EMERGENCY

Emergency medical services

Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves.

Emergency medical services may also be locally known as a paramedic service, a first aid squad, emergency squad, ambulance squad, ambulance service, ambulance corps, or life squad.

The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital. The term emergency medical service evolved to reflect a change from a simple system of ambulances providing only transportation, to a system in which actual medical care is given on scene and during transport. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care. In most places in the world, the EMS is summoned by members of the public via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.

Purpose

Six points on the Star of Life

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the six points, which are used to represent the six stages of high quality pre-hospital care, which are:^[40]

1. Early detection – members of the public, or another agency, find the incident and understand the problem
2. Early reporting – the first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted
3. Early response – the first professional rescuers arrive on scene as quickly as possible, enabling care to begin
4. Good on-scene care – the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident
5. Care in transit – the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
6. Transfer to definitive care – the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Levels of care

A patient arriving at hospital

Emergency Medical Service is provided by a variety of individuals, using a variety of methods. To some extent, these will be determined by country and locale, with each individual country having its own 'approach' to how EMS should be provided, and by whom. In some parts of Europe, for example, legislation insists that efforts at providing advanced life support Mobile Intensive Care Units services must be physician-staffed, while other permit some elements of that skill set to specially trained nurses, but have no paramedics.

Generally speaking, the levels of service available will fall into one of three categories; Basic Life Support, Advanced Life Support, and Critical Care Transport (CCT) by traditional healthcare professionals, meaning nurses and/or physicians working in the pre-hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate Life Support, which is essentially a BLS provider with a moderately expanded skill set, may be present, but this level rarely functions independently, and where it is present may replace BLS in the emergency part of the service. When this occurs, any remaining staff at the BLS level is usually relegated to the non-emergency transportation function. Job titles typically include Emergency Medical Technician, Ambulance Technician, or Paramedic. These ambulance care givers are generally professionals or paraprofessionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it.

Basic life support (BLS)

First responder

A first responder is the first person trained in basic life support who arrives at the scene of an emergency. First responders may be dispatched by the ambulance service, may be passers-by, citizen volunteers, lifeguards, or may be members of other agencies such as the police, fire department, or search and rescue who have some medical training—commonly CPR, basic first aid, and AED use.

Ambulance care assistant

Ambulance Care Assistants have varying levels of training across the world. In many countries, such staff are usually only required to perform patient transport duties, rather than acute care. However, there remain both countries and individual jurisdictions in which economics will not support ALS service, and the efforts of such individuals may represent the only EMS available. Dependent on the provider, they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.

Emergency medical technician

Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I and EMT-Paramedic. The New Educational Standards for EMS renamed the provider levels as follows: EMR, emergency medical responder, EMT, emergency medical technician, AEMT, advanced EMT, and Paramedic. Technicians are usually able to perform a wide range of emergency care skills, such as Automated defibrillation, care of spinal injuries and oxygen therapy. In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more advanced airway procedures, CPAP, and limited cardiac monitoring. Most advanced procedures and skills are not within the national scope of practice for an EMT-B. As such most states require additional training and certifications to perform above the national curriculum standards.

Emergency medical dispatcher

An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

Advanced life support (ALS)

Paramedic

A paramedic has a high level of prehospital medical training and usually involves key skills not performed by technicians, often including cardiac monitoring, tracheal intubation,pericardiocentesis, cardioversion, needle decompression and other skills such as performing a cricothyrotomy. The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification and Critical Care Emergency Medical Transport Program certification.

Critical care paramedic

Recently studies have looked at new level of pre-hospital care. What has developed is the critical care paramedic, also called an advanced practice Paramedic in some parts of USA and Canada. These providers represent a higher level of licensure above that of the DOT or respective paramedic level curriculum. The training, permitted skills, and certification requirements vary from one jurisdiction to the next. These providers transport critically ill or injured patients from one hospital to a receiving hospital with higher level of care  not available at referring facility.

