Introduction to Emergency Medical Care

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Introduction to Emergency © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1 NOTMedical FOR SALE OR DISTRIBUTION Care NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett CHAPTER Learning, OUTLINE LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The Emergency Medical Services System and the EMT Overview of the Emergency Medical Services System The Healthcare System © Jones & Bartlett Learning, LLCRoles and Responsibilities© ofJones the EMT & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Professional Attributes of the EMT Quality Improvement Medical Direction © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 2 Chapter 1 Introduction to Emergency Medical Care Sce nario The origins of EMS date back to antiquity, as in the story of © Jones & Bartlett Learning, LLC © Jonesthe “Good & Samaritan.”Bartlett Learning,The response toLLC another human in need NOT FORIt is your SALE fi rst day OR as anDISTRIBUTION emergency medical technician (EMT), and NOTis theFOR driving SALE force OR for theDISTRIBUTION EMSS and for all individuals who you respond to a call to aid a victim in a motor vehicle crash. On ar- participate when called to aid someone in distress. rival at the scene, you fi nd police directing traffi c, making the scene safe. Fire department rescue personnel are removing the driver’s Battlefi elds as Laboratory side door to gain access to the patient, and a trained fi rst responder The growth and development of EMS has occurred primarily is in the vehicle stabilizing the© victim’s Jones head & to Bartlett prevent further Learning, spi- over LLC the past 50 years. Although© much Jones of this & Bartlettgrowth has Learning, re- LLC nal injury. You enter the vehicleNOT and FOR perform SALE your initialOR DISTRIBUTIONassess- sulted from increased knowledgeNOT and FORtechnological SALE advances, OR DISTRIBUTION ment. The patient is complaining of pain in the neck and abdomen the value of a coordinated response to expected injury was fi rst and is breathing rapidly, and you note the skin is pale and sweaty. identifi ed, ironically, on the battlefi elds. Ambulances were de- You work with the fi refi ghters to remove the patient from the vehi- ployed during the Napoleonic Wars, when a French Army sur- cle, continue your assessment and treatment, and begin transport. geon, Baron Dominique-Jean Larrey, introduced his ambulance You notify ©the Jones local trauma & Bartlett center of Learning,the patient’s condition LLC and volantes, a French© Jones term meaning & Bartlett “fl ying fi Learning,eld hospital.” PatientsLLC approximateNOT time FORof arrival. SALE OR DISTRIBUTION were deliveredNOT by ambulances FOR SALE to fi eld ORhospitals, DISTRIBUTION where surgeons On arrival at the emergency department, the trauma team is wait- would tend to their wounds. Before this time, soldiers often ing and continues care. Before you leave, the trauma surgeon tells you were left to die on the fi eld of battle ( Table 1-1). he suspects the patient has a neck fracture and a ruptured spleen. In the United States, horse-drawn ambulances were introduced during the Civil War, under the direction of Dr. Jonathan © Jones & Bartlett Learning, LLC © JonesLetterman & (BartlettFigure 1-1 ). Learning, LLC Emergency treatment applied in the fi eld of battle included NOT FOR LEARNING SALE OBJECTIVE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION traction splinting of fractured femurs. Originally developed by • Defi ne emergency medical services (EMS) system. the orthopedic surgeon Hugh Owen Thomas (1834- 1891) in Liverpool, the “Thomas splint” decreased the mortality of com- pound fractures of the femur from 80% in 1916 to less than 8% The Emergency Medical© Jones Services & Bartlett System Learning, in LLC 1918. The traction splint is still© Jones applied to& fracturesBartlett of Learning, the LLC and the EMT NOT FOR SALE OR DISTRIBUTIONfemur. NOT FOR SALE OR DISTRIBUTION During the Korean War in the 1950s, helicopters were used An emergency is an unforeseen combination of circumstances to evacuate wounded soldiers to mobile army surgical hospi- or the resulting state that calls for immediate action. The term tals (MASH units), where, if necessary, immediate lifesaving medical means relating to or concerned with the practice of surgery was performed before transfer to more permanent medicine.