Chapter 2. Prehospital Emergency Services

Development of modern prehospital emergency medical services (EMS) stems primarily from lessons learned from providing medical care to soldiers in military conflicts and from government mandates.

In the 1960s, the President's Committee for Traffic Safety recognized the need to address health, transportation, and medical care in order to reduce fatalities and injuries on our nation's roadways.

In 1966, the National Academy of Science published a report entitled Accidental Death and Disability: The Neglected Disease of Modern Society. It described deficiencies in prehospital care regarding ambulance systems and the hazardous conditions of emergency care provision. The issues raised in this survey compounded with public outcry prompted the drafting of federal legislation, the Highway Safety Act of 1966. The legislation was intended to help states develop programs to improve emergency care. It required each state to have a highway safety program that complied with uniform federal standards including emergency services. Initial National Highway Transportation Safety Administration (NHTSA) efforts were focused on improving the education of prehospital personnel. Funding was provided to develop state emergency services offices. International activity around the same time included Professor Frank Pantridge (1916–2004) and colleagues demonstrating improvement in patient outcomes by outfitting cardiac defibrillators on ambulances in Belfast, Ireland.

The first national conference on EMS resulted in the development of a curriculum, certification process, and national registry for EMS personnel. In the 1970s, EMS systems were established by the Department of Transportation (DOT)–NHTSA in selected areas around the country to provide standardized ambulance services. As prehospital services expanded, so did the role of the EMS provider.

Public law 93-154: Emergency Medical Services System Act of 1973 identified the following essential components of an EMS system:

1. Communications

2. Training

3. Manpower

4. Mutual aid

5. Transportation

6. Accessibility

7. Facilities

8. Critical care units

9. Transfer of care

10. Consumer participation

11. Public education

12. Public safety agencies

13. Standard medical records

14. Independent review and evaluation

15. Disaster linkage

Unfortunately, this neglected two other essentials: medical direction and system financing.

Multiple changes have occurred over the ensuing years, and each component of the EMS system has gone through many stages of development. Federal financing has virtually been abolished by the Consolidated Omnibus Budget Reconciliation Act, which has shifted the burden on state and local agencies. In 1988, the Statewide EMS Technical Assessment Program was established by NHTSA and defined elements necessary to all EMS systems.

Communications

Communications are a critical part of prehospital emergency care. From universal access for the public to the EMS system, to adequate radio space for providers to communicate with each other in spite of disaster, communications are the lifeblood of EMS.

The 911 universal access system provides entry into the emergency system. The Wireless Communications and Public Safety Act of 1999 was enacted with the goal of implementing 911 as the universal access to emergency services. Enhanced 911 allows automatic reporting of number and location of the caller. Wireless enhanced 911 will soon provide the same automatic reporting from wireless phones. The FCC also regulates 911 services for satellite services, text telephone devices, and voice over Internet protocol devices.

A 911 call connects the caller with an emergency medical dispatcher (EMD), who then coordinates with other public agencies, for example, fire and police, and then prioritizes and dispatches resources available to the scene.

EMDs are trained to assign determinants that direct the level of response, that is, lights and sirens, and number of providers. They also give callers prearrival instructions for comfort and lifesaving interventions until prehospital personnel arrive on the scene.

Currently, EMS communications are changing from wide band to narrow band frequencies. Previously, prehospital providers used VHF or UHF 25-kHz bandwidths, but beginning in 2011, the FCC will no longer approve applications for these bandwidths. Nonfederal emergency providers that use frequencies below 512 MHz are required to transition to 12.5-kHz bandwidth by January 1, 2013. The goal of this change is to free up and streamline existing bandwidths, with a transition at some unspecified time in the future to a 6.25-kHz bandwidth.

Additionally, the FCC has designated the upper half of the 700-MHz public safety band for nationwide interoperable (real-time communication between different public safety groups) communications, to be administered at the state level. Most 700- and 800-MHz systems are trunked, meaning channels are shared among a group of users.