These Paramedics receive additional training beyond normal EMS medicine. have developed 'in-house' advanced practice paramedic providers. These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are Dopamine, Dobutamine, Propofol, Blood and Blood products to name just a few.

Paramedic practitioner / Emergency care practitioner

An emergency care practitioner is a position sometimes referred to as a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

Wilderness Emergency Medical Technician

Some paramedics and EMTs, known as Wilderness Emergency Medical Technicians, utilize expanded scope of practice protocols that are operationalized when in wilderness environments. Wilderness EMS Systems have been developed to deliver a standard and professional medical response to wilderness areas. Examples include the national-level agencies such as the National Ski Patrol in the United States as well as local responding agencies. Like traditional EMS providers, all WEMS providers must still operate under on-line or off-line medical oversight.

Traditional healthcare professions

Registered nurse

The use of registered nurses  in the pre-hospital setting is more common in countries that have a limited EMS infrastructure in place. Some European countries such as France or Italy, which do not use paramedics as they are intended in Anglo-Saxon countries, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed, as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

Physician

This 'hands-on' approach is less common in the United States. While one will occasionally see a physician with an ambulance crew on an emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained paramedics, or performing routine medical quality assurance. In some jurisdictions adult or pediatric critical care transports sometimes use physicians, but generally only when it appears likely that the patient may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during transport. Physicians are leaders of medical retrieval teams in many western countries, where they may assist with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when longer transport times are involved.

Prehospital Delivery of care

Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organisation. This variation may lead to large differences in levels of care and expected scope of practice.

The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was often the case in a historical context, and is still true in the developing world, where operators as diverse as taxi drivers and undertakers may operate this service. Most developed countries now provide a government funded emergency medical service, which can be run on a national level, as is the case in the United Kingdom, where a national network of ambulance trusts operate an emergency service, paid for through central taxation, and available to anyone in need, or can be run on a more regional model, as is the case in the United States, where individual authorities have the responsibility for providing these services.

Some charities or non-profit companies also operate emergency medical services, often alongside a patient transport function. These often focus on providing ambulances for the community, or for cover at private events, such as sports matches.

There are also private ambulance companies, with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care, although in some places these private services are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy or to respond to non-emergency home calls. Private companies are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews.

Strategies for delivering care

Models of care

Although a variety of differing philosophical approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician-led and the other led by pre-hospital specialists such as emergency medical technicians or paramedics. These models are typically identified by their locations of origin.

Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.

The second care structure, termed the Anglo-American model, utilizes pre-hospital care specialists, such as emergency medical technicians and paramedics, to staff ambulances, which may be classified according to the varying skill levels of the crews. In this model it is rare to find a physician actually working routinely in the pre-hospital setting, although they may be utilised on complex or major injuries or illnesses. In this system, a physicians involvement is most likely to be the provision of medical oversight for the work of the ambulance crews, which may be accomplished in terms of off-line medical control, with protocols or 'standing orders' for certain types of medical procedures or care, or on-line medical control, in which the technician must establish contact with the physician, usually at the hospital, and receive direct orders for various types of medical interventions.

Clinical governance

Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of The authority to practice in this semi-autonomous manner is granted in the form of standing order protocols and in some cases direct physician consultation via phone or radio. Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with clinical decision-making authority using standing orders or protocols.

See also :

Ø  In case of emergency, a programme that enables EMS workers to identify victims and contact their next of kin to obtain important medical information

Ø  Public utility model, a model for organizing Emergency Medical Services

Ø  Battlefield medicine

Ø  Wilderness medicine

Ø  Mass Gathering Medicine

Ø  Good Samaritan law

Ø  Medical amnesty policy

References

1. "Long Hill Township First Aid Squad". Retrieved 2007-06-18.
2. "Hennepin County Emergency Squad". Retrieved 2007-06-18.
3. "Nottingham Ambulance Squad". Retrieved 2007-06-18.
4. "Sardinia Life Squad". Retrieved 2007-06-18.
5. "EU document on European adoption of 112 emergency number". Retrieved 2007-06-29.

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