United States of America

DIEMS Home Page



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%


Note: Because of the abundance of information available on US-based EMS systems,
we’ve decided to avoid listing the innumerable nuances and intricacies that distinguish
each individual prehospital model, and instead direct our readers to
EMSwiki.com, where visitors are invited to add information for their own systems.


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

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

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


Lead Agency


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


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


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


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


Dispatch & National Emergency Telephone #

  • 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


Emergency Medicine & Emergency Care

  • 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


Disaster


References


Links

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