slide 1 copyright 2007, 2004, by mosby, inc., an affiliate of elsevier inc. all rights reserved....

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Introduction to Introduction to Emergency Medical CareEmergency Medical Care

Chapter 1Chapter 1


Case HistoryCase History

You respond to a call for a patient in cardiac You respond to a call for a patient in cardiac arrest. On arrival, you find a 52-year-old male arrest. On arrival, you find a 52-year-old male who is pulseless and not breathing. A family who is pulseless and not breathing. A family member is performing CPR. The family states member is performing CPR. The family states that he collapsed 4 minutes before your that he collapsed 4 minutes before your arrival.arrival.


Historical PerspectiveHistorical PerspectiveBattlefields Lay the FoundationBattlefields Lay the Foundation

Napoleonic Wars – Ambulance Napoleonic Wars – Ambulance volantesvolantes

Civil War – Horse-drawn Civil War – Horse-drawn ambulancesambulances

World War I – Motorized World War I – Motorized ambulancesambulances


Historical PerspectiveHistorical PerspectiveBattlefields Lay the FoundationBattlefields Lay the Foundation

Korean War – Helicopters Korean War – Helicopters and MASH unitsand MASH units Mobile Army Surgical HospitalMobile Army Surgical Hospital

Death rates from battle Death rates from battle casualtiescasualties 8% WW I8% WW I 4.5% Korea4.5% Korea 2% Vietnam2% Vietnam


Historical PerspectiveHistorical PerspectiveCivilian EvolutionCivilian Evolution

• Civilian evolution varied from region to Civilian evolution varied from region to region in U.S.region in U.S.

• Rural areas – UndertakersRural areas – Undertakers Fire departments and volunteer ambulance Fire departments and volunteer ambulance

replaced funeral directorsreplaced funeral directors



• Civilian evolution varied from region to Civilian evolution varied from region to region in U.S.region in U.S.

• Rural areas – UndertakersRural areas – Undertakers Fire departments and volunteer ambulance Fire departments and volunteer ambulance

replaced funeral directorsreplaced funeral directors• Urban areasUrban areas

Hospital-basedHospital-based Fire departmentsFire departments Police departmentsPolice departments Independent ambulance companiesIndependent ambulance companies



• Mid-1860s – First Mid-1860s – First hospital-based hospital-based ambulance servicesambulance services Cincinnati General and Cincinnati General and

Bellevue HospitalsBellevue Hospitals

• 1899 – The first 1899 – The first motorized ambulance motorized ambulance Michael Reese Hospital of Michael Reese Hospital of

ChicagoChicago


Trauma as an Trauma as an Impetus for EMS DevelopmentImpetus for EMS Development

• Preventable injury Preventable injury Leading cause of death in ages 1 to 45 Leading cause of death in ages 1 to 45

• Automobile caused surge in trauma deathsAutomobile caused surge in trauma deaths 1900 – 7th leading 1900 – 7th leading

cause of deathcause of death 2000 – 4th leading 2000 – 4th leading

cause of deathcause of death Automobiles account Automobiles account

for 50%for 50%


Knowledge and TechnologyKnowledge and Technology

• 1960 – CPR developed1960 – CPR developed Cardiopulmonary ResuscitationCardiopulmonary Resuscitation

• 1960s – Portable defibrillators1960s – Portable defibrillators

• First ALS units (Advanced Life Support)First ALS units (Advanced Life Support) Belfast, Ireland Belfast, Ireland St. Vincent’s Hospital (New York City)St. Vincent’s Hospital (New York City) Only physicians provided advanced careOnly physicians provided advanced care


Knowledge and TechnologyKnowledge and Technology

• Late 1960s – Biotelemetry developedLate 1960s – Biotelemetry developed Space race Space race

• Allowed EMS providers to deliver ALSAllowed EMS providers to deliver ALS DefibrillationDefibrillation Advanced airwayAdvanced airway

proceduresprocedures Drug therapyDrug therapy

• ““Johnny and Roy” Johnny and Roy” popularized paramedicspopularized paramedicson TV show on TV show Emergency!Emergency!


