EMS Systems and History


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Introductory lecture to EMS systems and history or EMS courses. 2 hours. Lots of little known information.

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  • Dr. Eugene Nagel8 trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967.
  • Freedom House           Summary:   In the 1960s, a group of concerned citizens started the first Emergency Medical Technician (EMT) service in Philadelphia, PA. The group, called Freedom House, offered emergency medical services to low income, primarily African-American regions of Philadelphia, which were underserved by the police force at them time. Freedom House quickly became very successful, hiring and serving similar communities. Eventually, the struggle became a political struggle filled with racial tension, and the city of Philadelphia took over the jobs of Freedom House. In many ways, despite their great contribution to the EMT movement, Freedom House has been largely forgotten. Pittsburgh's Freedom House paramedics are credited as the first emergency medical technician (EMT) trainees in the United States. Pittsburgh's Peter Safar is referred to as the father of CPR.3 In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service,4 the first paramedic squadron in the United States.56 Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida, Seattle, Washington, and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the fire departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970.7 Dr. Eugene Nagel8 trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. In Los Angeles, a pilot paramedic program, involving firefighters from only two county fire department rescue squads initially, began under the direction of Ronald Stewart, M.D.9
  • This is the official trailer for the documentary, Freedom House, the little known story of the birth of Mobile Emergency Care in the United States.      Freedom House was born in the chaos of the 1960s.  President Johnson had established a number of training programs through the War on Poverty initiative.  Most of the unemployed languished because they were not trained in skills that were needed by local employers.  Many had lost hope of ever finding a challenging job that paid a living wage.  This despair combined with the violence that grew out of the toxic mix of the Kennedy assassinations and the assassination of Dr. Martin Luther King combined with the anti war protests and riots, gave little hope to those who were poor and lived in the ghettos of Pittsburgh.     In 1967, in Pittsburgh, PA. Some community organizers and Dr. Peter Safar (the father of CPR) championed a radical and innovative plan to break the cycle of hopelessness and provide onsite emergency care to residents of the city.  Freedom House was created and became the first Emergency Medical Training program in the US.     The training was based on the assumption that a significant number of lives could be saved if emergency medical care was delivered onsite before transport to the hospital.  The program began with 25 Hardcore, unemployed black men who were recruited from the streets of the Hill District (the largest black ghetto in Pittsburgh).  The men were enrolled in a comprehensive course of Emergency Medical Training.  The first equipped vans containing life saving equipment were created through the Freedom House program and provided on-going medical care while the patient was enroute to the hospital.     The Freedom House program blossomed in the City of Pittsburgh.  The initial areas of coverage were the poor districts in the inner city .In the later years Freedom House was covering half of the city.  But success breeds many fathers and the mayor of the city took over operating control of the Freedom House Ambulance Service in 1975.  Little notice was given and no attempt was made to retain the current staff.  The name was changed to the City of Pittsburgh and the new staff replaced Freedom House employees.     By the end of the 1970s few remembered or cared about the Pioneers of Emergency Medical Care and many of the former staff left the medical field entirely.     This Documentary is a history of the beginnings of Freedom House Ambulance Service and the successes that made it a paradigm of Emergency Medical Care throughout the US.  You will meet the men and women who worked together at Freedom House during those initial exciting and challenging years.    The final story of the demise of Freedom House is also told though the eyes and words of those who were there and experienced it.                    
  • In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970.7
  • "Nearly 40 years ago, there was no Medic One and there were no paramedics in King County. But two forward thinking physicians (Dr. Michael Copass and Dr. Leonard Cobb), and the Seattle Fire Chief at the time (Gordon Vickery), had the idea that perhaps firefighters could be taught some of the same skills that doctors used to save people who were seriously injured or ill, and could apply these skills in a person's home or in the street where their accident occurred. But this was a rather radical concept, and many people resisted it. In spite of this, in 1970, the Seattle Fire Department, in cooperation with Harborview Medical Center and the University of Washington, trained the first class of firefighters as paramedics. The program was quite a success, and later classes soon followed. In 1977, the first paramedics came to work in King County."
  • In Los Angeles, a pilot paramedic program, involving firefighters from only two county fire department rescue squads initially, began under the direction of Ronald Stewart, M.D.9
  • Advocates for Emergency Medical Services is a coalition of major EMS organizations that was founded October 22, 2002 dedicated to promoting, educating and increasing awareness among decision-makers in Washington on issues affecting EMS providers. AEMS supports all providers of EMS, whether they are fire, hospital, volunteer, third service, or nongovernmental based, by monitoring and influencing legislation and regulatory activity involving EMS and raising awareness among lawmakers on issues of importance to EMS.
