Chapter 1: Emergency Medical Services

EMS is the extension of emergency medical care into the prehospital setting. The concept of bringing care to the sick or injured dates back to Roman times. However, today's EMS systems have their roots in legislative and clinical developments of the 1960s and 1970s. The 1966 report "Accidental Death and Disability—The Neglected Disease of Modern Society" highlighted the deficiencies of prehospital care for trauma victims, which were attributable to inadequate equipment and provider training. Up until that time, more than half of ambulance services were run by funeral homes because hearses were among the few vehicles able to transport a stretcher. The National Highway Safety Act of 1966 established the Department of Transportation and made it the lead agency responsible for upgrading EMS systems nationwide.¹

In 1967, J. F. Pantridge began using a physician-staffed mobile coronary care unit in Belfast, Northern Ireland, to extend cardiac care into the prehospital setting. By doing so, he was able to reduce mortality among myocardial infarction patients.² Using physicians to staff ambulances never gained popularity in the United States. However, in the late 1960s and 1970s, nonphysician prehospital personnel in the United States began to learn advanced medical skills, including IV placement, administration of medications, cardiac rhythm interpretation, and defibrillation.³

The U.S. EMS Systems Act of 1973 set aside large federal grants to develop regional EMS systems across the country. Approximately 300 EMS regions were established and became eligible for federal funding. To receive funding, the Act required that EMS systems address 15 key elements (Table 1-1). These elements form the foundation of many EMS systems today.⁴

The 1970s became something of a Golden Age for EMS in the United States. The U.S. Department of Transportation developed curricula for emergency medical technicians, paramedics, and first responders. EMS communications systems were formalized. In 1972, the Federal Communications Commission recommended that 9-1-1 be implemented as the emergency telephone number nationwide. The concept of designated trauma centers within EMS systems was introduced, the idea being that EMS personnel would transport seriously injured patients preferentially to these facilities.

The Omnibus Budget Reconciliation Act of 1981 eliminated direct federal funding for EMS. Instead, federal funds were given to states in the form of block grants. The result was a decrease in overall funding of EMS as well as decreased coordination of EMS systems. EMS systems took on a decidedly local flavor, with great variation between systems within states and across the country. This trend has had long-term consequences for the field.¹

In 2011, the American Board of Emergency Medicine recognized EMS as its seventh subspecialty. The certification examination is based on the Core Content of EMS Medicine⁵ with four major content areas: Clinical Aspects of EMS Medicine, Medical Oversight of EMS, Quality Management and Research, and Special Operations.

A review of the 15 elements of EMS systems identified by the EMS Systems Act of 1973 (Table 1-1) provides insight into the current structure of EMS systems and the challenges they face.

MANPOWER

In most urban areas, paid public safety and ambulance personnel provide prehospital medical care. In contrast, suburban, rural, or wilderness EMS systems commonly use volunteers. Regardless of setting, EMS personnel fall into one of four levels of training, or licensure levels, in accordance with the National EMS Scope of Practice Model, set forth by the National Highway Traffic Safety Administration. These are emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic. Each type of provider must master a minimum set of psychomotor skills. Emergency medical responders are usually first on the scene of a medical emergency. They are trained to perform CPR, spine immobilization, hemorrhage control, use of an automated external defibrillator, and other basic interventions while awaiting an ambulance. Emergency medical technicians function as part of an ambulance crew and are trained to take care of immediate life threats. Skills include oxygen administration; CPR; hemorrhage control; and patient extrication, immobilization, and transportation. They are also trained to assist patients in using some of their own medications and can administer to patients certain over-the-counter medications under medical oversight. Advanced emergency medical technician training includes additional assessment skills plus IV insertion, use of esophageal-tracheal multi-lumen airway devices, and administration of certain medications. Paramedics have the highest skill level, with greater training and broader scope of practice than advanced emergency medical technicians. Because of their advanced level of training, paramedics function under a designated physician's medical license.⁶

TRAINING

Training includes initial provider training and continuing education. As EMS call volume increases, providers often care for a disproportionate number of patients with minor medical issues. Maintaining proficiency in skills needed to manage critically ill patients may be difficult. Innovative training methods to ensure skills retention must be sought. Use of computerized human patient simulators is one option, both for reviewing skills and learning new ones.