The Physician and EMSThe Physician and EMS• Physician societies Physician societies

organized early EMS organized early EMS programsprograms American Academy of American Academy of

Orthopaedic SurgeonsOrthopaedic Surgeons(AAOS)(AAOS)

American College of Surgeons American College of Surgeons (ACS)(ACS)

• Worked with National Worked with National Highway and Traffic Safety Highway and Traffic Safety Administration (NHTSA)Administration (NHTSA)


The Physician and EMSThe Physician and EMS

• Physician groups still involvedPhysician groups still involved

American College of Emergency American College of Emergency Physicians (ACEP)Physicians (ACEP)

National Association of EMS National Association of EMS Physicians (NAEMSP)Physicians (NAEMSP)

National Association of State National Association of State EMS Medical Directors (NAEMSD)EMS Medical Directors (NAEMSD)


The Landmark Paper – 1966The Landmark Paper – 1966

““Accidental Death and Disability: The Neglected Accidental Death and Disability: The Neglected Disease of Modern Society”Disease of Modern Society”

Prompted federal money to develop EMS in 1973Prompted federal money to develop EMS in 1973

““Provide safe handling and transportation of ill or injured.”Provide safe handling and transportation of ill or injured.”

Provided impetus for rapid proliferationProvided impetus for rapid proliferation


EMS Agenda for the Future:EMS Agenda for the Future:14 Components14 Components

1.1. Integration of health Integration of health servicesservices

2.2. EMS researchEMS research3.3. Legislation and Legislation and

regulationregulation4.4. System financeSystem finance5.5. Human resourcesHuman resources6.6. Medical directionMedical direction7.7. Education systemsEducation systems

8.8. Public educationPublic education9.9. PreventionPrevention10.10. Public accessPublic access11.11. Communication Communication

systems systems12.12. Clinical careClinical care13.13. Information systemsInformation systems14.14. EvaluationEvaluation


Elements of a Elements of a Communications SystemCommunications System

The dispatch system – Enhanced 911The dispatch system – Enhanced 911 Formal national program to train dispatchers Formal national program to train dispatchers

Emergency Medical Dispatch (EMD)Emergency Medical Dispatch (EMD) Ambulance-to-hospitalAmbulance-to-hospital

RadioRadio Cell phoneCell phone LandlineLandline


Levels of TrainingLevels of Training

Lay rescuerLay rescuer First responderFirst responder EMT-BasicEMT-Basic EMT-IntermediateEMT-Intermediate EMT-ParamedicEMT-Paramedic


Lay RescuerLay Rescuer Carry little or no equipmentCarry little or no equipment

Recognize life-threatening illness or injuriesRecognize life-threatening illness or injuries

Provide lifesaving care until EMS arrivesProvide lifesaving care until EMS arrives CPRCPR Relief of airway obstructionRelief of airway obstruction Use of an AEDUse of an AED Bleeding controlBleeding control


First RespondersFirst Responders

Equipped withEquipped with OxygenOxygen AEDsAEDs Airway equipmentAirway equipment

Provide lifesaving Provide lifesaving care until EMS arrivescare until EMS arrives


EMT-BasicEMT-Basic Provide basic, Provide basic, noninvasivenoninvasive skills skills

Patient assessmentPatient assessment CPRCPR Airway adjunctsAirway adjuncts AED useAED use ChildbirthChildbirth SplintingSplinting Spinal immobilizationSpinal immobilization Administration and assistance with medicationsAdministration and assistance with medications

• Activated charcoal, metered-dose inhaler, Activated charcoal, metered-dose inhaler, nitroglycerin, epinephrinenitroglycerin, epinephrine

Use variety of transport devicesUse variety of transport devices


EMT-IntermediateEMT-Intermediate

Provide same skills as EMT-B Provide same skills as EMT-B

Provide additional advanced skills, Provide additional advanced skills, includingincluding Advanced airway techniquesAdvanced airway techniques ECG recognitionECG recognition Intravenous fluid therapyIntravenous fluid therapy Administration of multiple Administration of multiple

medications medications


EMT-ParamedicEMT-Paramedic Expanded scope of practice beyond EMT-B and EMT-IExpanded scope of practice beyond EMT-B and EMT-I