  • EMS Systems and History

    1. 1. EMS SystemsChapter 1Chapter 1
    2. 2. • This textbook is the primary resource forthe AEMT course.• EMS is a system.• This chapter discusses:– That system’s key components– How they influence and affect AEMTs– Administration, medical direction, qualitycontrol, and regulation of EMS services– Roles and responsibilities of AEMTsIntroduction
    3. 3. • Emergency medical services (EMS)– Team of health care professionals– Provides prehospital emergency care andtransport for the sick and injured– Part of a local or regional EMS system– Governed by state laws and typicallyregulated by a state EMS office• People who provide emergency care,except licensed physicians, must bestate-licensed or certified.Course Description
    4. 4. Course Description• levels:– EMR, formerlyfirst responder– EMT, formerlyEMT-Basic– AEMT, formerlyEMT-I– Paramedic,formerly EMT-ParamedicSource: © Corbis
    5. 5. Course Description• EMRs have verybasic training.– Provides care beforeambulance arrives– May assist withinambulance• EMTs have training inbasic life support(BLS), including:– Automated externaldefibrillation– Airway adjuncts– Assistance withcertain medications
    6. 6. Course Description• AEMTs have training in specific aspectsof advanced life support (ALS), including:– Intravenous (IV) therapy– Administration of certain emergencymedications
    7. 7. Course Description• Paramedics have extensive ALS training,including:– IV therapy– Pharmacology– Cardiac monitoring– Other advanced assessment andtreatment skills
    8. 8. Course Description• AEMT role and former EMT-I roles:– Formerly, there were two EMT-I curricula.• 1985 and 1999– AEMT role resembles EMT-I 1985 curriculum.• AEMTs do not perform skills that were part ofEMT-I 1999 level training, such as intubation.• AEMTs can assist with administering certainmedications, but not others.
    9. 9. Course Description• Upon completion of this course, youshould be able to take the statecertification exam.• After passing the exam, you are eligibleto apply for licensure.• Almost every state’s requirements followor exceed the guidelines in the currentNHSTA EMS Education Standards.
    10. 10. AEMT Training: Focus andRequirements• AEMTS provide emergency care to thesick and injured.– Some patients are in life-threateningsituations.– Others require only supportive care.– The skills to deliver this care are foundwithin this text.
    11. 11. AEMT Training: Focus andRequirements• Some of the subjects discussed include:– Scene size-up– Patient assessment– Treatment– Packaging– EMS as a career
    12. 12. Licensure Requirements• Requirements differ state to state;general requirements to be an AEMT are:– High school diploma or equivalent– Proof of immunization against certaincommunicable diseases– Valid driver’s license
    13. 13. Licensure Requirements• AEMT requirements (cont’d):– Successful completion of:• BLS/CPR course• State-approved AEMT course• State-approved written certification exam• State-approved practical certificationexam
    14. 14. Licensure Requirements• AEMT requirements (cont’d):– Demonstrated ability to meet mental andphysical criteria to perform the job– Compliance with other state, local, andemployer provisions
    15. 15. • State-recognized written and practicalexam may be the National Registry Exambased on the individual state.– Requires re-registration every 2 years– Most states recognize NREMTcertification– Provides reciprocityLicensure Requirements
    16. 16. Licensure Requirements• Americans With Disabilities Act (ADA)– Protects people with disabilities frombeing denied access to programs andservices provided by state and localgovernments– Prohibits employers from failing to providefull and equal employment to the disabled• States may exclude certain people fromAEMT certification, such as thoseconvicted of certain felonies.
    17. 17. History of EMSOur History and the Lessons WeCan Apply to Our Future
    18. 18. History of EMS• Origins of EMS include:– Volunteer ambulances in WWI– Specially trained field care providers inWWII– Field medic and rapid helicopterevacuation in Korean conflict– Advances in trauma care resulting fromcasualty experiences in Korean andVietnam conflicts
    19. 19. History of EMS• Horse-drawnambulancesintroduced in the CivilWar• Early motorizedambulance
    20. 20. History of EMS• As late as the early 1960s, emergencyambulance service and care variedwidely in the United States.• Modern EMS originated in 1966 with thepublication of Accidental Death andDisability: The Neglected Disease ofModern Society.– Congress mandated federal changes.– DOT published first EMT trainingcurriculum in early 1970s.
