EMT-Basic/Preparatory/Introduction

Lesson 1.1: Introduction to Emergency Medical Services

In the United States alone, there are over 750,000 Emergency Medical Technicians and Paramedics who have received certification from the Emergency Medical Service authorities in their state to provide emergency medical care to patients outside the hospital. These highly trained medical professionals serve in many different kinds of organizations, including fire departments, police departments, and government or private third service ambulance agencies. The EMT is a specialist in out-of-hospital care, providing immediate and life-saving interventions as well as prompt transport to an appropriate facility for the provision of definitive care. Today, you set off on a journey to become an Emergency Medical Technician, or EMT-Basic, an entry level provider in the Emergency Medical Services System. This lesson will introduce you to the system of which you are about to become a part, and will help you to understand where you, as an EMT-Basic, will fit into this complex system.

Objectives
By the end of this lesson, the EMT-Basic should be able to:
 * 1) Define Emergency Medical Services (EMS) Systems.
 * 2) Differentiate the roles and responsibilities of the EMT-Basic from other prehospital care providers.
 * 3) Describe the roles and responsibilities related to personal safety.
 * 4) Discuss the roles and responsibilities of the EMT-Basic towards the safety of the crew, the patient and bystanders.
 * 5) Define quality improvement and discuss the EMT-Basic's role in the process.
 * 6) Define medical direction and discuss the EMT-Basic's role in the process.
 * 7) State the specific statutes and regulations in your state regarding the EMS System.
 * 8) Assess areas of personal attitude and conduct of the EMT-Basic.
 * 9) Characterize the various methods used to access the EMS System in your community.

A brief history of EMS
The Emergency Medical Services System has a long history. Like many advances in science and technology, the first use of ambulances and specialized medical personnel in the field were a military innovation, in this case, during the American Civil War. The first civilian ambulance service was in Cincinnati, Ohio, in 1865. More civilian ambulance services appeared into the early 1900's, but these services operated primarily on a transport-only basis, offering little to no emergency medical care. Commonly, especially in smaller communities, the local funeral home would provide a hearse for transport of patients, and in the few communities that did provide emergency care in the field, the Fire Department was typically the agency responsible for this care.

In the 1960's, in response to the high number of motor vehicle accidents resulting in hospitalization and even death, President Lyndon B. Johnson and the President's Commission on Highway Safety of the National Academy of Sciences published a report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society." Today referred to as the EMS White Paper, this document laid the foundation for the modern day EMS system and, along with the National Highway Traffic Safety Act, provided a federal standard by which local EMS systems could be built.

Today, National EMS Standards are published by the National Highway Traffic Safety Administration (NHTSA), an agency of the United States Department of Transportation (DOT). Specifically, the Technical Assistance Program of the NHTSA has developed a set of Assessment Standards which set standards in certain categories, as outlined below, for EMS agencies nationwide.


 * Regulation and policy: Regulations must be in place in each state, in the form of legislation creating funding for EMS, a lead EMS agency, and regulations, policies, and procedures regarding the certification of EMS providers and agencies, and the provision of EMS in the state.
 * Resource Management: resources must be centrally managed so that everyone needing access to Emergency medical services can receive care from appropriately trained and equipped providers and transport to an appropriate facility in a timely manner.
 * Human Resources and Training: All personnel providing patient care on an ambulance should be trained to the EMT-Basic level or above using a standardized curriculum.
 * Transportation: Safe and reliable means of transportation must be secured for all patients. This can be in the form of a ground ambulance, or in some situations, air ambulances including helicopters and fixed-wing aircraft.
 * Facilities: Acutely ill or injured patients should be transported in a timely manner to the nearest appropriate facility.
 * Communications: An effective communications system should begin with a universal access number (9-1-1), and includes appropriate and efficient mechanisms for dispatch-to-ambulance, ambulance-to-ambulance, ambulance-to-facility, and facility-to-facility communications.
 * Public Information and Education: EMS personnel can and should continuously work to educate the public about their role in the EMS system, how the public should access the EMS system, and ways to prevent injury and illness before it requires the use of the EMS system.
 * Medical Direction: Every EMS provider must work under the authority of a medical director, and every EMS agency should have a designated medical director who delegates the necessary authority to practice medicine to providers in that agency.
 * Trauma Systems: Each state must establish, through legislation, a trauma system consisting of one or more hospitals designated as trauma centers, and creating triage and transfer guidelines for trauma patients, rehabilitation programs, data collection programs, mandatory autopsies, and a means for maintaining the system and assuring its continued efficient operation.
 * Evaluation: Each state should establish a program for Quality Improvement which evaluates and improves the effectiveness and efficiency of the provision of emergency medical care in the state.