COMMUNICATIONS

The adoption of 9-1-1 as a nationwide emergency number in the United States has greatly facilitated public access to emergency medical care. In many systems, the local answering center or public safety answering point has enhanced equipment that provides the number and location of a caller (enhanced 9-1-1). Widespread use of cellular telephones has prompted the development of enhanced technology to identify and locate these callers as well, in accordance with Federal Communications Commission regulations. Emergency call takers are trained to collect the necessary information, dispatch appropriate resources, and offer first aid or prearrival instructions, while the ambulance is en route. Ambulance personnel should also be able to communicate with the destination hospital. Most EMS personnel operate under standing orders and protocols developed by physicians. However, there are times when providers may require online medical control, talking directly with a physician for direction.⁷ Historically, communications represent the weakest link in most disaster responses. It is therefore important that EMS communication systems have built-in redundancy to ensure uninterrupted service.

TRANSPORTATION

Ambulances have evolved from simple transport vehicles into mobile patient care vehicles. Ambulance design must enable EMS personnel to provide airway and ventilatory support while transporting the patient safely. Basic life support ambulances carry equipment appropriate for personnel trained at the emergency medical technician level, such as automated external defibrillators, oxygen, bag-mask ventilation devices, immobilization and splinting devices, and wound dressings. They do not carry medications and cannot transport patients requiring IVs or cardiac monitoring. Advanced life support ambulances are equipped for paramedics or advanced emergency medical technicians with supplies appropriate for their scope of practice, including IV fluids and medications, intubation equipment, cardiac monitors, and pulse oximeters. Ground transportation is appropriate for the majority of patients, especially in urban and suburban areas. However, air transport, generally by helicopter, should be considered for critically ill patients when the ground transport time would be dangerously long or if the terrain is difficult to navigate.⁴

FACILITIES AND CRITICAL-CARE UNITS

Patients are often transported to the closest appropriate hospital. In recent years, the number of specialty hospitals has increased. These include pediatric hospitals, trauma and spinal cord injury centers, burn centers, stroke centers, and centers with advanced cardiac or resuscitation capabilities.⁸ Tertiary care centers, often affiliated with medical schools, provide many of these services and may also have a large number of critical-care unit beds. The decision to bypass hospitals to go directly to a specialty center or a hospital with a large critical-care capacity, often at greater distances, is not a simple one. Although specialty hospitals often have more resources, transporting an unstable patient past an ED to get to the specialty hospital is not without risks. Furthermore, bypassing hospitals may have negative financial consequences for those facilities that are bypassed.¹ It is wise to solicit input from the local, regional, or statewide medical community before developing destination policies involving such specialty centers.

Due to increasing hospital inpatient censuses and ED overcrowding, at a given time, even the largest hospitals may not have adequate resources to care for EMS patients. This may result in prolonged offload times of ambulance patients, long wait times for patients to be seen, and ED boarding of admitted patients. Furthermore, some EDs may request that EMS divert patients to other hospitals.⁹ Because of these issues, regional EMS systems should develop methods to monitor in real-time available resources of their receiving hospitals. A secure, Internet-based Web site of hospital resources, including ED and inpatient bed availability, is one option.

PUBLIC SAFETY AGENCIES

EMS systems should have strong ties with police and fire departments. Many large U.S. EMS systems are run by municipal fire departments. In addition to providing scene security, public safety agencies can provide first responder services because they are often first on the scene. Fire and police automated external defibrillator programs are common.^10,11 In some locations, these have been shown to improve outcomes for cardiac arrest victims. Finally, EMS personnel often provide medical support to police and fire departments in hazardous circumstances.

CONSUMER PARTICIPATION

Public support, both political and financial, is necessary for a good EMS system. It is therefore important that laypersons contribute to the policy-making process. One way to accomplish this is to encourage representation of the general public on the membership of regional EMS councils. In addition, the public can participate by volunteering for local EMS agencies.

