygen therapy. [55] [56] In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more advanced airway procedures, CPAP, and limited cardiac monitoring. [57] Most advanced procedures and skills are not within the national scope of practice for an EMT. [58] As such most states require additional training and certifications to perform above the national curriculum standards. [59] [60] In the US, an EMT certification requires intense courses and training in field skills. A certification expires after two years and holds a requirement of taking 48 CEUs (continuing education credits). 24 of these credits must be in refresher courses while the other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric care, specific traumas, etc.

Emergency medical dispatcher

An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

Advanced life support (ALS)

Paramedic

A girl treated by a paramedic Cervical Collar Emergency.jpg
A girl treated by a paramedic

A paramedic has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform endotracheal intubation), cardiac monitoring, tracheal intubation, pericardiocentesis, cardioversion, needle decompression and other skills such as performing a cricothyrotomy. [61] The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. [62] In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. [63] In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, [64] Flight Paramedic Certification (FP-C), [65] and Critical Care Emergency Medical Transport Program certification. [66]

Critical care paramedic

A critical care paramedic, also known as an advanced practice paramedic or other titles, is a paramedic with additional training to deal with critically ill patients. [66] [67] [68] Critical care paramedics often work on air ambulances, which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances. [69] The training, permitted skills, and certification requirements vary from one jurisdiction to the next. It also varies to whether they are trained externally by a university or professional body [69] [70] [71] [72] or 'in house' by their EMS agency. [73] [74]

These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are dopamine, dobutamine, propofol, blood and blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tubes.

Paramedic practitioner / emergency care practitioner

In the United Kingdom and South Africa, some serving paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics. An emergency care practitioner is a position sometimes referred to as a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, [75] and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

Traditional healthcare professions

Registered nurses

The use of registered nurses (RNs) in the pre-hospital setting is common in many countries. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed, [76] as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure that is above the Paramedic. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT. [77] In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs. [78] [79] And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain. [80] In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, [81] while SAMU-SMUR units are staffed by physicians and nurses [82]

Physician

In countries with a physician-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a paramedic, as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions. [49]

In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the air ambulances in the UK. [83] [84] They may also provide advice and devise protocols for treatment, with a medical director acting as the most senior medical adviser to the ambulance service.

Specialist EMS

Air ambulance

A Canadian STARS helicopter ambulance. Air ambulances often have staff who are specially trained for dealing with major trauma cases. STARS BK117 helicopter Exterior.jpg
A Canadian STARS helicopter ambulance. Air ambulances often have staff who are specially trained for dealing with major trauma cases.

Air ambulances often complement a land ambulance service. In some remote areas, they may even form the primary ambulance service. Like many innovations in EMS, medical aircraft were first used in the military. One of the first recorded aircraft rescues of a casualty was in 1917 in Turkey, when a soldier in the Camel Corps who had been shot in the ankle was flown to hospital in a de Havilland DH9. [85] In 1928, the first civilian air medical service was founded in Australia to provide healthcare to people living in remote parts of the Outback. This service became the Royal Flying Doctor Service. [86] The use of helicopters was pioneered in the Korean War, when time to reach a medical facility was reduced from 8 hours to 3 hours in World War II, and again to 2 hours by the Vietnam War. [87]

Aircraft can travel faster and operate in a wider coverage area than a land ambulance. They have a particular advantage for major trauma injuries. The well-established theory of the golden hour suggests that major trauma patients should be transported as quickly as possible to a specialist trauma center. [88] [89] Therefore, medical responders in a helicopter can provide both a higher level of care at the scene, faster transport to a specialist hospital [90] and critical care during the journey. [91] A disadvantage is that it can be dangerous for them to fly in bad weather. [92] [93]

Tactical (hazardous area)

New York City Fire Department Haz-Tac Ambulance FDNY Haz-Tec.JPG
New York City Fire Department Haz-Tac Ambulance

Some EMS agencies have set up specialist teams to help those injured in a major incident or a dangerous situation. [94] These include tactical police operations, active shooters, bombings, hazmat situations, building collapses, fires and natural disasters. In the US, these are often known as Tactical EMS teams and are often deployed alongside police SWAT teams. [94] The equivalent in UK ambulance services is a Hazardous Area Response Team (HART).

