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History of The
Emergency
Medical
Services
System by
Troy W. Pennington DO, MS, FAAEM
EMS Director- ARMC
Stethoscope Invented 1816
By
Rene Theophile Hyacinthe Laennec
Ancient Times
First “protocols” established in
Mesopotamia. Evidence of medications,
patient assessment techniques, and
bandages.
18th & 19th Centuries
First efforts of field care developed by
one of Napoleon’s surgeons.
Triage, a method of sorting patients by
severity, developed.
•-Rule 4 - "To Excite Inspiration - During the
employment of the above method excite the
nostrils with snuff or smelling salts, tickle the
throat with a feather. Rub the chest and face
briskly, and dash cold and hot water alternately
on them."
Rule 5 - "To Induce Circulation and Warmth -
Wrap the patient in dry blankets and commence
rubbing the limbs upwards firmly and
energetically. The friction must be continued
under the blankets or over the dry clothing.
Promote the warmth of the body by the
application of hot flannels, bottles or bladders of
hot water, heated bricks etc., to the armpits, the
pit of the stomach, between the thighs and the
soles of the feet.”
•"On the restoration of life, when the power of
swallowing has returned, a teaspoon of warm
water, small quantities wine, warm brandy and
water, or coffee should be given. The patient
should be kept in bed and a disposition to sleep
encouraged. During reaction, large mustard
plasters to the chest and below the shoulders will
greatly relieve the distressed breathing."
Peter Shepherd, M.B. "Surgeon Major"
Army Medical Department
Associate of the Order of St. John of Jerusalem
Rule 1 - "To Maintain a Free Entrance of Air into the
Windpipe - Cleanse the mouth and nostrils; open the
mouth; draw forward the patient's tongue, and keep it
forward: an elastic band over the tongue and chin will
answer the purpose. Remove all tight clothing from
about the neck and chest."
Rule 2 - "To Adjust the Patient's Position - Place the
patient on his back on a flat surface, inclined a little
from the feet upwards; raise and support the head and
shoulders on a small firm cushion or folded article of
dress under the shoulder blades."
Rule 3: Dr. Shepherd goes on to describe the method
of manual artificial respiration developed by Dr. H.R.
Sylvester. To wit:
The procedure should be done "deliberately and
perserveringly, fifteen times a minute, until
spontaneous effort to respire is perceived, immediately
upon which, cease to imitate breathing and proceed to
INDUCE CIRCULATION AND WARMTH."
"Should a warm bath be procurable, the body may be
placed in it up to the neck, continued to imitate
breathing. Raise the body for twenty seconds in a
sitting position, dash cold water against the chest and
face, and pass ammonia under the nose. The patient
should not be kept in a warm bath for longer than five
to six minutes."
1878
TREATMENT TO RESTORE
NATURAL BREATHING AND CIRCULATION
6
Ambulance as a specialized
Vehicle
Ambulances
Volantes
 Designed by
Dominique Jean
Larrey (1766-1842)
 Napoleon
Bonaparte’s Chief
Physician.
7
First Know Hospital-Based
Ambulance Service
Cincinnati General-1865
Soon Followed by other services
Bellevue Hospital- New York
1869
Carrying equipment such as:
morphine, brandy, stomach
pump, splints
7
1900’s Early Horse-Drawn
Ambulance in Florida
The first motorized ambulance is said to have been
provided by Michael Reese Hospital of Chicago in
1899.
Michael Reese Hospital Chicago
1899
Followed in 1900 by New York City...
Both of these ambulances were electrically powered
with 2hp motors on the rear axle.
An Early Motorized Ambulance
11
The Incomparable White
1908
Resuscitation
in 1926
20th Century
World Wars I and II and the Vietnam and
Korean conflicts resulted in great
advances inpatient care delivery systems
including transportation and patient care
procedures.
EMS Helicopters
• Invented in the
early 1940’s by
Igor Sikorsky
•Envisioned them
as rescue vehicles
•Expense &
complexity kept
the helicopter in
the military for the
first three decades
15
Korea & Vietnam
More than 20,000 wounded soldiers
transported to emergency care
facilities by Helicopter
During the Vietnam War over
200,00 soldiers transported
Battlefields as a Laboratory
 Korean War
 1. Helicopters first
 used
 2. Rapid
evacuation
 increased
survival
Vietnam
1. Reinforced
value of rapid
transport
2. Early surgery
for trauma
victims
Ambulance Origins in a HEARSE?
1929 Cunningham Ambulance 1936 Cadillac Ambulance
1895 Horse Drawn Hearse
1960 Buick Premier Ambulance
1956 Cadillac
Limousine-Style Ambulance
1962 Cadillac Royal Rescuer
Sold for $11,552.00
1972 Toyota Hearse With Japanese Coach Work
Advances in the 1960’s
CPR & Defibrillation as the new
standard for out-of-hospital
cardiac arrest
The White Paper-1966
Accidental Death and Disability:
The Neglected Disease of Modern
Society
0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)
Circulatory
Phase
Electrical
Phase
Metabolic
Phase
Shock CPR ?
Importance of CPR
Three-Phase Model
Important Points
Rate
Depth
Release
Five key
aspects
to Great
CPR
!