ACCESS TO CARE

Successful EMS systems ensure that all individuals have access to emergency care regardless of ability to pay. Often, the EMS system is a patient's primary point of entry into the healthcare system. There should be no barriers or disincentives preventing timely access. A more difficult problem exists when terrain or low population densities result in longer response times for some citizens, as in rural or wilderness areas of the country. Possible solutions include stationing or predeploying ambulances throughout the area with one central dispatching center. Another option is heavier reliance on air medical services.

PATIENT TRANSFER

Patients are often transferred from one medical facility to another for a higher level of care. Safe transfer is an important concept. Many problems can be avoided if the transferring and receiving facilities develop transfer agreements in advance. The Emergency Medical Treatment and Active Labor Act, passed in 1986, sets forth rules that hospitals participating in the Medicare program must adhere to when considering a patient transfer. Under the Emergency Medical Treatment and Active Labor Act, all patients must receive a medical screening exam and be stabilized before transfer is considered. There must also be explicit acceptance of the transfer by the receiving hospital.¹²

COORDINATED PATIENT RECORD KEEPING

Maintaining good medical records is important to any patient encounter. Prehospital medical records need to be legible, intelligible, and readily accessible to hospital providers. Standardization of EMS medical records among different agencies within a region helps to streamline transfer of information between prehospital and hospital providers. The adoption of electronic charting and cloud-based electronic medical record keeping by many EMS systems is a step toward this goal. Electronic charts can be printed out in the receiving ED or downloaded from a secure Internet Web site. Regardless of the charting system used, EMS systems must comply with the stipulations of the U.S. Health Insurance Portability and Accountability Act of 1996, designed to protect the privacy of patient health information.¹³

PUBLIC INFORMATION AND EDUCATION

EMS systems have a responsibility to train the public on how to access EMS and use it appropriately. As EMS call volumes rise and available resources decline, educating the public to use 9-1-1 only for true emergencies is an appropriate goal. However, given the obstacles that many patients encounter in trying to access office- or hospital-based care, conveying this message is not simple. The public needs to know that EMS will always be there when needed.

Another important message that EMS can convey to the public is the importance of learning CPR, first aid, and basic disaster preparedness. The responses to Hurricanes Katrina, Rita, and Irene and other recent disasters illustrated that, at times, the emergency response infrastructure may be so seriously disrupted that it may take hours, if not days, for help to arrive. A public that is adequately prepared and trained will be in a better position to safely await help.¹⁴

REVIEW AND EVALUATION

To ensure proper functioning of an EMS system and high-quality patient care, there must be a process for ongoing review and evaluation. This requires input from personnel involved in day-to-day operations and active involvement of a physician medical director. A continuous quality improvement program should be established to assess system performance and formulate improvements.¹⁵ Routine audits of communications, response times, scene times, and patient care records should be performed. Outcome studies of conditions such as cardiac arrest and trauma may be valuable. However, obtaining such outcomes may be problematic. An unforeseen consequence of the Health Insurance Portability and Accountability Act is that hospitals are often resistant to releasing patient information, even to EMS services, for fear of liability. Solutions to this problem are being investigated.

EMS research is invaluable to evaluate prehospital interventions and develop new ones. It is not valid to assume that what works in the hospital will also work in the prehospital setting. Issues such as limited funding, barriers to obtaining patient outcomes, and obtaining informed consent from critically ill patients, or waivers of consent, can make prehospital research daunting. However, these barriers must be overcome if patients are to receive quality care.¹⁶

DISASTER PLAN

The EMS system is an integral part of disaster preparedness and should be involved in planning along with other agencies and the medical community. The Omnibus Budget Reconciliation Act legislation of 1981 ended direct federal block grants to EMS. Because EMS is often not considered to fall into the category of public safety, emergency preparedness funding for EMS has fallen behind that of police and fire services.¹ Despite this, EMS agencies must maintain a high level of disaster preparedness. This involves having written policies and procedures, stockpiling supplies that may be rapidly depleted in multi-casualty situations, and participating in regional disaster drills with other emergency response agencies and hospitals.¹⁷

MUTUAL AID

EMS services should develop mutual aid agreements with neighboring jurisdictions so that emergency care is available when local agencies are overwhelmed or unable to respond.¹⁸ Depending on the size and resources of the system, mutual aid may be required frequently or only under dire circumstances. Working out in advance details such as reimbursement, credentialing, liability, and chain of command at incident scenes will streamline the process.