    21. 21. Focus of the Emergency Careof the 1950’s and 60’s• Emergency Care ofthe 1950’s and 60’swas presumed tobegin upon arrival atthe hospital• Pre Hospital activitiesfocused only uponspeedy transportation
    22. 22. The Seminal Events that Lead to theFormation of the EMS System• 1950’s, CPR was proven to bebeneficial– Able to be taught to laypeople proven in early 60’s• 1966 Report titled AccidentalDeath and Disability: TheNeglected Disease of ModernSociety.• 1967 meeting of the AmericanMedical Association• National Traffic and MotorSafety Act of 1966• Highway Safety Act of 1966
    23. 23. Miami, Florida (1967)
    24. 24. Freedom House (1967)• Pittsburgh, PA• Founded by PeterSafar and NancyCaroline• Underemployed andunemployed AfricanAmericans
    25. 25. http://www.youtube.com/watch?v=hHUA0E3KYgA
    26. 26. Seattle, Washington (1968)
    27. 27. Moby-Pig
    28. 28. They do it right in Seattle!
    29. 29. And elsewhere..in the land of thedead…
    30. 30. Haywood County, NorthCarolina (1969)
    31. 31. Los Angeles CountyDecember 1969
    32. 32. The National EMS Act of 1973• Provided federal guidelines for EMSSystems• Outlined 15 components of an EMSSystem• Provided Federal funding for additionalprograms
    33. 33. Funding Efforts in the EarlyDays• US Department Health, Education andWelfare allocated 16 million dollars forsystems in 5 states• Robert Wood Johnson Foundationprovides 15 million dollars to fund 44 EMSprojects in 32 states
    34. 34. History of EMS• The AAOS prepared the first EMTtextbook in 1971.– Your textbook is the AEMT level of thatbook.• Through the 1970s, EMS systemdeveloped.
    35. 35. The Paramedic Program isRecognized!• Emergency!
    36. 36. History of EMS• Availability of ALS-level care grew.– Definitions of EMS providers began tovary.– Efforts are underway to standardize levelsof EMS education nationally.
    37. 37. Things that make you goHMMMMM..• QUESTION FOR DISCUSSION:– Is the spread of ALS care a good thing?• Why or Why not?• Is there a down side?
    38. 38. EMS systems
    39. 39. EMS Systems•If you have seen oneEMS System…•…You’ve seen oneEMS system
    40. 40. EMS Models• 3rdService• Fire Service• Law Enforcement• Public Utility• Private For Profit• Hospital Based– HEMS often fall under this model• Industrial• Military/Federal
    41. 41. Levels of Training• Licensure is a statefunction– Creates some variationbetween AEMTs• Federal level:– National EMS Scope ofPractice Modelprovides guidelines forEMS skills at eachlevel.• State level:– Laws regulate EMSprovider operations.• Local level:– Medical directordecides day-to-daylimits.
    42. 42. • Millions of laypeople are trained inBLS/CPR.– Many have taken basic first aid courses.• Designed to provide necessary criticalcare before responders can arrive– Teachers, coaches, babysitters, etc.– People who regularly accompany groupson trips to remote locations are trained infirst aid.Public BLS and Immediate Aid(AKA “First Aid”)
    43. 43. • Detect treatable life-threatening cardiacarrhythmias and deliver appropriateelectrical shock• Designed to be used by untrainedlaypeople• Included in every level of prehospitalemergency trainingPublic Access AutomatedExternal Defibrillators (PA-AEDs)
    44. 44. Emergency Medical Responders(EMR)• In EMS becausepresence of trainedperson on scenecannot be ensured• EMRs include:– Law enforcementofficers– Fire fighters– Park rangers– Ski patrollers– Industrial SettingsCourtesy of Robert Kaufmann/FEMA
    45. 45. Emergency Medical Responders(EMR)• Trained to initiate immediate care andassist other EMS personnel on theirarrival• Good Samaritans trained in first aid andCPR often show up at a scene.– They can provide valuable assistance.– They can also interfere with operationsand endanger themselves and others.– Identify during scene size-up.
    46. 46. Emergency Medical Technicians(EMT)• EMT course requires about 150 hours.– More in some states– Includes the essential knowledge andskills to provide basic emergency care• On arrival at scene, EMT and otherproviders assume responsibility forassessment, care, packaging, andtransport of patient.
    47. 47. Advanced Emergency MedicalTechnicians (AEMT)• AEMT courseprovides knowledgeand skills in specificaspects of limitedALS.• Depending on area,the student is:– Building on EMTtraining– Entry level
    48. 48. Paramedics• Extensive course oftraining– 800 to 1500 hoursor more– May be offeredwithin context ofassociate orbachelor degreeprogram• Wide range of ALSskills
    49. 49. Components of theEMS System• Modern-day EMS system is a complexnetwork of coordinated services.– These services work in unison to meetneeds of the community.– As an AEMT, you are part of this networkand must stay active.