Under these new standards, the concept of an ambulance as merely a means of transport was no longer sufficient. Ambulance personnel were to receive an education to enable them to be efficient providers of emergency medical care in the field, meaning that the hospital emergency department was effectively extended to reach the sick and injured at the scene of their emergency. Ambulance attendants who had previously only been required to lift and move victims became Emergency Medical Technicians, allied health professionals with training to assess and treat certain critical injuries and illnesses while still providing efficient and safe transport to appropriate medical facilities.

Access to the EMS System
In the past, in order to access emergency services, the public would have to remember a standard seven digit phone number for emergency service agencies in their area. Sometimes, they would even need to remember separate numbers for police, fire, and ambulance agencies. Today however, most communities have access to a centralized dispatch center which can be easily accessed with the national emergency number, 9-1-1 (appropriately spoken as nine-one-one).

Under the 9-1-1 system, when a citizen calls 9-1-1, their call is automatically directed to the appropriate Public Safety Answering Point (PSAP), where a trained emergency dispatcher answers the call and obtains necessary information in order to provide emergency responders with enough information in order to respond to the emergency being reported.

Some PSAPs feature equipment which enables dispatchers to automatically identify the caller’s phone number and location. This is known as Enhanced 9-1-1. This allows for emergency responders to be dispatched to the incident even if the line is disconnected or the caller is unable to communicate effectively with the dispatcher. Another enhancement in 9-1-1 relevant to EMS is the training of dispatchers as Emergency Medical Dispatchers (EMDs). These specially trained dispatchers are able to obtain more appropriate information from callers with medical emergencies, and can also help to direct callers in certain life-saving procedures, such as CPR and bleeding control.

Some communities still do not have a 9-1-1 system. In these areas, calls placed to 9-1-1 are often connected to a standard operator, who will have to obtain enough information in order to connect the caller to the appropriate dispatcher. This extra step can cost vital seconds in an emergency, and so it is important that all emergency providers (including EMTs) in these areas take steps to educate the public on the appropriate phone number to call when they have an emergency, and to advocate for the creation of a 9-1-1 system in their area.

Levels of EMS Training
Under the national standards for EMS, there are four levels of EMS education and certification. These levels may vary in your state or locality, so your instructor should explain any differences that exist in your area. The four national levels of EMS providers are outlined below.


 * First Responder: Also known as a Certified First Responder (CFR) or Emergency Medical Responder (EMR), these providers are often found in police and fire departments or in industrial facilities. These are individuals whose jobs often place them as the first responder on the scene of a medical emergency, so their EMS training focuses on activating the EMS system if it has not already been activated, and providing care for immediate life threats while preparing for the arrival of an ambulance.
 * Emergency Medical Technician - Basic: An EMT-Basic is the technical minimum level of certification for personnel providing patient care in an ambulance during transport. EMT-Basics are trained in non-invasive techniques of assessment and management of the ill or injured patient, and have completed a course compliant with the US DOT's EMT-Basic National Standard Curriculum or its equivalent, as approved by the state emergency medical services authority.  This text is designed to prepare you to perform at this level.
 * EMT-Intermediate: The next level of Emergency Medical Technician is the EMT-Intermediate. These EMT-Is can provide some level of invasive care, including the initiation of intravenous (IV) lines, advanced airway techniques, and the administration of certain limited medications beyond those administered as an EMT-B. Some states further divide this category to include Shock-Trauma Technicians or Critical Care Technicians.
 * EMT-Paramedic: While still technically considered an Emergency Medical Technician, EMT-Paramedics are often referred to only as Paramedics. Their training meets or exceeds the US DOT National Standard Curriculum for Paramedics, and these providers represent the highest level of prehospital care.  They can provide a wide assortment of medications to patients, and can perform a variety of invasive procedures including IV access and placement of Endotracheal (ET) tubes, as well as interpretation of Electrocardiograms (ECG or EKG) and manual cardiac defibrillation and pacing.

The Health Care System
While the primary image of the EMS system is the back of an ambulance, the health-care facilities which interface with Ambulance services are an important part of the backbone of the EMS System. Traditionally, most patients will be turned over to a hospital Emergency department, where physicians specialized in the treatment of acute injuries and illnesses provide definitive care to fully diagnose and treat the patient's medical problems. These departments, however, serve only as general treatment centers, and are not appropriate for all patients. Patients such as those who have experienced major trauma, burns, or poisoning, and certain pediatric patients, require specialized care which can only be provided in specialty facilities.