Uninterrupted
Ventilation
1966
The National Highway Safety Act
established the Department of
Transportation which provided grants
for EMS
1969
The EMT-Ambulance program was
made public. The first paramedic
curriculum followed in 1977.
1970 California’s
Wedworth-Townsend
Paramedic Act
 First official definition under the law, the Act
listed them as “Mobile Intensive Care
Paramedics”
 Funding came principally from two federal
agencies. The U.S. Department of Health,
Education and Welfare (DHEW) and the U.S.
Department of Transportation (DOT)... they
opted to use the word paramedic
4 Certification Levels
 First Responder
 Emergency Medical Technician-Basic
 Emergency Medical Technician-Intermediate
 Emergency Medical Technician-Paramedic
First
Responder
 The First Responder
is Usually the First
EMS-trained
Provider to Arrive on
the Scene
EMT-I
 The EMT-I Should
Possess All the
Skills of an EMT-B
and Be Competent
in Advanced
Airway, IV Therapy,
and Other Skills.
EMT-B
The EMT-Basic is
trained to do all that
a first responder
can do, plus other
complex skills
Basic Life Support
(BLS)
…Refers to the basic life-
saving procedures such as
artificial ventilation and
cardiopulmonary
resuscitation.
EMT-P
 The most advanced provider, includes all basic and
advanced life support techniques, plus numerous
medications and special skills such as intubation,
intraosseous infusions, needle decompression of
tension pneumothorax and surgical airway.
Advanced Life Support
(ALS)
 …Refers to advanced life-saving
procedures such as intravenous therapy,
drug therapy, intubation, and defibrillation.
 Some systems are tiered in which BLS
arrives first and then, if required, ALS
arrives later.
A Type-I Ambulance
Type II Ambulance
A Type III Ambulance
Online Medical Direction
 The Medical Director /
MICN can provide on-
line guidance to EMS
personnel in the field.
This is known as on-
line medical direction.
Off-Line Medical
Direction
 Off-line medical direction refers
to medical policies, procedures,
and practices that medical
direction has set up in advance of
a call, such as standard protocols
or standing orders
1978- Emergency Medicine
recognized as the 23rd Medical
Speciality
AmerAA -1979
The Paramedics International Magazine
became JEMS...The Journal of
Emergency Medical
1980
ABEM- began conducting
certifying exams
National Registry of EMT’s
approved a standizardied Exam
for EMT’s
Regan Elected
March 1981
Regan Shot
1981 Block Grants by States to
administer EMS Funds
Did the Trauma System Success in
saving Regan’s Life change the funding
in EMS Development Program
Emergency Medical Dispatch-1981
Dr. Jeff Klauson- February 1981
 Emergency Medical Dispatcher
Hyatt Hotel
Jack Stout- 1983
 System Status Management
 changed economics of working the streets
 1982- Personal computers just starting
Emergency Medical Dispatcher
(EMD)
 The activities of an EMD are
crucial to the efficient
operation of EMS. EMDs not
only send ambulances to
scenes, they also make sure
that system resources are in
constant readiness. EMDs
must be medically and
technically trained.
Hyatt Hotel
Walkway Collaspes
AIDS- Reacting to the threat
CLEAR- “Shocking at 360”
November 1983- a statement from a
group of esteemed cardiologists working
with the Physio Control Company
supporting the use of AED’s & SAED’s
in the prehospital setting.
1985
National Association of EMS Physicians
 Increased number of homeless stress EMS
system
1987- Electronic tracking of EMS
vehicles
1989- Regulation of tools & Devices in
EMS
MAST Pants Challenged
American Heart Association
Chain of Survival
 Early Access… Dial 9-1-1
 Early CPR
 Early Defibrillation
 Early ACLS
High-quality CPR saves lives!!High-quality CPR saves lives!!
 ““PUSH IT HARD & PUSH IT FASTPUSH IT HARD & PUSH IT FAST””
 OrOr
 in the words of the infamousin the words of the infamous

 saltsalt ‘‘nn’’ pepapepa
Importance of CPR
“Priming the Pump”
1990’s
The Trauma Care Systems planning
and development Act
 Barely enough funding to support
Attempt at bombing the World Trade
Center
 One of the biggest challenges seen by an
EMS system up to that point
The Sleeping Giant- Awakens
Fire Service begins to embrace
medicine
American Medical Response
August 1992- four private ambulance
company’s joined together and began to
sell stock through the NYSE...