Wilderness

Wilderness EMS-like systems (WEMS) have been developed to provide medical responses in remote areas, which may have significantly different needs to an urban area. Examples include the National Ski Patrol or the regional-responding Appalachian Search and Rescue Conference (USA based). Like traditional EMS providers, all wilderness emergency medical (WEM) providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the Wilderness Medical Society and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course, [95] which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011. [96] Skills taught in WEMT courses exceeding the EMT-Basic scope of practice include catheterization, antibiotic administration, use of intermediate Blind Insertion Airway Devices (i.e. King Laryngeal Tube), Nasogastric Intubation, and simple suturing; [97] however, the scope of practice for the WEMT still falls under BLS level care. A multitude of organizations provide WEM training, including private schools, [98] [99] [100] [101] [102] [103] [104] non-profit organizations such as the Appalachian Center for Wilderness Medicine [105] and the Wilderness EMS Institute, [106] military branches, community colleges and universities, [107] [108] EMS-college-hospital collaborations, [109] and others.

Organization in different countries

See also

Related Research Articles

Emergency medical technician healthcare provider

Emergency medical technician (EMT), paramedic and ambulance technician are terms used in some countries to denote a health care provider of emergency medical services. EMTs are clinicians, trained to respond quickly to emergency situations regarding medical issues, traumatic injuries and accident scenes.

Paramedic healthcare professional who works in emergency medical situations

A paramedic is a specialist healthcare professional who responds to emergency calls for medical help outside of a hospital. Paramedics mainly work as part of the emergency medical services (EMS), most often in ambulances. The scope of practice of a paramedic varies among countries, but generally includes autonomous decision making around the emergency care of patients.

Certified first responder profession

For the more current term, see Emergency medical responder

A medical director is a physician who provides guidance and leadership on the use of medicine in a healthcare organization. These include the emergency medical services, hospital departments, blood banks, clinical teaching services and others. A medical director devises the protocols and guidelines for the clinical staff and evaluates them while they are in use.

National Association of Emergency Medical Technicians

The National Association of Emergency Medical Technicians (NAEMT) is a national Emergency medical services professional association representing all EMTs and Paramedics. The NAEMT educational programs also have an international scope.

Paramedics in Canada

A paramedic is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. Paramedics are increasingly being utilized in emergency rooms by providing patient care in collaboration with physicians, physician assistants, nurse practitioners, registered nurses, registered/licensed practical nurses and registered respiratory therapists. Increasingly in Canada, paramedics are actively pursuing self-regulation.

Paramedics in the United States

In the United States, the paramedic is a professional whose primary focus is to provide advanced emergency medical care for critical and emergency patients who access Emergency Medical Services (EMS). This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response, under medical oversight. Paramedics perform interventions with the basic and advanced equipment typically found on an ambulance. The paramedic is a link from the scene into the health care system. One of the eligibility requirements for state certification or licensure requires successful completion of a nationally accredited Paramedic program at the certificate or associate degree level. Each state varies in requirements to practice as a paramedic, and not all states require licensure.

Wilderness emergency medical technician (WEMT) is an emergency medical technician that is better equipped than licensed healthcare providers, who typically function almost exclusively in urban environments, to better stabilize, assess, treat, and protect patients in remote and austere environments until definitive medical care is reached. Despite the term, WEMT training is available and geared not just to the EMT, but also the paramedic, prehospital registered nurse, registered nurse, physician assistant, and medical doctor. After all, without an understanding of the applicable gear, skills, and knowledge needed to best function in wilderness environments, including a fundamental understanding of the related medical issues more commonly faced, even an advanced provider may often become little more than a first responder when called upon in such an emergency. WEMT training and certification is similar in scope to wilderness advanced life support (WALS) or other courses for advanced providers such as AWLS, WUMP, WMPP, and RMAP. Unlike more conventional emergency medicine training, wilderness emergency medicine places a greater emphasis on long-term patient care in the backcountry where conventional hospital care can be many hours, even days, away to reach.

