Chapter 20: EMS and Disaster Medicine

ORIGINS OF EMERGENCY MEDICAL SERVICES

Modern emergency medical service (EMS) systems began to evolve in the 1960s and 1970s to deliver emergency care in the prehospital environment rather than simply as a means of transport to the hospital. Several important steps in the development of modern EMS in the United States resulted in improved training, regulation, and quality of prehospital care.

• Highway Safety Act (1966)

  • Authorized the U.S. Department of Transportation (DOT) to develop prehospital services

  • Established the National Highway Traffic Safety Administration (NHTSA)

• Emergency Medical Services System Act (1973)

  • Provided government funding and training to encourage development of regional, county, and local EMS systems

  • Identified essential components of an EMS system

• Development of communication and ambulance standards (1973-1974)

  • 911 system

  • Dedicated radio frequencies for EMS

  • Federal specifications for ambulances

• Emergency Medical Treatment and Active Labor Act (EMTALA) 1985

  • Part of the Consolidated Omnibus Budget Reconciliation Act (COBRA)

  • A condition of Medicare funding that requires a medical screening examination and stabilization of any emergent medical condition (including active labor) for any patient who presents to a hospital with an emergency department

• Trauma Care Systems Planning and Development Act (1990)

  • Authorized government funds to states for development of trauma systems

EMS SYSTEM DESIGNS

Multiple EMS system designs exist and depend on the type of community served. In general, there should be 1 ambulance per 7000-10,000 people.

• Volunteer model: Used primarily in rural areas where there are no funds to pay personnel.

• Public utility model: Allows a local government to contract calls for service to a private company that provides basic life support (BLS) and/or advanced life support (ALS); the government oversees and regulates performance.

• Third service model: A separate department of local government owns, operates, and staffs ambulances.

• Fire department-based model: The fire department provides all EMS services as well as fire suppression services.

• Combined public/private model: Parts of the EMS response come from different organizations, eg, the fire department provides first response while transportation to the hospital is provided by a private ambulance service or government “third service.”

• Hospital-based EMS model: Not as common as in the past; EMS services are provided by the local hospital.

All models rely on lesser-trained medical (or “first”) responders, but the subsequent level of care of an EMS system varies:

• Single-tier system: Provides only BLS or only ALS (including EMT-Intermediate and/or EMT-Paramedic) response.

• Multitiered system: Provides a mixed BLS/ALS response (becoming less common). In a multitiered system, the level of response (BLS or ALS) depends on the nature of the call.