© Service Jones refers & toBartlett the occupation Learning, or function LLC of serv- care units. The© VietnamJones War& Bartlett experience Learning, reinforced the LLC value ing, or a contributionNOT FOR toSALE the welfare OR ofDISTRIBUTION others. Finally, system of rapid transportNOT and FOR early SALE surgery OR for traumaDISTRIBUTION victims. The refers to a regular interaction or interdependent group of items death rates of battle casualties who reached a hospital decreased forming a unifi ed whole. An emergency medical services system from 8% in World War I, to 4.5% in Korea, to less than 2% in (EMSS) is the planned confi guration of community resources Vietnam. and personnel necessary to provide immediate medical care to The medical and transport strategies developed during war © Jonespatients & Bartlett with sudden Learning, or unexpected LLC illness or injury. An EMSS © Jonesalso served & asBartlett a model forLearning, change in civilian LLC life. Physicians who NOT FORcan be SALE local, regional, OR DISTRIBUTION or statewide. NOTworked FOR as SALEsurgeons OR in Korea DISTRIBUTION and Vietnam came to appreciate The key word in this definition is “service.” By becoming the value of early fi eld care and transport. When they returned an emergency medical technician (EMT), you have decided home, they were keenly aware that some victims who died from to serve a community. Indeed, you will help a wide variety motor vehicle crashes might have been saved if they had the of people in need of care. Some patients, such as victims of same care as was provided during their wartime experience. sudden cardiac death, will© depend Jones on & you Bartlett to literally Learning, save This LLC revelation led many physicians© Jones to become & Bartlett the “champi- Learning, LLC their lives. Others will relyNOT on yourFOR support SALE and OR care DISTRIBUTION for ons” of civilian EMSS development.NOT FOR SALE OR DISTRIBUTION what may seem a relatively minor complaint to you but that has caused them to become a patient in need. In either case, Civilian Evolution you are playing a critical role in the healthcare system. You The civilian evolution of EMS varied greatly from region to will often be the first medical provider to see and care for region. In rural areas, undertakers had routinely transported the patient.© Jones & Bartlett Learning, LLC victims of “accidents”© Jones because & Bartlett their vehicles Learning, were well LLC suited NOT FOR SALE OR DISTRIBUTION to transport peopleNOT onFOR their SALE back. In OR many DISTRIBUTION communities, fi re Historical Perspective departments and volunteer ambulance companies, who still Emergency medical services (EMS) is a relatively new and ex- provide EMS coverage for many rural populations today, re- citing fi eld that is still evolving. In the 1950s, EMS was little placed undertakers. In urban areas, EMS was often provided by more than fi rst aid and often was provided by the local mor- paid services based at hospitals, fi re departments, police depart- © Jonestician & andBartlett a hearse. Learning, Current systems LLC link ambulances and © Jonesments, or & independent Bartlett Learning, ambulance companies. LLC Organized vol- NOT FORhospitals SALE to optimize OR DISTRIBUTION care for patients with many different NOTunteer FOR EMS SALE squads OR often DISTRIBUTION provided the ambulance service for a conditions. local community or supplemented service, even in urban areas,

© Jones & Bartlett Table 1-1 Learning,Emergency LLCMedical Services (EMS) Chronology© Jones & Bartlett Learning, LLC NOT FORYear SALE Event OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1797 Napoleon’s chief physician implements a “prehospital system” designed to triage and transport injured soldiers from the battlefi eld to aid stations. 1860s Civilian ambulance services begin in Cincinnati and New York City. 1915 First known air© medical Jones transport & Bartlett occurs during Learning, the retreat LLCof the Serbian army from Albania.© Jones & Bartlett Learning, LLC 1920s First volunteer NOTrescue squadsFOR organizeSALE inOR Roanoke, DISTRIBUTION Virginia, and along the New Jersey coast.NOT FOR SALE OR DISTRIBUTION 1958 Dr. Peter Safar demonstrates the effi cacy of mouth-to-mouth ventilation. 1960 Cardiopulmonary resuscitation (CPR) is shown to be effi cacious. 1966 National Academy of Sciences – National Research Council publishes Accidental Death and Disability: the Neglected Disease of Modern Society. 1966© Jones Highway &Safety Bartlett Act of 1966 Learning, establishes LLCthe Emergency Medical Services© Program Jones in the& U.S.Bartlett Department Learning, of Transportation. LLC 1972 NOTU.S. FOR Department SALE of Health,OR DISTRIBUTION Education and Welfare allocates $16 million NOTto EMS FORdemonstration SALE programs OR DISTRIBUTION in fi ve states. 