The 2006 Institute of Medicine publication Emergency Medical Services at the Crossroads¹ detailed many of the challenges facing EMS. These include fragmentation and lack of interoperability between EMS systems, between EMS and other public safety agencies, and between EMS and the rest of the healthcare infrastructure. These limit the efficiency of EMS systems and may have serious consequences in disaster response. In addition, the fallout from the Omnibus Budget Reconciliation Act legislation of 1981 is still being felt. Funding for EMS continues to fall behind other public safety agencies, both for day-to-day operations and for emergency preparedness. Also, restructuring of how Medicare pays for advanced life support and basic life support services jeopardizes reimbursements. Therefore, many EMS agencies must either find other funding sources or cut services. This is occurring at a time when call volumes are rising in many parts of the country, in part due to the aging of the population and limited access to health care.¹

Although demand for EMS steadily grows, in many parts of the country EMS staffing is not keeping pace. Factors such as low pay, high stress, and limited advancement opportunities cause high turnover rates among providers. As the length of EMS training curricula increases, alternative careers in health care may appear more appealing.¹⁹ Many EMS systems are currently experiencing real or perceived paramedic shortages, prompting them to look at alternative staffing configurations or resource deployment.

As a consequence of funding and staffing constraints amid increasing call volumes, many EMS systems routinely operate at full capacity. As a result, their surge capacity, or ability to accommodate a sudden, large increase in demand for services, is limited. Surge capacity is determined by a system's staffing capabilities, its available resources, and the ability of its organizational structure to react effectively to the increased demand. To enhance surge capacity, EMS systems need funding for additional personnel, vehicles, and stockpiles of supplies that can be readily deployed. They must also participate in frequent training that is realistic and based on those threats they are most likely to encounter.^20,21,22,23

Despite the many challenges EMS faces, the quality of care provided by EMS personnel continues to improve, driven in part by EMS research. Some of the advances involve regionalization of care, resuscitation of cardiac arrest victims, and management of ST-elevation myocardial infarction patients. The quality of cardiac arrest studies has been enhanced by adoption of the Utstein template for data reporting. Developed in 1990, the Utstein style presents a systematic and standardized format for reporting cardiac arrest data. This facilitates the comparison of results of studies performed in different EMS systems.²⁴ The importance of basic life support skills in cardiac arrest and other emergencies is being rediscovered. Basic interventions in some cases can have a greater impact on outcome than advanced life support skills. More widespread use of automated external defibrillators by first responders and the public has the potential to increase rates of resuscitation in cardiac arrest. The emphasis on high-quality, uninterrupted CPR, as set forth by the international 2007 guidelines for CPR and emergency cardiovascular care,²⁵ is widely reflected in EMS protocols across the United States.^26,27 Automatic chest compression devices and devices that provide instant feedback on the quality of CPR are being introduced in the prehospital setting.²⁸ Some EMS systems are beginning to induce hypothermia in resuscitated cardiac arrest patients.^29,30 Prehospital use of 12-lead electrocardiograms on patients with chest pain is becoming common.^31,32,33,34 Some systems transmit electrocardiograms to receiving EDs. Others activate cardiac catheterization labs directly when an ST-elevation myocardial infarction is identified on electrocardiogram.

EMS is maturing as an important subspecialty of emergency medicine in the United States and abroad. Growing populations and increased urbanization are driving the development of EMS systems worldwide.^35,36 The aftermath of the 2004 Asian tsunami emphasized the need for organized and effective prehospital care in developing countries, as well as for international cooperation among EMS agencies.^37,38 Although EMS systems in some countries are very similar to those in the United States, in other countries, differences in geography, healthcare system design, funding, and political structure present unique challenges and the potential for novel solutions. These developing EMS systems have the advantage of not being encumbered by decades of tradition, so they can take advantage of lessons learned elsewhere. They also present the opportunity for collaboration on international research initiatives that can lead to improved patient outcomes.³⁹