[accordion] [acc_item title=”General”]

Capital – Washington, D.C.
Land Size – 9,826,275 sq km
Population – 310,232,863
Language(s) – English 82.1%; Spanish 10.7%; other Indo-European 3.8%; Asian and Pacific island 2.7%; other 0.7%

[/acc_item] [acc_item title=”Prehospital Care Overview”]
  • Anglo-American
    • “An almost universal reliance on physician surrogates to provide advances pre-hospital care” (Pozner, 241).
  • Highly fragmented system
    • Standards of care can change from state to state, and even city to city
[/acc_item] [acc_item title=”History”]

  • In US Civil War, ambulance services were attempted, “however, a lack of money, governmental support, and dedicated personnel prevented any initial success” (Pozner, 240)
  • 1865 – Commercial Hospital of Cincinnati (Cincinnati General): First civilian-run, hospital-based ambulance service
  • Bellevue Hospital (NYC): First municipal-based EMS
  • Chicago Fire Dept: Established First-Aid Training Program  which became prototype for modern EMT training program
  • 1966 – “The White Paper”:Accidental Death and Disability: the neglected disease of modern society
    • Released by the National Academy of Sciences (NAS)
    • Outlined inadequacies of prehospital and ED care in US
    • Prescribed 24 recommendations for improvement
    • Became stimulus for federal gov’t to create organized EMS and trauma system.
  • Highway Safety Act: response by feds to NAS paper, creating U.S. Dept. of Transportation (DOT)
    • Charged with improving EMS in US, developing 70hr basic EMT curriculum
    • ALS curriculum created years later
  • Wedworth Townsend Act of 1970: signed by Ronald Regan (Gov.) for EMS in CA
    • “Permitted paramedics to act as physician surrogates providing advanced-level care under direction of off-site physicians” (Pozner, 240)
    • Prior to law, paramedics required nurse/physician present in ambulance to administer meds
    • Subsequent acts passed throughout nation
  • EMS Act of 1973: intended to improve and coordinate EMS throughout US
    • Provided millions of dollars for training, equipment and research.
    • Identified 15 essential components in development of EMS system:
      • Personnel
      • Training
      • Communication
      • Transport
      • Emergency Facilities
      • Critical-Care Units
      • Public Safety Agency
      • Consumer Participation
      • Access to Care
      • Patient Transfer
      • Standard Record Keeping
      • Public Teaching/Education
      • System Review/Evaluation
      • Disaster Planning
      • Mutual Aid
    • “EMS development progressed in a disorganised manner resulting in a heterogeneous mosaic of systems with varied successes, some of which met the intended goals, others falling short” (Pozner, 240)
  • 1981 – Omnibus Budget Reconciliation Act: “effectively brought an end to the golden era of EMS” (Pozner, 240)
    • Rearranged federal funding so that each state was charged with appropriating funds as they best saw fit
    • Reallocation of funds to different areas resulted in substantial budget cuts
    • Significantly reduced federal involvement in EMS care
      • Created nearly complete reliance on state/local initiatives to fund EMS development
      • Perpetuated further fragmentation of national EMS systems
[/acc_item] [acc_item title=”EMS System Model”]
  • Fragmentary system
  • Multiple System models
    • Affected by jurisdictional, political and fiscal disparities
    • Difficulty in “obtaining objective scientific evidence by which to define and implement ‘ideal’ systems” (Pozner, 241)
    • Disparities in geography, topography and resource allocation
  • Governmental/Municipal Services:
    • Most commonly fire-based
    • “Third [Essential] Services” – independent of FD, most often employed in counties or large cities.
  • Private Services: independent, private company
    • Hybrid Partnership – private service provides all or some components of EMS
    • Hospital-Based
    • Paid or Voluntary Services
    • “Community volunteers staff significant percentage of EMS systems, mostly in rural areas” (Pozner, 242)
  • “Tiers” of Care
    • FD/PD as First Responders (most common)
      • Provide life-saving airway, bleeding control, AED
    • BLS/ALS Transport
    • Non-Transport ALS – typically FD providing ALS assessment, followed by transporting agency
[/acc_item] [acc_item title=”Lead Agency”] [/acc_item] [acc_item title=”Funding”]