1973 Robert Wood Johnson Foundation appropriates $15 million to fund 44 EMS projects in 32 states and Puerto Rico. 1973 Emergency Medical Services Systems (EMSS) Act provides additional federal guidelines and funding for the development of regional EMS systems; the law establishes 15 components of EMS systems. 1981 Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive health and health services block grants and © Jones & Bartletteliminates Learning, funding LLC under the EMSS Act. © Jones & Bartlett Learning, LLC NOT FOR1984 SALE EMSOR for DISTRIBUTION Children program, under the Public Health Act, NOTprovides FOR funds forSALE enhancing OR the DISTRIBUTION EMS system to better serve pediatric patients. 1985 National Research Council publishes Injury in America: a Continuing Public Health Problem, describing defi ciencies in the progress of addressing the problem of accidental death and disability. 1988 National Highway Traffi c Safety Administration (NHTSA) initiates the Statewide EMS Technical Assessment program based on 10 key components of EMS systems. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1990 Trauma Care Systems and Development Act encourages development of inclusive trauma systems and provides funding to states for traumaNOT system FOR planning, SALE implementation, OR DISTRIBUTION and evaluation. NOT FOR SALE OR DISTRIBUTION 1993 Institute of Medicine publishes Emergency Medical Services for Children, which points out defi ciencies in the U.S. healthcare system’s ability to address the emergency medical needs of pediatric patients. 1995 U.S. Congress does not reauthorize funding under the Trauma Care Systems and Development Act.

Data from© NHTSA;Jones US Health & andBartlett Human Services, Learning, Public Health Services, LLC Health Resources and Services Administration,© Jones Maternal & and Bartlett Child Health Bureau: Learning, Emergency medical LLC systems educationNOT agenda FOR for the future: SALE a systems OR approach, DISTRIBUTION Washington, DC, 2000, US Department of Transportation.NOT FOR SALE OR DISTRIBUTION

working alongside paid EMS providers. This practice continues in many EMS systems today. The fi rst hospital-based ambulance services were at major ur- © Jones &ban Bartlett hospitals, suchLearning, as Cincinnati LLC General and Bellevue Hospitals© Jones & Bartlett Learning, LLC NOT FORin SALE the mid-1860s. OR DISTRIBUTION The fi rst motorized ambulances were placedNOT FOR SALE OR DISTRIBUTION into service by Michael Reese Hospital of Chicago in 1899 and St. Vincent’s Hospital in New York ( Figure 1-2). As automotive technology progressed, the style and capabilities changed accordingly (Figure 1-3). Many early ambulances were cramped and provided little room© toJones work during & Bartlett transport. Learning, The intro- LLC © Jones & Bartlett Learning, LLC duction of trucks and modifiNOT ed FOR vans inSALE the 1960s OR allowed DISTRIBUTION EMS NOT FOR SALE OR DISTRIBUTION providers to stand up inside the patient compartment. In 1972, St. Anthony’s Hospital in Denver, Colorado, began Flight for Life, which was the fi rst private air ambulance. This offered a faster mode of transport to specialized hospitals such as trauma centers.© JonesCurrent ambulances& Bartlett are Learning, “high-tech” LLCmobile intensive Figure 1-1© A Jones horse-drawn & Bartlett ambulance. Learning, Courtesy Flushing LLC Hospital, care unitsNOT capable FOR of SALE bringing OR advanced DISTRIBUTION medical care to patients Flushing, NewNOT York. FOR SALE OR DISTRIBUTION in need. The patient care areas are spacious enough to accom- modate several healthcare workers and equipment. seventh leading cause of death in the United States. It is now Trauma: a Force for Change in EMS the fi fth leading cause of death, with motor vehicle crashes ac- © Jones &Preventable Bartlett injury Learning, is the leading LLC cause of death in persons© Jones counting & Bartlett for approximately Learning, half theseLLC fatalities. NOT FOR1 SALEto 45 years OR of DISTRIBUTIONage. In civilian life the automobile has causedNOT a FORWhen SALE the battle-experiencedOR DISTRIBUTION physicians and surgeons saw powerful surge in deaths from trauma. In 1900, trauma was the that many of these patients could have been saved with earlier