 This sparked a consolidation of the Nation’s
private ambulance company’s
1992
The Los Angeles Riot’s
1992
Oklahoma City Bombing 1995
Casino AED Programs
 Very rapid response (< 3 mins)
 Amazing survival rates : 53%
 N=105 WITH V-FIB
 Security with AEDs with BLS
 90 were witnessed arrests
 Valenzuela TD et al, NEJM Oct 2000
Airport PAD Programs
 LAX, Chicago, others
 3 airports in report from Chicago…
 Prominently placed cabinets with automatic dispatch
alarm and public service announcement
 2 year study: 26 AED uses by Good Samaritans
 61% of non-traumatic arrests LIVED TO D/C
 $7000 per life saved
 Caffrey SL et al, NEJM 347 (16) : 1242 Oct 17, 2002
September
11, 2001
The World
Trade Center
& The
Pentagon
Hurricane Katrina 2005
The Largest natural Disaster in the history of
the United States, with damage estimates
well in excess of 100 billion dollars.htt
Hurricane Katrina
The Astrodome in Houston
Scott Paraznyski
Hurricane Katrina
AEDs for children
Sudden witnessed collapse in a child
 Call 911 immediately
 AED asap
Unwitnessed
 AED/Call after 2 minutes of CPR
“Child” energy dose
 2J/kg initial…subsequent 4j/kg
SAN
BERNARDINO
COUNTY
PROTOCOLS
Protocols are designed
around the four “T’s” of
emergency care
Triage
Treatment
Transport
Transfer
Patient Triage – START Triage
The START system is based upon three
simple parameters.
• Respirations ( > or < 30 per minute)
• Perfusion (Capillary Refill > or < 2 seconds)
• Mental Status (Follow simple commands)
ICEMA Region
Inland Counties Emergency
Medical Agency
Base Hospitals- San Bernardino County
 Arrowhead Regional Medical Center
 Chino Valley Medical Center
 Hi-Desert Medical Center
 Loma Linda University Medical Center
 Redlands Community Hospital
 San Antonio Community Hospital
ICEMA Region
Inland Counties Emergency
Medical Agency
Inyo County
 Northern Inyo Hospital
Mono County
 Mammoth Hospital
ICEMA Region
Inland Counties Emergency
Medical Agency
Trauma Centers...WE HAVE
TWO!
 ARMC...ACS Accredited LEVEL 2
 Loma Linda...LEVEL 1
STEMI Centers...We Have
FIVE
 Loma Linda Regional Medical Center
 San Antonio Community Hospital (SACH)
 St. Bernardines Hospital
 Pomona Valley Hospital
 St. Mary’s
ICEMA RegionInland Counties
Emergency Medical Agency
EMCC
Emergency Medical Care
Committee
The EMCC is a platform for the
diverse groups and individuals which
form our Emergency Medical Services
System. They serve as an advisory
group for the Board of Supervisors.
MAC
Medical Care Committee
The MAC is made up of representatives
of our local health care system-
Including, base hospital physicians,
nurses, paramedics, medical educators.
 The MAC committee helps set the
guidelines for field EMS operations and
acts as an advisory board to the EMCC.
EMS Requirements...
As A Resident
During your EMS Rotation:
 EIGHT Ride-Alongs
 Public Fire Departments...SBCFD, Rialto, etc.
 Private Ambulance Companies...AMR,etc.
 Optional Flights with Mercy Air or Sheriffs Air
 Ride Along with Sheriff’s Department Major Enforcement
Teams
 Eight Hour orientation to the Base Station operations
 One Lecture during your EMS rotation weeks
 Review EMS pertinent Literature
Two other Assigned EMS Lectures Per
Year
The DEER
THANK YOU
 Questions?
 You can contact me at:
 troypenn@aol.com
 1-951-544-5433

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History of EMS

  • 1. 1 History of The Emergency Medical Services System by Troy W. Pennington DO, MS, FAAEM EMS Director- ARMC
  • 2. Stethoscope Invented 1816 By Rene Theophile Hyacinthe Laennec
  • 3. Ancient Times First “protocols” established in Mesopotamia. Evidence of medications, patient assessment techniques, and bandages.
  • 4. 18th & 19th Centuries First efforts of field care developed by one of Napoleon’s surgeons. Triage, a method of sorting patients by severity, developed.
  • 5. •-Rule 4 - "To Excite Inspiration - During the employment of the above method excite the nostrils with snuff or smelling salts, tickle the throat with a feather. Rub the chest and face briskly, and dash cold and hot water alternately on them." Rule 5 - "To Induce Circulation and Warmth - Wrap the patient in dry blankets and commence rubbing the limbs upwards firmly and energetically. The friction must be continued under the blankets or over the dry clothing. Promote the warmth of the body by the application of hot flannels, bottles or bladders of hot water, heated bricks etc., to the armpits, the pit of the stomach, between the thighs and the soles of the feet.” •"On the restoration of life, when the power of swallowing has returned, a teaspoon of warm water, small quantities wine, warm brandy and water, or coffee should be given. The patient should be kept in bed and a disposition to sleep encouraged. During reaction, large mustard plasters to the chest and below the shoulders will greatly relieve the distressed breathing." Peter Shepherd, M.B. "Surgeon Major" Army Medical Department Associate of the Order of St. John of Jerusalem Rule 1 - "To Maintain a Free Entrance of Air into the Windpipe - Cleanse the mouth and nostrils; open the mouth; draw forward the patient's tongue, and keep it forward: an elastic band over the tongue and chin will answer the purpose. Remove all tight clothing from about the neck and chest." Rule 2 - "To Adjust the Patient's Position - Place the patient on his back on a flat surface, inclined a little from the feet upwards; raise and support the head and shoulders on a small firm cushion or folded article of dress under the shoulder blades." Rule 3: Dr. Shepherd goes on to describe the method of manual artificial respiration developed by Dr. H.R. Sylvester. To wit: The procedure should be done "deliberately and perserveringly, fifteen times a minute, until spontaneous effort to respire is perceived, immediately upon which, cease to imitate breathing and proceed to INDUCE CIRCULATION AND WARMTH." "Should a warm bath be procurable, the body may be placed in it up to the neck, continued to imitate breathing. Raise the body for twenty seconds in a sitting position, dash cold water against the chest and face, and pass ammonia under the nose. The patient should not be kept in a warm bath for longer than five to six minutes." 1878 TREATMENT TO RESTORE NATURAL BREATHING AND CIRCULATION
  • 6. 6 Ambulance as a specialized Vehicle Ambulances Volantes  Designed by Dominique Jean Larrey (1766-1842)  Napoleon Bonaparte’s Chief Physician.