Federal goals for EMS communications include: demonstration of response-level communications within 1 hour for routine events involving multiple jurisdictions and agencies by 2010, by 2011 same for non-UASI jurisdictions, and by 2013 all jurisdictions' response level within 3 hours of significant event (as outlined in the National Emergency Communications Plan).

Transportation

Since 1966, requirements for vehicles used to provide emergency medical care have become standardized. Care is also provided in rotor- and fixed-wing aircraft. Many EMS services are fire based, and first responder vehicles include fire trucks and nonambulance trucks and automobiles. Bike EMS providers patrol civic events, and providers on motorcycles are a critical part of the system in Europe.

EMS vehicles may be equipped for basic life support (BLS), advanced life support (ALS), or specialty care depending on the need and availability (eg, specialized transport systems and vehicles for neonates, patients on ECMO, and intensive care transports).

Facilities

EMS systems typically include hospitals with a variety of treatment capabilities. These may include any number and mix of local community hospitals with limited services, moderate-sized facilities with more advanced capabilities, and tertiary care facilities with capabilities to provide all levels of care. Hospital facilities are also frequently classified according to their relationship to EMS in addition to their ability to provide definitive care.

1. Base station hospitals: Physicians or specially trained personnel, generally paramedics or nurses, with physician backup provide EMS units with online medical supervision during treatment and transport. In many EMS systems, the base station hospital may also be the one most capable of providing definitive care.

2. Receiving hospitals: Receiving hospitals are facilities within the EMS's geographic service area to which patients may be transported. The receiving hospital may be selected according to its proximity; capabilities; and patient, family, or physician preference.

In general, patients should be transported to the nearest facility capable of treating them, but since not all hospitals have equal capabilities they are sometimes bypassed. Bypass is driven by the EMS system generally by local or regional protocol that directs and allows transport directly to specialized facilities, for example, burn centers, trauma centers, or cardiac care centers rather than stopping at the closest facility. Diversion is a request by a hospital for an EMS provider to not bring a patient to them due to lack of capacity or capability.

The Joint Commission on Accreditation of Healthcare Organizations has categorized hospitals into four levels of acute care based on availability of physicians, nurses, allied health personnel, and other hospital resources. This ranges from a level 1 that is a comprehensive facility to a level 4 that is a triage and lifesaving aid station. Hospitals may also be categorized by the type and level of specialty care they can provide. The most well-known system is the American College of Surgeons Verification of Trauma Centers:

• Level 1: A full-service trauma center that provides comprehensive care with immediate availability of services and a commitment to research and education.
• Level 2: Similar to a level 1 center in ability to provide most clinical care, but does not necessarily include a commitment to education or research.
• Level 3: Provides initial stabilization and lifesaving care prior to transfer to a higher-level facility if necessary.

Training and Human Resources

EMS providers are trained in accordance with regional, state, and federal standards.

First Responders

First responders include law enforcement, rescue squad members, firefighters, or volunteer EMS personnel. This level of training requires approximately 40 hours of didactic and clinical training in basic first aid and cardiopulmonary resuscitation (CPR).

At the most basic provider level, providers are known as emergency medical responder (EMR), formerly known as emergency care attendants (ECAs)—training includes basic lifesaving interventions, and providing assistance to higher level of skill providers before and during transport.

Emergency Medical Technicians

The National Registry of Emergency Medical Technicians currently recognizes three levels of training: EMT-A (basic), EMT-I (intermediate), and EMT-P (paramedic). Each level requires specific training as defined by state protocol.

EMT-A

Basic EMTs constitute the essential workforce of EMS systems throughout the United States. Most state laws require at least one certified EMT onboard ambulance vehicles that transport patients.