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 1-3 An ambulance of the 1930s. Courtesy Flushing Hospital, Figure 1-2 An early motorized ambulance. The early models Flushing, New York. lacked the space and head clearance of modern ambulances. Courtesy Flushing Hospital, Flushing, New York. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION care, they helped focus national attention on the need for the (ECG) monitoring, defibrillation, intravenous (IV) therapy, rapid prehospital intervention that had been successfully dem- administration of medications, insertion of endotracheal onstrated on battlefi elds. Simple steps were recognized, includ- (ET) tubes, and other invasive medical skills. Dr. William ing bleeding control at the scene, safe patient handling, spinal Grace at St. Vincent’s Hospital in New York City quickly immobilization, and rapid transportation© Jones & toBartlett organized Learning, trauma adopted LLC this innovation so that© physicians, Jones & nurses, Bartlett and am-Learning, LLC centers. NOT FOR SALE OR DISTRIBUTIONbulance personnel could respondNOT to cardiacFOR SALE emergencies OR DISTRIBUTIONin In 1966 the U.S. National Academy of Sciences published the lower Manhattan. landmark paper Accidental Death and Disability: the Neglected Until this point, only physicians were providing advanced Disease of Modern Society, documenting that more Americans care in the prehospital setting. The introduction of biotelemetry died from accidental injuries in 1965 than died on the battlefi elds (transmission of electrocardiogram [ECG] by radio) extended in Vietnam.© Further,Jones if & seriously Bartlett wounded, Learning, a person LLC would have prehospital care© byJones allowing & EMS Bartlett providers Learning, to deliver advanced LLC a better chanceNOT of FOR survival SALE in a combat OR DISTRIBUTION zone than on an average life support underNOT the FOR direction SALE of a physician OR DISTRIBUTION at a base hospital. city street. The newly created Department of Transportation As part of its role in studying cardiovascular emergencies and (DOT) and National Highway Traffi c Safety Administra- treatment, every 5 years the American Heart Association (AHA) tion (NHTSA), a division of the DOT, were empowered with offers the Emergency Cardiovascular Care (ECC) guidelines, regulating EMSS, offering $48 million in grants between 1966 adopted by most agencies as the standard of care. © Jonesand &1973. Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The Physician and Emergency Medical Services NOT FOR In 1973,SALE federal OR legislationDISTRIBUTION provided funding for the devel- NOT FOR SALE OR DISTRIBUTION opment of EMS systems throughout the United States. After The physician’s role in the development of EMS systems demonstrations of effective trauma systems in Illinois and has been extremely important. Medical societies such as the Maryland, these grants accounted for the rapid growth of EMS American Academy of Orthopedic Surgeons and the Ameri- systems across the country. Money was allocated for the devel- can College of Surgeons played a signifi cant part in early opment of training programs,© communicationJones & Bartlett systems, Learning, hospi- EMSS LLC development. The DOT Bureau© Jones of Traffi & Bartlett c Safety asked Learning, LLC tal designations, and other essentialNOT FOR system SALE components. OR DISTRIBUTION Many these physician groups to developNOT a FORstandardized SALE curricu- OR DISTRIBUTION EMS systems developed as a direct result of this legislation and lum for ambulance personnel. Physicians still work closely funding. with the EMS Division of NHTSA under DOT to ensure the Medical knowledge and related technology were incorpo- continued development of national training curricula at all rated into EMS care as new advances became available. For levels. example, ©in Jonesthe 1960s, & cardiopulmonaryBartlett Learning, resuscitation LLC (CPR) Physician groups© Jones such & as Bartlettthe American Learning, College of LLC Emer- using chestNOT compression FOR SALE and positive-pressure OR DISTRIBUTION ventilation was gency PhysiciansNOT and FOR the SALE National OR Association DISTRIBUTION of EMS introduced, and portable defi brillators to resuscitate victims Physicians have joined their surgical colleagues and have of cardiac arrest became available. Physicians brought resusci- an active leadership role in national EMSS development. tation equipment into the fi eld to reach their patients earlier, Physicians are the “medical conscience” of EMS. All levels when they had a better chance of survival. of EMS provider function under the direction of a physician © Jones The & Bartlettfirst advanced Learning, life support LLC unit was introduced © Jonesadvisor or& Bartlett medical director. Learning, Medical LLC directors work locally NOT FORin Belfast, SALE Ireland, OR DISTRIBUTIONunder the direction of Dr. Frank Pan- NOTwith FOR services SALE to establish OR DISTRIBUTION protocols, monitor patient care, and tridge. Advanced life support included electrocardiographic provide continuing education.