  • 7. 7 First Know Hospital-Based Ambulance Service Cincinnati General-1865 Soon Followed by other services Bellevue Hospital- New York 1869 Carrying equipment such as: morphine, brandy, stomach pump, splints 7
  • 9. The first motorized ambulance is said to have been provided by Michael Reese Hospital of Chicago in 1899. Michael Reese Hospital Chicago 1899 Followed in 1900 by New York City... Both of these ambulances were electrically powered with 2hp motors on the rear axle.
  • 10. An Early Motorized Ambulance
  • 13. 20th Century World Wars I and II and the Vietnam and Korean conflicts resulted in great advances inpatient care delivery systems including transportation and patient care procedures.
  • 14. EMS Helicopters • Invented in the early 1940’s by Igor Sikorsky •Envisioned them as rescue vehicles •Expense & complexity kept the helicopter in the military for the first three decades
  • 15. 15 Korea & Vietnam More than 20,000 wounded soldiers transported to emergency care facilities by Helicopter During the Vietnam War over 200,00 soldiers transported
  • 16. Battlefields as a Laboratory  Korean War  1. Helicopters first  used  2. Rapid evacuation  increased survival Vietnam 1. Reinforced value of rapid transport 2. Early surgery for trauma victims
  • 17. Ambulance Origins in a HEARSE?
  • 18. 1929 Cunningham Ambulance 1936 Cadillac Ambulance 1895 Horse Drawn Hearse
  • 19. 1960 Buick Premier Ambulance 1956 Cadillac Limousine-Style Ambulance 1962 Cadillac Royal Rescuer Sold for $11,552.00
  • 20.
  • 21. 1972 Toyota Hearse With Japanese Coach Work
  • 22. Advances in the 1960’s CPR & Defibrillation as the new standard for out-of-hospital cardiac arrest The White Paper-1966 Accidental Death and Disability: The Neglected Disease of Modern Society
  • 23. 0 2 4 6 8 10 12 14 16 18 20 Arrest Time (min) Circulatory Phase Electrical Phase Metabolic Phase Shock CPR ? Importance of CPR Three-Phase Model
  • 24. Important Points Rate Depth Release Five key aspects to Great CPR ! Uninterrupted Ventilation
  • 25. 1966 The National Highway Safety Act established the Department of Transportation which provided grants for EMS
  • 26. 1969 The EMT-Ambulance program was made public. The first paramedic curriculum followed in 1977.
  • 27. 1970 California’s Wedworth-Townsend Paramedic Act  First official definition under the law, the Act listed them as “Mobile Intensive Care Paramedics”  Funding came principally from two federal agencies. The U.S. Department of Health, Education and Welfare (DHEW) and the U.S. Department of Transportation (DOT)... they opted to use the word paramedic
  • 28.
  • 29. 4 Certification Levels  First Responder  Emergency Medical Technician-Basic  Emergency Medical Technician-Intermediate  Emergency Medical Technician-Paramedic
  • 30. First Responder  The First Responder is Usually the First EMS-trained Provider to Arrive on the Scene
  • 31. EMT-I  The EMT-I Should Possess All the Skills of an EMT-B and Be Competent in Advanced Airway, IV Therapy, and Other Skills.
  • 32. EMT-B The EMT-Basic is trained to do all that a first responder can do, plus other complex skills
  • 33. Basic Life Support (BLS) …Refers to the basic life- saving procedures such as artificial ventilation and cardiopulmonary resuscitation.
  • 34. EMT-P  The most advanced provider, includes all basic and advanced life support techniques, plus numerous medications and special skills such as intubation, intraosseous infusions, needle decompression of tension pneumothorax and surgical airway.
  • 35. Advanced Life Support (ALS)  …Refers to advanced life-saving procedures such as intravenous therapy, drug therapy, intubation, and defibrillation.  Some systems are tiered in which BLS arrives first and then, if required, ALS arrives later.
  • 38. A Type III Ambulance
  • 39. Online Medical Direction  The Medical Director / MICN can provide on- line guidance to EMS personnel in the field. This is known as on- line medical direction.