Provides advanced techniques, such as Provides advanced techniques, such as ECG interpretationECG interpretation Drug therapyDrug therapy Invasive airway techniquesInvasive airway techniques Defibrillation Defibrillation

Often have more standing orders in protocols than EMT-IOften have more standing orders in protocols than EMT-I


Chain of SurvivalChain of Survival

Early Early Access Early CPR Early CPR Early Defibrillation EarlyEarly Defibrillation Early Advanced Care Advanced Care


The Health Care SystemThe Health Care System Emergency departmentsEmergency departments

Specialty referral centersSpecialty referral centers

Hospital personnelHospital personnel


Liaison with Other Public Safety Liaison with Other Public Safety WorkersWorkers

Conflicts may occur when overlaps with other public safety Conflicts may occur when overlaps with other public safety personnelpersonnel Police take charge at crime scene, traffic and crowd control issuesPolice take charge at crime scene, traffic and crowd control issues Fire take charge at fire sceneFire take charge at fire scene EMS responsible for patient careEMS responsible for patient care Cooperation is essentialCooperation is essential Incident command system should be in placeIncident command system should be in place


Professional AttributesProfessional Attributes Demonstrate skill and knowledge for the good of the Demonstrate skill and knowledge for the good of the

patientpatient

Promote high standards of behaviorPromote high standards of behavior

Add to your body of knowledge to continue to Add to your body of knowledge to continue to advance in the professionadvance in the profession


Professional AttributesProfessional Attributes AppearanceAppearance

A professional appearance and attitude help evoke a sense A professional appearance and attitude help evoke a sense of confidence in patients and family members.of confidence in patients and family members.

• Clean and appropriate clothingClean and appropriate clothing

Attitude more important than outer appearanceAttitude more important than outer appearance• Show an interest in your jobShow an interest in your job• Possess a sensitive awareness of environment and needs Possess a sensitive awareness of environment and needs

othersothers• Putting patient/family needs ahead of your own will protect and Putting patient/family needs ahead of your own will protect and

preserve safetypreserve safety


EMT-BasicEMT-BasicPrimary ResponsibilitiesPrimary Responsibilities

Patient assessmentPatient assessment

Personal safety and safety of Personal safety and safety of othersothers

Patient carePatient care

Lifting and moving patients Lifting and moving patients safely safely

Transport/transfer of careTransport/transfer of care


Other ResponsibilitiesOther Responsibilities Record keepingRecord keeping

Patient advocacyPatient advocacy

ExtricationExtrication

CommunicationsCommunications

Vehicle and equipment Vehicle and equipment maintenancemaintenance


Local, State, and National IssuesLocal, State, and National Issues National Registry of Emergency Medical TechniciansNational Registry of Emergency Medical Technicians

National Association of Emergency Medical TechniciansNational Association of Emergency Medical Technicians

The American Heart AssociationThe American Heart Association

Continuing educationContinuing education

Refresher coursesRefresher courses

Record keeping/Data CollectionRecord keeping/Data Collection


Quality Improvement:Quality Improvement:DefinitionDefinition

A system of internal/external reviews A system of internal/external reviews and audits of all aspects of an and audits of all aspects of an emergency medical services system emergency medical services system that identifies aspects that need that identifies aspects that need improvement to ensure that the public improvement to ensure that the public receives the highest quality of receives the highest quality of prehospital careprehospital care


Role of the EMT-Basic Role of the EMT-Basic in Quality Improvementin Quality Improvement

DocumentationDocumentation

Run reviews and auditsRun reviews and audits

Gathering feedback from patients/hospital staffGathering feedback from patients/hospital staff

Conducting preventive maintenanceConducting preventive maintenance

Continuing educationContinuing education

Skills maintenanceSkills maintenance


Medical DirectionMedical Direction Accountability for the medical conduct of EMS Accountability for the medical conduct of EMS

personnel by a physician knowledgeable in patient personnel by a physician knowledgeable in patient carecare