The basic EMT course requires at least 81 hours of training standardized by the DOT. Basic classes frequently exceed this minimum by up to 140 hours. Students learn basic principles of patient care, how to identify signs and symptoms central to patient assessment and diagnosis, and how to provide treatment in specific emergencies. The use of automated external defibrillators (AEDs) is also now standard curriculum for EMTs in most regions. Optional modules for EMTs include advanced airway management, intravenous access, and assisting patients with self-administration of medications. Additionally, some states allow administration of medications, including epinephrine in anaphylaxis, albuterol in asthma, and aspirin in suspected cardiac chest pain.

EMT-I

Advanced Emergency Care Technician, also known as EMT-I, is trained to provide a level of advanced care in areas that are underserved by paramedics. The scope of practice has evolved since 1990 to incorporate many advanced cardiac life support procedures, including cardiac monitoring, treatment of arrhythmias, defibrillation, and advanced airway management with either endotracheal intubation or an alternative airway.

EMT-P

Advanced EMTs (paramedics) receive over 1000 hours of training in ALS techniques. Their skills include the basic EMT procedures as well as intravenous cannulations, invasive airway management, recognition and treatment of cardiac dysrhythmias, defibrillation, and the use of specific emergency medications. In addition to extensive classroom training, EMT-P personnel also complete clinical training and a field internship with experienced paramedic teams.

Special Qualifications

Additional training is available at all levels for specific care settings. A Winter Emergency Care course has been developed by the National Ski Patrol to address special situations that occur in ski areas. Similarly, there are Wilderness modules at all levels of training that provide additional training for care provided in a remote setting with anticipated long evacuations and transportation.

EMT-tactical courses train EMTs and paramedics to deliver care so they may support or be a part of law enforcement, for example, SWAT, team. Finally, paramedic–critical-care training enables the advanced provider to provide care to critically injured or ill patients who are being transferred from one facility to another.

The air and surface transport nurse is generally a registered nurse with or without additional paramedic training. He or she usually serves on helicopters and fixed-wing and specialty care transports. Other personnel who provide care on specialty teams, especially pediatric and neonatal transports, include respiratory therapists and nurse practitioners.

Physician team members are more frequent outside of the United States. Within the United States, they are generally found only on rotor or fixed-wing transports.

Resource Management

Each state must have central control of EMS resources to ensure all patients have equal access to acceptable emergency care. State EMS agencies are typically responsible for allocating funds to local systems, implementing legislation regarding the prehospital practice of medicine, licensing and certification of field providers and personnel, enforcing regulations, and appointing advisory councils.

At the municipal and regional level, the EMS agency is responsible for managing the local systems resources, developing operational protocol, and establishing standards and guidelines. Local agencies develop policies consistent with the state requirements, implement a quality assurance or quality improvement program to ensure that the patient's best interest is served, and develop mutual aid agreements. Mutual aid agreements ensure a continuum of care during multiple casualty incidents and can be between departments, municipalities, or states. The agreements should provide for situations that may overwhelm local or regional resources.

Local agencies are typically composed of community representatives, including emergency physicians, EMS providers, firefighters, police, and local citizens. EMS providers may function in a variety of ways. They may be a part of a municipal fire department or independent as in the “third service” model, with fire and police being the first and second services provided. Providers may also be independent businesses with municipal contracts or community, usually volunteer, based.

Responses

Many possible combinations of prehospital services exist with the variables of BLS versus ALS, volunteer versus paid, governmentally run versus independent with or without first responders or a tiered response. There may even be a mixture of providers to serve the emergency and nonemergency transport needs of a community. No one system is ideal, and all have advantages and disadvantages.

Medical Direction

Prehospital care by EMS personnel is a delegated medical practice. EMS systems must retain a physician who is legally responsible for clinical and patient care aspects of the system. The medical director, in conjunction with local and state entities, develops and oversees training programs and clinical protocols and authorizes EMS personnel under his or her direction. He or she participates in personnel and equipment selection, directs the quality improvement and quality assurance programs, provides direct input into patient care, and is a liaison between the EMS system and other health care agencies. The medical director is the ultimate authority for all medical direction.