  • 40. Off-Line Medical Direction  Off-line medical direction refers to medical policies, procedures, and practices that medical direction has set up in advance of a call, such as standard protocols or standing orders
  • 41. 1978- Emergency Medicine recognized as the 23rd Medical Speciality AmerAA -1979 The Paramedics International Magazine became JEMS...The Journal of Emergency Medical
  • 42. 1980 ABEM- began conducting certifying exams National Registry of EMT’s approved a standizardied Exam for EMT’s Regan Elected
  • 43. March 1981 Regan Shot 1981 Block Grants by States to administer EMS Funds Did the Trauma System Success in saving Regan’s Life change the funding in EMS Development Program
  • 44. Emergency Medical Dispatch-1981 Dr. Jeff Klauson- February 1981  Emergency Medical Dispatcher Hyatt Hotel Jack Stout- 1983  System Status Management  changed economics of working the streets  1982- Personal computers just starting
  • 45. Emergency Medical Dispatcher (EMD)  The activities of an EMD are crucial to the efficient operation of EMS. EMDs not only send ambulances to scenes, they also make sure that system resources are in constant readiness. EMDs must be medically and technically trained.
  • 47. AIDS- Reacting to the threat
  • 48. CLEAR- “Shocking at 360” November 1983- a statement from a group of esteemed cardiologists working with the Physio Control Company supporting the use of AED’s & SAED’s in the prehospital setting.
  • 49. 1985 National Association of EMS Physicians  Increased number of homeless stress EMS system 1987- Electronic tracking of EMS vehicles 1989- Regulation of tools & Devices in EMS MAST Pants Challenged
  • 50. American Heart Association Chain of Survival  Early Access… Dial 9-1-1  Early CPR  Early Defibrillation  Early ACLS
  • 51. High-quality CPR saves lives!!High-quality CPR saves lives!!  ““PUSH IT HARD & PUSH IT FASTPUSH IT HARD & PUSH IT FAST””  OrOr  in the words of the infamousin the words of the infamous   saltsalt ‘‘nn’’ pepapepa
  • 53. 1990’s The Trauma Care Systems planning and development Act  Barely enough funding to support Attempt at bombing the World Trade Center  One of the biggest challenges seen by an EMS system up to that point
  • 54. The Sleeping Giant- Awakens Fire Service begins to embrace medicine
  • 55. American Medical Response August 1992- four private ambulance company’s joined together and began to sell stock through the NYSE...  This sparked a consolidation of the Nation’s private ambulance company’s
  • 56. 1992
  • 57. The Los Angeles Riot’s 1992
  • 59. Casino AED Programs  Very rapid response (< 3 mins)  Amazing survival rates : 53%  N=105 WITH V-FIB  Security with AEDs with BLS  90 were witnessed arrests  Valenzuela TD et al, NEJM Oct 2000
  • 60. Airport PAD Programs  LAX, Chicago, others  3 airports in report from Chicago…  Prominently placed cabinets with automatic dispatch alarm and public service announcement  2 year study: 26 AED uses by Good Samaritans  61% of non-traumatic arrests LIVED TO D/C  $7000 per life saved  Caffrey SL et al, NEJM 347 (16) : 1242 Oct 17, 2002
  • 61. September 11, 2001 The World Trade Center & The Pentagon
  • 62. Hurricane Katrina 2005 The Largest natural Disaster in the history of the United States, with damage estimates well in excess of 100 billion dollars.htt
  • 64.
  • 65.
  • 66.
  • 67.
  • 68.
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
  • 74.
  • 75. The Astrodome in Houston
  • 77.
  • 79. AEDs for children Sudden witnessed collapse in a child  Call 911 immediately  AED asap Unwitnessed  AED/Call after 2 minutes of CPR “Child” energy dose  2J/kg initial…subsequent 4j/kg
  • 81. Protocols are designed around the four “T’s” of emergency care Triage Treatment Transport Transfer
  • 82. Patient Triage – START Triage The START system is based upon three simple parameters. • Respirations ( > or < 30 per minute) • Perfusion (Capillary Refill > or < 2 seconds) • Mental Status (Follow simple commands)
  • 83. ICEMA Region Inland Counties Emergency Medical Agency Base Hospitals- San Bernardino County  Arrowhead Regional Medical Center  Chino Valley Medical Center  Hi-Desert Medical Center  Loma Linda University Medical Center  Redlands Community Hospital  San Antonio Community Hospital
  • 84. ICEMA Region Inland Counties Emergency Medical Agency Inyo County  Northern Inyo Hospital Mono County  Mammoth Hospital
  • 85. ICEMA Region Inland Counties Emergency Medical Agency Trauma Centers...WE HAVE TWO!  ARMC...ACS Accredited LEVEL 2  Loma Linda...LEVEL 1
  • 86. STEMI Centers...We Have FIVE  Loma Linda Regional Medical Center  San Antonio Community Hospital (SACH)  St. Bernardines Hospital  Pomona Valley Hospital  St. Mary’s ICEMA RegionInland Counties Emergency Medical Agency
  • 87. EMCC Emergency Medical Care Committee The EMCC is a platform for the diverse groups and individuals which form our Emergency Medical Services System. They serve as an advisory group for the Board of Supervisors.
  • 88. MAC Medical Care Committee The MAC is made up of representatives of our local health care system- Including, base hospital physicians, nurses, paramedics, medical educators.  The MAC committee helps set the guidelines for field EMS operations and acts as an advisory board to the EMCC.