    50. 50. Public Access (EMD and 911)• Easy access to helpin an emergency isessential.• 9-1-1 system isusually the publicsafety access point.– Trained dispatchersobtain informationand dispatchresponders.
    51. 51. EMD and 911• Enhanced 9-1-1 systems provideadditional data, like address, phonenumber of caller.• Training the public on how to summon anEMS unit is an important part of thepublic education responsibility.
    52. 52. EMD and 911• EMD system assists dispatchers in givingcallers instructions until EMS arrival.– Reality of call may differ from dispatchdescription.
    53. 53. • From caller information, dispatcherselects parts of emergency system toactivate.• EMS may be:– Part of fire department– Part of police department– Independent• New technology helps responders locatetheir patients.EMD and 911
    54. 54. Clinical Care andMedical Control
    55. 55. Clinical Care and Operations• You will use a wide range of equipment.• Check equipment before going on duty toensure:– It is in the assigned place.– It is working properly.– You are familiar with the specific model.
    56. 56. Clinical Care and Operations• You may be called on to drive the ambulance.– Become familiar with roads in PSA or sector.– Before going on duty, check:• Equipment and supplies• Communications equipment• Vehicle, for key fluids and condition oftires• Driver’s controls• Built-in units and controls in patientcompartment
    57. 57. Medical Direction andControl• Physician medicaldirector authorizesproviders to givemedical care infield.• Appropriate careis described instanding ordersand protocols.© Andrei Malov/Dreamstime.com
    58. 58. Medical Direction andControl• Medical director acts as liaison amongmedical community, hospitals, and AEMTs.• Medical control can be off-line or online.– Online (direct)• Physician directions given over the phone orradio• Can be communicated by designee (In somestates)– Off-line (indirect)• Standing orders, training, supervision
    59. 59. Legislation and Regulation• Training, protocols, and practice followstate legislation, rules, regulations, andguidelines.– Medical directors, along with EMSsupervisors and others, develop protocolsfor service areas.– EMS services are usually administered bysenior EMS official.– Daily operation and direction of serviceare provided by an appointed chief
    60. 60. Evaluation/CQI• Medical director maintains quality control.– Reviews patient care reports with otherstaff• CQI, also known as QA, reviews andaudits all aspects of an EMS call.– Review meetings are held and feedbackgiven.• Refresher training and continuingeducation is important.– Skill decay can occur.
    61. 61. Evaluation /CQI• Eliminating errors is the goal. For example:– Understand the circumstances and mainsources of errors.– Be aware of your environment.– Handing off patients is a high-risk activity– When you are about to perform a skill, askyourself, “Why am I doing this?”– Use “cheat sheets.” , “Check Lists”– Use downtime to refresh infrequently usedskills.– Discuss troublesome calls with your partner.
    62. 62. Transport to SpecialtyCenters• Some centers focus on specific types ofcare, such as trauma, or specific types ofpatients, such as children.• Transport time may be longer.– But patients will receive definitive caremore quickly.• Know location of specialty centers andprotocol for transport.
    63. 63. Interfacility Transports– Provided tononambulatorypatients or patientsrequiring medicalmonitoring– May be betweenhospitals, skillednursing facilities,home residence– AEMTs are
    64. 64. Working With Hospital Staff• Become familiar with hospital byobserving:– Equipment and how it is used– Functions of staff members– Policies and procedures in emergencyareas• AEMTs may consult medical staff byradio.• Best patient care occurs with rapportbetween all emergency care providers.
    65. 65. Working With Public SafetyAgencies• Some public safetyworkers have EMStraining.– Become familiar withtheir roles andresponsibilities.– They may be betterprepared to performcertain functions.– Best patient care isachieved throughcooperation.Courtesy of MIEMSS
    66. 66. Prevention and PublicEducation• Focus is on public health.– Works to prevent injury by being proactive• EMS works with public health agencieson:– Primary prevention– Secondary prevention• AEMTs may be involved in illness andinjury surveillance.
    67. 67. Prevention and PublicEducation• AEMTs can help educate the public.– One-on-one after an accident– By going to local schools– Working with health care institutions– Teaching people immediate aid skills• Public education increases respect andcan lead to increased funding.