Online medical directionOnline medical direction Direct real-time contact via telephone or radioDirect real-time contact via telephone or radio

Offline medical directionOffline medical direction Written protocols, policies, proceduresWritten protocols, policies, procedures


SummarySummary EMT-Basic plays a key EMT-Basic plays a key

role in EMS systemrole in EMS system

Teamwork with other Teamwork with other providers is essential for providers is essential for effective patient careeffective patient care

Quality assurance is an Quality assurance is an important role of the important role of the EMT-BasicEMT-Basic


Basic or Advanced?Basic or Advanced? Basic life support called BLS describes the Basic life support called BLS describes the

care given by First Responders and EMT-care given by First Responders and EMT-BasicsBasics

Advanced life support, called ALS, is the Advanced life support, called ALS, is the higher level of care performed by EMT-higher level of care performed by EMT-Intermediates and ParamedicsIntermediates and Paramedics Permitted to perform Permitted to perform invasive proceduresinvasive procedures

• Procedures that introduce foreign substances or Procedures that introduce foreign substances or equipment into the patient’s body equipment into the patient’s body


TrainingTraining The EMS provider is legally prohibited from The EMS provider is legally prohibited from

performing skills that are beyond his or her performing skills that are beyond his or her level of traininglevel of training

Each group of skills requires the proper Each group of skills requires the proper certificationcertification

The length of time required for learning the The length of time required for learning the advanced skills is considerableadvanced skills is considerable


First Responder TrainingFirst Responder Training Prerequisite: Health Care Professional level Prerequisite: Health Care Professional level

CPRCPR 8 hours8 hours

24-hour class24-hour class Three-year certification periodThree-year certification period

Certification is maintained with a refresher courseCertification is maintained with a refresher course• 12 hours12 hours


EMT Basic TrainingEMT Basic Training Prerequisite: Health Care Professional level Prerequisite: Health Care Professional level


110-hour class plus110-hour class plus Five patient contactsFive patient contacts

State certification application and feeState certification application and fee $150.00$150.00

Two-year certification periodTwo-year certification period 24-hour refresher course24-hour refresher course 28 hours of continuing education28 hours of continuing education $150.00 recertification fee$150.00 recertification fee


EMT Intermediate TrainingEMT Intermediate Training Prerequisite: Health Care Professional level Prerequisite: Health Care Professional level


180-hour class plus 180-hour class plus 100 hours of clinical observations and skills100 hours of clinical observations and skills

• 30 i.v. starts30 i.v. starts• 10 intubations10 intubations

100 hours of field observations and skills100 hours of field observations and skills• 10 i.v. starts10 i.v. starts• 1 intubation1 intubation


EMT Intermediate TrainingEMT Intermediate Training State certification application and feeState certification application and fee

$150.00$150.00 State administered examState administered exam

Minimum passing grade: 70%Minimum passing grade: 70% Two-year certification periodTwo-year certification period

24-hour refresher course24-hour refresher course 28 hours of continuing education28 hours of continuing education $150.00 recertification fee$150.00 recertification fee


EMT Paramedic TrainingEMT Paramedic Training Prerequisite: Health Care Professional level Prerequisite: Health Care Professional level

CPR & EMT-B certificationCPR & EMT-B certification X contact hours as an EMT-BX contact hours as an EMT-B 400-hour class plus 400-hour class plus

200 hours of clinical observations and skills200 hours of clinical observations and skills• 60 i.v. starts60 i.v. starts• 10 intubations10 intubations

200 hours of field observations and skills200 hours of field observations and skills• 30 i.v. starts30 i.v. starts• 1 intubation1 intubation


EMT Paramedic TrainingEMT Paramedic Training State certification application and feeState certification application and fee

$150.00$150.00 State administered examState administered exam

Minimum passing grade: 70%Minimum passing grade: 70% Two-year certification periodTwo-year certification period

24-hour refresher course24-hour refresher course 28 hours of continuing education28 hours of continuing education $150.00 recertification fee$150.00 recertification fee

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