Trauma Centers are facilities which are equipped to provide comprehensive Emergency Medical services to patients who have suffered from a major trauma. These facilities are required to have certain specialized physicians on staff and certain specialized equipment available at all times in order to maintain their designation as a trauma center. Lower levels of trauma centers may also be established by agreements with major trauma centers, so that remote regions can have faster access to hospitals equipped to stabilize critical trauma patients before transferring them to a fully equipped trauma center.

Burn Centers feature specialized equipment and facilities for the management of patients with critical burns. The unique treatment implications and possible complications of critical burns mandate treatment at one of these highly specialized facilities.

While any emergency department should theoretically be able to handle pediatric patients, certain facilities will be able to provide better care for certain pediatric emergencies, and thus are favorable destinations when transporting pediatric patients. In addition to general pediatric emergencies, certain facilities featuring more advanced Neo-natal ICUs or NICUs will be better suited for pregnant patients in pre-term labor.

Poison centers are specialized facilities for the treatment of poisoning. Typically reached by phone, they can provide assistance and medical direction to various levels of emergency medical providers, from citizen family members and bystanders, to EMTs and even physicians at other facilities. Generally speaking, patients are not transported to these facilities since they operate over a wide geographic range.

Other specialty centers exist, including emergency hyperbaric centers for the treatment of conditions such as decompression sickness or CO poisoning, or local hospitals which specialize in conditions such as heart attack or stroke. Your instructor or agency will be able to provide you with more information regarding what specialty centers are found in your area.

Hospital Personnel
Once a patient arrives at a hospital, their treatment will involve a wide variety of individual providers from a number of different medical and allied health professions. The highest medical provider who is ultimately responsible for the patient's care is the physician, who is a highly trained medical professional who has obtained a doctoral degree (either MD or DO) from an accredited medical college. In addition to this, the managing (or attending) physician has completed a residency in their particular specialty. In some facilities, the attending will also supervise residents who have completed their degree but are currently undergoing specialty training.

Nurses are typically the primary care providers in the emergency department, carrying out most basic procedures such as taking vital signs, establishing IV access, drawing blood, administering medications, and generally monitoring the patient's condition. They work closely with physicians to provide the physician with information relevant to the patient's case, and to initiate appropriate interventions as directed by the physician.

Other health professionals in the hospital might include patient care technicians or Certified Nurse Assistants (CNAs) who assist the nurse in many aspects of patient care, patient transporters, X-ray technicians, physical therapists, speech therapists, occupational therapists, and social workers.

Other Public Safety Workers
While not traditionally part of the EMS System, other public safety providers can often be found on the scene of medical emergencies. Police and fire departments both can play critical roles at certain types of incidents, and the EMT-Basic will often have to work closely with these providers.

State and/or local police departments will often be dispatched to the scene of behavioral emergencies or any call where violence is suspected, in order to properly secure the scene before EMS arrival. They may also be dispatched to certain types of medical emergencies if they have specialized equipment and medical training such as in the use of an AED.

Fire Departments, when they are not the primary EMS providers, are often still dispatched simultaneously with third agency ambulance services. They may provide ALS care or BLS first response, and they will also play a key role on many rescue scenes when complex extrication will be required.

The EMT-Basic will have to learn to work with these other providers in order to provide seamless care to patients in all varieties of emergency situations.

Roles and responsibilities of the EMT-Basic
As an EMT-Basic, you will have to perform a wide range of tasks. When dispatched to an emergency, your role will depend on the crew with which you respond, but in general you will have several basic roles and responsibilities, as outlined below.
 * Personal Safety: First and foremost, you must work to ensure your own safety. As an EMT-Basic you are dispatched to the scene of emergencies to mitigate whatever situation caused the emergency, and you cannot perform your duties if you fail to ensure your own safety and thus become just another part of the problem.
 * Safety of crew, patient, and bystanders: The same dangers which you protect yourself from can affect every person on the incident scene, so you should always take steps to ensure that other crew members and bystanders don't become additional patients, and that your patient does not suffer any further injury while under your care.
 * Patient Assessment: As an EMT-Basic, one of your primary responsibilities is the assessment of your patient in order to gain enough information about your patient's medical condition to provide the appropriate emergency medical care.
 * Patient Care: Only after properly assessing your patient can you begin your next responsibility of providing appropriate medical care based on your assessment findings. From simple emotional support to life-saving CPR and defibrillation with an AED, patient care consists of the actions that you perform to help the patient deal with their medical problems.
 * Lifting and moving patients: Unfortunately, patients are sometimes found in the most inconvenient places. Often you will find patients who are unable to walk or otherwise move themselves to the ambulance.  In any case, every patient will ultimately need to be safely transported from where they were found on the scene onto the ambulance before they can be taken to an appropriate facility.  This will often involve lifting and carrying patients.  When lifting and carrying patients, you should always take care to ensure that you are not going to injure yourself or further injure your patient.
 * Transport/Transfer of Care: Virtually every patient you encounter will need to be transported to a hospital and turned over to medical providers at that facility. It is an important part of the job of an EMT-Basic to ensure that the ambulance is operated safely at all times, and that the patient is properly secured in the ambulance when they are on board.  It is also an important responsibility of the EMT-Basic to ensure that the receiving hospital is provided with a full report of the condition of the patient and any interventions performed to ensure continuity of care after the patient transfer.
 * Record keeping/Data Collection: EMTs are responsible for accurate record keeping as their written reports serve as a permanent part of the patient's medical record and document the care which was provided by the EMT as both a medical and legal record. The data obtained by EMTs is also used for billing purposes, and to review and improve the quality of care through the Quality Improvement process.
 * Patient Advocacy: As an EMT you will be expected to advocate for your patient, both in terms of presenting your patient to the receiving department and in terms of ensuring that your patient's rights are protected at all times. As a medical provider, you are expected to treat more than just the symptoms - you are expected to treat the patient as a whole.  It is a very important responsibility, and one that may very well determine how you and your agency are viewed by the community you serve.