Medical direction may be described as online or offline. Online medical communication provides EMTs with clinical consultation in the field via telephone or radio communication with a physician at a base station. Offline medical communication is a function of the EMS organization. Nonphysician prehospital personnel operate under standing orders and treatment protocols developed by a physician medical director that are appropriate for the provider's level of training. These protocols determine the type and level of care administered at the emergency site. Physicians who provide online medical supervision of paramedics from base hospitals may permit paramedics to deviate from established protocols or to provide treatment not specifically covered in standing orders as long as prehospital providers do not deviate from their given scope of practice. The medical director assumes authority for offline medical direction via policies, procedures, standing orders, and field protocols.

Protocols and standing orders are instruments developed and approved by the medical director to instruct and guide prehospital personnel. As every system is different in its composition, geographic coverage, and capabilities, there is no ideal set of protocols or standing orders that can be applied broadly. The breadth and depth of the protocols are most dependent on the system's ability to monitor the care given.

Field supervision and direct observation of care by the medical director, known to many as grassroots medical direction, is the most effective means to manage and oversee the care provided. This is commonly practiced in larger communities that can afford full-time medical direction. Unfortunately, EMS medical direction has been poorly valued and many times is undercompensated or uncompensated and as a result is inconsistent.

Trauma Systems

Each state should develop a system of specialized care for trauma patients, including acute care trauma centers and rehabilitation programs. It must also develop systems for assigning and transporting patients to those facilities.

Regulation, Policy, and Quality Improvement

EMS organizations are administered by the states. Currently, there is no federal agency that oversees EMS. Each state must have laws, regulations, policies, and procedures that govern its EMS system. The individual state is also required to provide leadership to local jurisdictions and is responsible for education and data collection. These agencies may supply medical protocols, or otherwise establish scope of practice, and oversee communication systems. States coordinate disaster response and planning. In addition, each state and system must have a quality improvement system in place for continuing evaluation and upgrading of its EMS system.

Current discussion centers on moving EMS under the umbrella of Homeland Security from its current place under the NTHSA. Placing EMS under this umbrella will facilitate its interaction with other divisions, and place EMS in line for federal funding. Resistance to the idea comes from fire department–associated systems and organizations.

Public Education and Information

EMS systems provide for education of the public not only to recognize an emergency but also how to access the EMS system and initiate BLS. Classes in CPR, AED operation, and control of bleeding are offered to encourage bystanders to take an active role in providing emergency care prior to the arrival of trained personnel.

Over the past decade, a multitude of natural and manmade disasters have illuminated the deficiencies in EMS coordination and administration during such disasters. In order to facilitate communication and coordination of EMS during these events, the National Incident Management System (NIMS) was created to improve preparation, coordination, and incident management in disaster situations. NIMS was designed to allow federal, state, and local governments to work together to “prepare for, respond to, and recover from” domestic disasters, regardless of how large or small. Its goal is to provide both flexibility and standardization in delivery of emergency care during disasters. This includes coordinating diverse groups and ensuring adequate communication between them.

Other entities have come into being since the World Trade Center attacks in 2001. The Emergency Care Coordination Center within the Department of Health and Human Services was created to facilitate coordination between levels and types of EMS at a federal level.

In 2007, the NHSTA, which currently oversees the EMS system, convened to reevaluate where EMS is now, and where it is headed. Renewed focus on research, collecting data, evidenced-based medicine, increasing standardization, and, eventually, reciprocal state licensure and national licensure is on the agenda as EMS heads into the 21st century.

EMS is a relatively new field, with potential for growth and expansion. Federal mandates for research and education will encourage evidence-based practice to become the accepted norm for providers. Improved technology and education such as transmission of field EKGs will allow EMS to provide cutting edge care as first responders. Prehospital providers will coordinate disaster care with local, state, and federal agencies, and continue to improve in this area through hard-won experience and constant review and evaluation.