    68. 68. EMS Research• Provides scientific basis for standards– Evidence-based decision making isbecoming an integral part of functioning inEMS.• AEMTs may be involved in researchthrough gathering data.• Important to stay current on latestresearch– Make sure you understand what resultsmean.
    69. 69. Roles and Responsibilitiesof AEMTs
    70. 70. Who would you trust?
    71. 71. Professional Attributes• Integrity• Empathy• Self-motivation• Appearance andhygiene• Self-confidence• Time management
    72. 72. Professional Attributes• Communications• Teamwork and diplomacy• Respect• Patient advocacy• Careful delivery of care
    73. 73. A professional is:• Involved in the profession!• Leads by example first, position second.• Models what the profession should be…
    74. 74. Norris Rule:Norris Rule:• 1) Don’t be a douche!• 2) Don’t make the rest of us look bad!
    75. 75. National Registry ofNational Registry ofEmergency Medical TechniciansEmergency Medical Technicians
    76. 76. NREMT• Non Lobbying• Not a GOVT Entity• NEUTRAL• A certifying agency only• National Minimum Standard andUniformity is ONLY Goal• www.nremt.org
    77. 77. National Association of EMT’s• Lobbying• Medical Malpractice• PHTLS• AMLS• PEPP• www.naemt.org
    78. 78. Advocates for EMS• Advocates for EMS– PAC– Board members include other major EMSorganizations
    79. 79. Patient Interaction• Every patient is entitled to compassion,respect, and the best care.• Remember: whether paid or volunteer,you are a health care professional.– Bound by patient confidentiality• Be familiar with the HIPAA requirements.
    80. 80. • EMS is the system that provides theemergency medical care needed bypeople who have been injured or havean acute medical emergency.• The standards for prehospitalemergency care and the people whoprovide it are governed by the laws ineach state and are typically regulated bya state office of EMS.Summary
    81. 81. • The AEMT course that you are nowtaking will present the information andskills that you will need to pass therequired examination needed to becomea licensed AEMT.• The EMS ambulance is staffed byproviders who have been trained to theEMT, AEMT, or paramedic levelaccording to recommended nationalstandards and have been licensed bythe state.Summary
    82. 82. • An EMT has training in basic emergencycare skills, including automated externaldefibrillation, use of airway adjuncts, andassisting patients with certainmedications.• An AEMT has training in specific aspectsof advanced life support (ALS), such aswith intravenous therapy and theadministration of certain emergencymedications.Summary
    83. 83. • A paramedic has extensive training inALS, including endotracheal intubation,emergency pharmacology, cardiacmonitoring, and other advancedassessment and treatment skills.• When the dispatcher at the 9-1-1emergency communications centerreceives a call for emergency care, he orshe dispatches to the scene thedesignated EMS ambulance squad andany fire, rescue, or police units that maySummary
    84. 84. Summary• Emergency medical responders, such aslaw enforcement officers, fire fighters,park rangers, ski patrollers, or otherorganized rescuers often arrive at thescene before the ambulance andAEMTs.
    85. 85. • Key components of an AEMT’s jobinclude scene size-up, patientassessment, treatment, and packaging.After assessing the scene and thepatient, you will provide the emergencycare and transport that is indicated byyour findings and ordered by yourmedical director in the service’s standingorder protocols or the physician who isproviding online medical direction.Summary
    86. 86. • As an AEMT, you will work in a primaryservice area and will have theresponsibility of ensuring that allequipment and supplies are functionaland ready for use.• Each EMS system has a physicianmedical director who authorizes theproviders in the service to providemedical care in the field. Medical controlis off-line (indirect) or online (direct).Summary
    87. 87. • Continuous quality improvement is acircular system of continuous internaland external reviews and audits of allaspects of an EMS call.• It is important to determine ways toreduce human error by ensuring that youunderstand your protocols, ensuring thatyour environment is organized andfunctional, and acting as a patientadvocate.Summary
    88. 88. Summary• As an AEMT, you will work with many otherprofessionals, including hospital staff andpublic safety personnel. Remember that thebest, most efficient patient care is achievedthrough cooperation among agencies.• EMS research and evidence-based decisionmaking are beginning to have a role infunctioning as an EMS provider. Stay aware ofresearch, and focus patient care onprocedures that have proven useful inimproving patient outcomes.
    89. 89. • AEMT attributes include compassion andmotivation to reduce suffering, pain, anddeath in people who are injured oracutely ill; a desire to provide eachpatient with the best possible care;commitment to obtain the knowledgeand skills that this requires; and the driveto continually increase knowledge, skills,and ability.Summary
    90. 90. REVIEW