Professional and personal attributes of the EMT-Basic
An EMT-Basic is a professional. As a professional, you will be expected to look and act like a professional at all times. Your appearance should be neat and clean, and you should present a positive image to your patient and your community. You should maintain up-to-date knowledge and skills through continuing education and refresher courses, and you should maintain current knowledge of local, state, and national issues affecting EMS. You must also learn to put patients' needs as a priority, without putting yourself at risk.

Quality improvement
The EMT-Basic is expected to consistently strive to improve the quality of care that you provide to your patients. Your agency and state EMS System should have a Quality Improvement (QI) System in place, which should consist of a system of internal and/or external reviews and audits of all aspects of the EMS system which can identify those aspects needing improvement in order to assure that the public receives the highest possible quality of prehospital care.

You will play a key role in QI as an EMT-Basic. Your responsibilities with regard to QI include appropriate documentation of all actions taken on calls, performing call critiques with crew members and more formal run reviews and audits, gathering feedback from patients and hospital staff, conducting preventative maintenance on vehicles and equipment, constantly pursuing opportunities for continuing education, and ensuring that you are properly maintaining your competency at skills you are required to perform, especially those which you perform least often.

Medical Direction
Every EMS system and agency has a medical director, a physician who is ultimately responsible for the clinical and patient care aspects of that system or agency. As an EMT-Basic, you act as a designated agent of your physician medical director. This means that the authority for your actions is actually derived from the physician's license to practice medicine, and as such all actions which you take in the field must be approved by your physician medical director.

Obviously the physician cannot be present on every call, so a system of medical direction has been established to ensure that non-physician providers are able to provide an appropriate level of care pursuant to their training while responding to emergency medical calls. This medical direction comes in the form of both on-line and off-line medical direction.

On-line medical direction takes place over the phone or radio and consists of an EMT giving a report to a physician who in turn gives orders to the EMT to provide a particular intervention in order to correct the suspected underlying issue. When seeking on-line medical direction, it is important that the EMT is able to provide a report to the physician which is both thorough and accurate so that the physician has the best possible picture of the patient from which to determine what interventions, if any, would be appropriate for the EMT to perform. It is also important that the EMT repeat any orders back to the physician to confirm that the order was heard properly, and for the EMT to accurately record information about the physician giving the order and about the order itself so that the EMT has proof that on-line medical direction was used.

Off-line medical direction comes in the form of written protocols and standing orders. Protocols outline actions which should be taken for patients with particular complaints, and are established in advance by medical advisory committees, so that on-line medical direction does not have to be used on every call. Standing orders are those orders which would otherwise require on-line medical direction, but which are included in the protocols as actions that can be taken without such on-line direction, and thus can be completed off-line.

In addition to creating protocols and standing orders and providing for on-line medical direction, medical directors are responsible for reviewing the QI process and assuring that their agencies and providers are providing the highest quality of care to all patients.

Summary
The modern EMS System incorporates the highest quality of prehospital and in-hospital emergency medical care into one continuous system so that patients can receive the best possible care during all stages of their emergency treatment. Many individuals have parts to play in the EMS System, from the dispatchers who answer 9-1-1 calls, to the various levels of prehospital providers, and to the physicians, nurses, and allied health professionals who provide care in the hospital.

As an EMT-Basic, you will have many roles and responsibilities which include safety, patient assessment and care, as well as lifting, moving, and transporting patients for transfer to an appropriate facility. You will serve as a patient advocate through all stages of emergency care, and you must have certain personal and professional qualities to perform successfully in this role!