  • 89. EMS Requirements... As A Resident During your EMS Rotation:  EIGHT Ride-Alongs  Public Fire Departments...SBCFD, Rialto, etc.  Private Ambulance Companies...AMR,etc.  Optional Flights with Mercy Air or Sheriffs Air  Ride Along with Sheriff’s Department Major Enforcement Teams  Eight Hour orientation to the Base Station operations  One Lecture during your EMS rotation weeks  Review EMS pertinent Literature Two other Assigned EMS Lectures Per Year
  • 91. THANK YOU  Questions?  You can contact me at:  troypenn@aol.com  1-951-544-5433

Editor's Notes

  1. 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.[22][23][24] 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.[23] These &amp;apos;flying ambulances&amp;apos; were first used by Napoleon&amp;apos;s Army of the Rhine is 1793. Larrey subsequently developed similar services for Napoleon&amp;apos;s other armies, and adapted his ambulances to the conditions, including developing a litter which could be carried by a camel for a campaign in Egypt.[23]
  2. Hospital based services begin The first known hospital based ambulance service was based out of Commercial Hospital, Cincinnati , Ohio (now the Cincinnati General) by 1865.[19] This was soon followed by other services, notably the New York service provided out of Bellvue Hospital. Edward Dalton, a former surgeon in the Union Army , was charged with creating a hospital in lower New York, and his experiences from war lead him to start an ambulance service to bring the patients to the hospital faster and in more comfort, which started in 1869. He claimed the service was the first of its kind, being unaware of the work in Cincinnati four year earlier. (VM DIRECTORS NOTE: Bellevue was in fact the first MUNICIPAL Hospital based service in the U.S.) These ambulances carried medical equipment, such as splints, a stomach pump, morphine , and brandy , reflecting contemporary medicine. Dalton believed that speed was of the essence, and horses were left harnessed, being attached to the ambulance by a &amp;apos;drop&amp;apos; or &amp;apos;snap&amp;apos; harness , meaning they were ready to go within 30 seconds of being called. The scene was very popular, and it&amp;apos;s fame spread – During the year 1870, the ambulances attended 1401 emergency calls, but twenty one years later, this had more than tripled to 4392.[19] By the turn of the century, interns accompanied New York City ambulances, treated patients on scene, and often left them at home.[20] In 1867, the city of London &amp;apos;s Metropolitan Asylums Board , in the United Kingdom , received six horse-drawn ambulances for the purpose of conveying smallpox and fever patients from their homes to a hospital. These ambulances were designed to resemble private carriages, but were equipped with rollers in their floors and large rear doors to allow for a patient, lying on a specially designed bed, to be easily loaded. Space was provided for an attendant to ride with the patient, and the entire patient compartment was designed to be easily cleaned and decontaminated. Anyone willing to pay the cost of horse hire could summon the ambulance by telegram or in person.[21] Dedicated services begin In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London.[22] It was modeled on a military-style command and discipline structure. The St John Ambulance Association had already been teaching first aid to the public for 10 years prior to that.[22] National or state based branches of St John Ambulance now provides ambulance and first aid services in many countries around the world. [23] In Queensland , a state in Australia , military medic Seymour Warrian called a public meeting in Brisbane and established an ambulance service after witnessing an event at the Brisbane showgrounds during Show Week in 1892.[24] A fallen rider, suffering a broken leg was walked off the field by well meaning but misguided bystanders, worsening his injury. As a result of the meeting, the Queensland Ambulance Transport Brigade was formed on the 12th September.[24] The first ambulance station in Queensland operated out of the Brisbane Newspaper Company and officers on night duty slept on rolls of newspaper on the floor. They had a stretcher, but no vehicle and transported patients on foot, although in time, they gained horse drawn stretchers and eventually vehicles. A year after the establishment of the Brisbane centre, another was established in Charters Towers in north Queensland, growing to over 90 community controlled ambulance centres. In 1991 the independent QATB centres amalgamated to form the Queensland Ambulance Service which is now the fourth largest ambulance service in the world.[24] ***********References 19.   Barkley, Katherine T. 1990. &amp;quot;The Ambulance&amp;quot;. Exposition Press. ISBN 0-682-48983-2 20.  Kuehl, Alexander E. (Ed.). Prehospital Systems and Medical Oversight, 3rd edition. National Association of EMS Physicians. 2002 . @ ch. 1. 21.  Higginbotham, Peter (October 2005). The MAB Land Ambulance Service . Retrieved on 2007 - 06-02 .  22.  St John Ambulance in the Industrial Revolution . St John Ambulance UK. Retrieved on 2007 - 06-16 . 23.  St John Ambulance First Aid Cover for Events . St John Ambulance UK. Retrieved on 2007 - 06-02 . 24.  History of Queensland Ambulance Service. Retrieved on 2007-06-16. Keywords: Bellevue, Dalton,Cincinnatti Last Revision Date: 6/25/07 - 3:05 PM
  3. 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.[24] 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 2hp motors on the rear axle.[24