  • “Funding, for most part, depends on local (city and state) systems and federal Medicare rules while approaching a multi-billion dollar a year endeavour” (Pozner, 242)
  • Public EMS Systems:
    • Funded through local tax income
    • Then individual patients/insurance carriers billed directly for services
  • Public-Private Systems:
    • Town has contract for number/level of EMS responders
    • Agrees on average response time
    • Private company bills patient/insurer for reimbursement
    • Dependent on level of service/demographics, town may be required to partially subsidize company, or company may be asked to pay town for opportunity to provide EMS
  • Other Expenses:
    • Equipment acquisition and maintenance
    • Communications Systems
    • Personnel and Education
    • Medical Direction
    • Licensing and Regulation Activities
[/acc_item] [acc_item title=”Levels of Care, Education & Training”]
  • Four Distinct Levels of Care
  • First Responders: Most commonly employed/affiliated with local public safety agencies; 40-50hrs
    • Basic First-Aid
    • CPR
    • Uncomplicated Obstetric Delivery
    • Basic Wound Management
    • Fracture Immobilization (including spine)
    • AED
  • EMT-Basic: majority staffing level of US ambulances
    • First-Responder training
    • Oxygen administration
    • Scene Triage
    • Patient Extrication
    • Patient Transfer
    • Rural exceptions (in general):
    • Tracheal intubation
    • Transport of Pt’s receiving IV crystalloid fluids
    • ASA in Acute Coronary Syndrome
    • Nitroglycerine
    • Inhaled Bronchodilators
    • Epi Autoinjectors
  • EMT-Intermediate: level of training and local regulations vary greatly
    • IV lines (w/possible first-line cardiac meds)
    • Tracheal Intubation
    • Cardiac Monitoring
    • Manual Defibrillation
  • EMT-Paramedic: highest level of training; national curriculum, though program components vary depending on locale; typically >1000hrs
[/acc_item] [acc_item title=”Medical Direction”]
  • Originally, physicians responded with paramedics to treat patients and observe paramedics
    • Paramedics eventually began to operate “under the license” of physicians
  • “On-Line” Medical Direction:
    • direct communication between Paramedic and MD/MICN (Mobile Intensive Care Nurse)
  • “Off-Line” Medical Direction:
    • Employment of Standard Protocols, pre-established by system’s Medical Director
  • 3 Essential Components
    • Protocol development – treatment, hospital bypass etc.
    • Quality assurance
    • Continuing education
[/acc_item] [acc_item title=”Specialty Services”]
  • Aeromedical Transport
    • Fixed-Wing: Phoenix, 1969
      • Interfacility transport
    • Helicopter: Denver, 1967
      • Primarily used for short and medium distance transports, from scene or for interfacililty transport
      • Provide rapid transport of trauma patients to trauma centers
[/acc_item] [acc_item title=”Dispatch”]
  • 911: available to 99% of population; 96% of geography
    • “Enhanced 911”: first begun in Chicago 1977, provides callers location on computer.
  • Emergency Medical Dispatch (EMD) – trained medical dispatch
    • Formal Training available – only 18 states have regulatory legislation covering EMD
    • Role: answer calls from public and communicate with units in field
      • Number of dispatchers required to fulfill roles depends on size of community
    • Gathers information:
      • Location of Call
      • Nature of Call
    • May provide pre-arrival instructions over phone
[/acc_item] [acc_item title=”Emergency Medicine”]
  • Trauma Centers
    • Emergency/Surgery Departments specifically orientated to care of major trauma patients
    • Trauma Team: Surgeons. Anesthesiologists available in hospital 24hrs/day
    • Most systems have standing protocols where units bypass closest hospital to transport to trauma center with greater capabilities
      • Trauma Criteria
        • Mechanism of Injury
        • Anatomical Location of Injuries
        • Vital signs
      • Revised Trauma Score
        • Resp. Rate
        • Chest Wall Expansion
        • Systolic BP
        • Glasgow Coma Scale (GCS)
  • Pediatric Hospital – Specifically designated for Peds
[/acc_item] [acc_item title=”Disaster”] [/acc_item] [acc_item title=”References”] [/acc_item] [/accordion]
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