Emergency Health Services

Emergency Health Services (EHS), a Canadian emergency medical services (EMS) agency, is responsible for providing emergency and primary health care to patients outside of a hospital. It also deals with transportation between hospitals and medical facilities.

Emergency medical services in the United States

In the United States, emergency medical services (EMS) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the National Highway Traffic Safety Administration, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual state governments, which often require higher standards from the services they oversee.

National Registry of Emergency Medical Technicians

The National Registry of Emergency Medical Technicians serves as the nation’s emergency medical services certification organization. Created in 1970, The Registry is an independent, non-governmental, non-profit organization, headquartered in Columbus, Ohio. The mission of The Registry is to protect the public through national certification based on uniform standards for training and examination of EMS personnel. It exists as a way to unify EMS personnel across the United States in a uniform and standardized level of competency. By providing a National EMS Certification, the NREMT issues a validated and legally defensible attestation of competency.

Advanced emergency medical technician (AEMT) is provider of prehospital emergency medical services in the United States. A transition to this level of training from the Emergency Medical Technician-Intermediate (EMT-I), which had somewhat less training, began in 2013 and has been implemented by most states at this point. The AEMT is not intended to deliver definitive medical care in most cases, but rather to augment prehospital critical care and provide rapid on-scene treatment. AEMTs are most usually employed in ambulance services, working in conjunction with EMTs and paramedics, however are also commonly found in fire departments and law enforcement agencies as non-transporting first responders. Ambulances operating at the AEMT level of care are commonplace in rural areas, and occasionally found in larger cities as part of a tiered-response system, but are overall much less common than EMT and Paramedic level Ambulances. The AEMT provides a low-cost, high-benefit option to provide advanced-level care when the paramedic level of care is not feasible. The AEMT is authorized to provide limited advanced life support, which is beyond the scope of an EMT.

Emergency Medical Technician is the entry level of Emergency Medical Technician in the United States.

In the United States, the licensing of prehospital emergency medical providers and oversight of emergency medical services are governed at the state level. Each state is free to add or subtract levels as each state sees fit. Therefore, due to differing needs and system development paths, the levels, education requirements, and scope of practice of prehospital providers varies from state to state. Even though primary management and regulation of prehospital providers is at the state level, the federal government does have a model scope of practice including minimum skills for EMRs, EMTs, Advanced EMTs and Paramedics set through the National Highway Traffic Safety Administration (NHTSA).

Emergency medical responders are people who are specially trained to provide out-of-hospital care in medical emergencies. There are many different types of emergency medical responders, each with different levels of training, ranging from first aid and basic life support. Emergency medical responders have a very limited scope of practice and have the least amount of comprehensive education, clinical experience or clinical skills of emergency medical services (EMS) personnel. The EMR program is not intended to replace the roles of emergency medical technicians or paramedics and their wide range of specialties. Emergency medical responders typically assist in rural regions providing basic life support where pre-hospital health professionals are not available due to limited resources or infrastructure.

Emergency medical services in the Netherlands is a system of pre hospital care provided by the government in partnership with private companies.

Emergency medical services in Sri Lanka is being established using a public/private system aimed at the provision of emergency ambulance service, including emergency care and transportation to hospitals. The Pre-Hospital Care Committee is part of the Trauma Secretariat of the Sri Lanka Ministry of Healthcare and Nutrition and was established following the 2004 tsunami. The goal of the Pre-Hospital Care Sub-Committee is “During this generation and continuing for future generations, everyone in Sri Lanka will have access to trained pre-hospital medical personnel, ambulances are available to transport the sick and injured safely to hospitals, complications from harmful or inadequate pre-hospital care is eliminated so physician and nursing personnel at hospitals are delivered patients they are able to professionally treat and rehabilitate back to society as contributing citizens.” Pre-Hospital care is an essential, core component of trauma system.

Intermediate Life Support (ILS) is a level of training undertaken in order to provide emergency medical care outside medical facilities. ILS is classed as mid-level emergency medical care provided by trained first responders who receive more training then Basic Life Support providers, but less as Advanced Life Support providers. Intermediate Life Support is also known as Limited Advanced Life Support (LALS).

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Further reading