  4. ORIGINS OF THE NICKNAME &amp;quot;BUS&amp;quot; IN NEW YORK CITY EMS Cross Posted: EMS History; Ambulances; Biographies; By Era; Public Sector ServicesSubmitter/Author: Mark Peck EMT-P, New York City EMS/FDNY EMS In New York City, EMS responds with a Bus BUS, AMBO, RESCUE, RA/RESCUE AMBULANCE, MEAT WAGON, ORANGE &amp; WHITE BUS COMPANY, BIG WHITE TAXI- EVERY REGION HAS ITS OWN SLANG. THE SLANG “BUS” IS A PROUD PART OF NEW YORK CITY AMBULANCE HERITAGE     When I came on the job (another NY term), I too asked why our ambulances were called buses. My partner, with some 30 years experience, told me to go stand in front of the bus and look at it. We were still in the ambulances we called “Bread Boxes”  the step vans based on the Bread delivery trucks popular in the 60’s,with a single front door, and a split windshield that resembled the Transit Authority buses of the 40’s,50’s and 60’s.  He was wrong.                                                                      New York City Department of Hospitals &amp;quot;Bread Box&amp;quot;- Built on an Olson Kurbmaster Jr. body             1958 New York City Transit Authority -General Motors       Past and present members of the FDNY/EMS continue to spread many incorrect myths of the terms origin. Another myth is they are called buses because of the first modular Grumman ambulances the service purchased in 1974. They are not. Most of the NYC buses in the 50’s and 60’s were General Motors. Grumman did not enter the transit bus business until 1978 when they purchased the Flxible Company , and NYC did not purchase a Grumman Flxible until 1980. The entire fleet was found to be defective and the city sued until the entire fleet purchase was returned.New York City Transit and MTA Bus Models Retired Metropolitan Transportation Authority Bus Fleet                                       1980 Grumman Flxible- Metropolitan Transit Authority                                                                                                 The first reliable reference I can find for the use of Bus as an ambulance in NYC dates back to 1903…long before GM, or Grumman. The mode of ambulance propulsion was four legs. If you read the autobiography of Dr. Emily Dunning Barringer- “Bowery to Bellevue, The story of New York’s First Woman Ambulance Surgeon”, you will find it was a common reference to the horse drawn carriage ambulance of the day. How it came into existence is still a mystery, but it is thjought to come from the word omnibus. It is a tradition that has survived more than a century. Its use a celebration of tradition. It honor the ambulance men that came before.      (Random House Historical Dictionary of American Slang, Vol. I A-G) bus n. (...) 2. an automobile or other motor vehicle. 1914 T.A. Dorgan, in Zwilling TAD Lexicon 22: A friend of mine just bought a new car. A flivver...Thats like mine - some bus. 1916 W.J. Robinson At Front 121: The old &amp;apos;bus made the most of what she had. 1917 Imbrie War Ambulance 115: A car was a &amp;quot;buss.&amp;quot; 1917 in Dos Passos 14th Chronicle 92: Our ambulance however is simply peppered with holes - how the old bus holds together is more than I can make out.       If you examine some of the terms for ambulance in use around the country, many exist out of tradition or common use. The use of RESCUE for an ambulance these days is often inaccurate. Most have nothing to do with physical rescue. They carry few if any rescue tools. The term is a holdover from the days when the Fire Department Rescue truck members were the only ones trained in even basic first aid, and carried a Pulmotor or a Reviv a Life or an E&amp;J. They are Trucks or Rigs, because their ancestors were part of the fire service. In many parts of the country, the ambulances were double duty funeral cars, or station wagons. They earned the “Meat wagon” tag because most of their personnel had little medical training and even less equipment. Load and Go was the method of the day.                More information on Dr Dunning:             Dr. Emily Dunning Barringer  Video- Dr. Dunning Riding the Bus( The Girl in White)                   If you would like more information on the history of EMS in New York:             FDNY/New York City EMS History     The Coney Island Ambulance Station Keywords: NYC EMS, FDNY, Bus, Breadbox, Olson Kurbmaster, New York City EMS, nicknames, Emily Dunning, First Woman Ambulance Surgeon, The Girl in White, New York City Department of Hospitals External Resource Link: www.ConeyIslandEMS.com Last Revision Date: 5/5/11 - 0:49 AM
  5. The White Steamers were a popular ambulances among the municipal hospitals operated by the Department of Public Charities serving Brooklyn, Queens and Staten island, as well as the Bellevue and Allied Hospitals serving Manhattan and the Bronx
  6.   New York Gas Light Company was founded in 1823 in New York City, providing a distribution system for both home and streetlight posts. In 1884, six other gas distribution companies joined to form Consolidated Gas Company of NY.      Thomas Alva Edison- The Wizard of Menlo Park- invented the first incandescent light bulb in 1879.  Recognizing the benefit to mankind, as well as the commercial potential, he went on to design and patent an electrical distribution system. In 1878, Edison formed the Edison Electric Light Company in New York City, followed by the Edison Illuminating Company in 1880. On September 4, 1882, Edison switched on his Pearl Street generating station&amp;apos;s electrical power distribution system, which provided 110 volts direct current to 59 customers in lower Manhattan.      By 1920, New York Edison became part of Consolidated Gas  and then in 1936, as electrical use began to significantly replace gaslighting, the name was changed to Consolidated Edison Company of New York, Inc. Con Ed, as it is commonly known to New Yorkers, provides gas, electric, and high pressure steam service to Manhattan buildings.     With the widespresd use of early gas, and then elecric power, came the new life hazards of gas leaks, carbon monoxide poisoning, and electrocution. In an effort to respond to these emergencies, Consolidaed Gas began staffing emergency response units with the Pulmotor Resuscitator.
  7. 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.[26] Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, 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.[27][28]
  8. Advances in the 1960s, especially the development of CPR &amp; 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.[29] In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper.[30] These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. Part of the result was 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), in the equipment (and thus weight) that an ambulance had to carry, and several other factors.
  9. Rather than treating all “shockable” rhythms with direct countershock, the current model of VF arrest suggests that the optimal treatment changes over time. While the treatment for VF in the first 4 minutes is still a shock, very few out of hospital cardiac arrest patients are reached in this phase. The notable exception is witnessed arrest patients, who should always be shocked immediately. The optimal therapy after 10+ minutes, when the metabolic phase is reached, is still unknown. It is worth pointing out that the morphology of VF appears to change over time, which is an observation that most EMS providers have made before.
  10. Background The phrase &amp;quot;chain of survival&amp;quot; was first used as a slogan for the 1988 Conference on Citizen CPR.[3][4] It then appeared in JEMS editorial in August 1989, and the first issue of Currents in Emergency Cardiac Care in 1990.[3] The concept was elaborated in the American Heart Association&amp;apos;s 1992 guidelines for cardiopulmonary resuscitation and emergency cardiac care,[5][6] and then echoed by the International Liaison Committee on Resuscitation (ILCOR) in 1997.[1] [edit] Early access Someone must witness the cardiac arrest and activate the EMS system[1] with an immediate call to the emergency services[7]. [edit] Early CPR In order to be most effective, bystander CPR should be provided immediately after collapse of the patient.[1][8] Properly performed CPR can keep the heart in VF for 10-12 minutes longer.[2] [edit] Early defibrillation Most adults who can be saved from cardiac arrest are in ventricular fibrillation or pulseless ventricular tachycardia.[9] Early defibrillation is the link in the chain most likely to improve survival.[1] Public access defibillation may be the key to improving survival rates in out-of-hospital cardiac arrest,[1] but is of the greatest value when the other links in the chain do not fail.[2] [edit] Early advanced care Early advanced cardiac life support by paramedics is another critical link in the chain of survival.[1] In communities with survival rates &amp;gt; 20%, a minimum of two of the rescuers are trained to the advanced level.[1] In some countries, EMS delivery may be performed by ambulancemen, nurses, or doctors.[2] [edit] See also Cardiac arrest Cardiac Arrest Registry to Enhance Survival Cardiopulmonary resuscitation Defibrillation [edit] References ^ a b c d e f g h i j &amp;quot;Part 12: From Science to Survival - Strengthening the Chain of Survival in Every Community,&amp;quot; Circulation 2000;102:I-358 ^ a b c d e Bossaert LL (1997). &amp;quot;Fibrillation and defibrillation of the heart&amp;quot;. British journal of anaesthesia 79 (2): 203–13. PMID 9349131. ^ a b &amp;quot;The Addition of the Fifth Link in the Chain of Survival to Include Myocardial Infarction,&amp;quot; ChestPainCenters.org, Accessed July 11, 2007. ^ &amp;quot;Chain of Survival: Converting a Nation,&amp;quot; Citizen CPR Foundation, Accessed July 11, 2007. ^ Cummins RO, Ornato JP, Thies WH, Pepe PE (1991). &amp;quot;Improving survival from sudden cardiac arrest: the &amp;quot;chain of survival&amp;quot; concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association&amp;quot;. Circulation 83 (5): 1832–47. PMID 2022039. ^ , (1992). &amp;quot;Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part I. Introduction&amp;quot;. JAMA 268 (16): 2171–83. doi:10.1001/jama.268.16.2171. PMID 1404767. ^ &amp;quot;Strengthening Each Link in the Chain of Survival,&amp;quot; American Heart Association, Accessed July 10, 2007. ^ Eisenberg MS, Bergner L, Hallstrom A (1979). &amp;quot;Cardiac resuscitation in the community. Importance of rapid provision and implications for program planning&amp;quot;. JAMA 241 (18): 1905–7. doi:10.1001/jama.241.18.1905. PMID 430772. ^ &amp;quot;Early Defibrillation,&amp;quot; Circulation 1997;95:2183-2184. [edit] External links &amp;quot;The Links in the Chain of Survival,&amp;quot; American Heart Association &amp;quot;Chain of Survival: Converting a Nation,&amp;quot; Citizen CPR Foundation
  11. These VF tracings demonstrate the priming effect from an electrophysiological perspective. As pointed out with the 3-phase model schematic, the morphology of VF changes as time passed. The VF at 1 min is well within the electrical phase, with greater amplitude and median frequency. After 8 min, the morphology is very different; a shock at this point would likely be unsuccessful in producing return of spontaneous circulation (ROSC). However, after only 90 sec of chest compressions, the morphology looks similar to the “fresh” VF on the left.