Although physicians have functioned as prehospital pro- © Jones viders& Bartlett in some Learning, areas in the LLCUnited States, their role as fi© eld Jones Overview & Bartlett of Learning,the Emergency LLC Medical NOT FORproviders SALE ORhas beenDISTRIBUTION limited since the 1940s. For many rea-NOT FORServices SALE System OR DISTRIBUTION sons, including resource allocation and costs, nonphysicians currently staff almost all ambulances in North America. In As described in the EMS Agenda for the Future, EMS systems some countries, such as Russia, Norway, France, Brazil, and require many components to function effectively. Each compo- Germany, physicians still routinely respond in ambulances or nent must be carefully designed and based on the needs of the helicopters. © Jones & Bartlett Learning, LLCindividual EMSS. © Jones & Bartlett Learning, LLC The Future of EMSNOT FOR SALE OR DISTRIBUTION Public Access NOT FOR SALE OR DISTRIBUTION The EMS Agenda for the Future, developed in cooperation with Because an EMSS involves a large number of resources, some several national organizations, provides recommendations to method of coordination and communication is essential. In refi ne and continue development of EMS systems over the many areas, simple and convenient access has been accom- coming© years,Jones as follows: & Bartlett Learning, LLC plished through© Jones the 9-1-1& Bartlett emergency Learning, telephone system.LLC This NOT FOR SALE OR DISTRIBUTION system allowsNOT rapid FOR access SALE to all elements OR DISTRIBUTION of emergency care and Emergency medical services (EMS) of the future will be commu- support services, including EMS, fi re department, and police. In nity-based health management that is fully integrated with the overall the 9-1-1 system a central dispatch center coordinates resources health care system. It will have the ability to identify and modify illness and personnel within the system. and injury risks, provide acute illness and injury care and follow-up, Some EMS systems have “enhanced 9-1-1” (E-911) commu- © Jones &and Bartlett contribute Learning,to treatment of LLC chronic conditions and community© Jones nication & Bartlett systems. E-911Learning, allows the LLC dispatcher to track the call- health monitoring. This new entity will be developed from redistribu- er’s exact location. This knowledge becomes important when NOT FORtion SALE of existing OR health DISTRIBUTION care resources and will be integrated with otherNOT FOR SALE OR DISTRIBUTION the caller disconnects, becomes unconscious during the call, or health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of when a bystander unfamiliar with an area calls for help. In the acute health care resources. EMS will remain the public’s emergency case of some natural disasters a “reverse 9-1-1” system has been medical safety net. used to notify residents of a community to evacuate. With the © Jones & Bartlett Learning, LLCwide use of cell phones, new© technologies Jones & are Bartlett being introduced Learning, LLC The agenda lists 14NOT essential FOR components: SALE OR integration DISTRIBUTION of to track the caller’s location NOTand aid FOR response. SALE Some OR vehicles DISTRIBUTION are health services, EMS research, legislation and regulation, system now equipped with tracking and monitoring equipment such fi nance, human resources, medical direction, education systems, as Onstar. With this equipment a vehicle can notify the central public education, prevention, public access, communication dispatch center if the vehicle has been involved in a collision systems, clinical care, information systems, and evaluation. and can alert authorities of the vehicle’s location. A ©partner Jones document & Bartlett to the Learning,agenda is the LLC EMS Education Other ©areas Jones still rely & on Bartlett different seven-digitLearning, telephone LLC num- AgendaNOT for the FOR Future. SALE Focusing OR on DISTRIBUTION the educational structure for bers to accessNOT emergency FOR SALE assistance. OR DISTRIBUTION EMS, this document identifi es a specifi c scope of practice for each level, then replaces the “DOT objectives” with “education Elements of a Communication System standards” for each level (Figure 1-4). A modern EMSS may contain several communication components. A dispatch system receives the call for help and sends the © Jones & Bartlett Learning, LLC © Jonesappropriate & Bartlett response Learning, vehicles to theLLC scene. An ambulance com- The universe of Periodic munication system allows the prehospital provider in the fi eld NOT FOR SALE OR DISTRIBUTIONNational EMS NOT FOR SALE OR DISTRIBUTION EMS knowledge updates of to communicate with dispatch, with receiving hospitals, and and skills core content these three documents with medical control. The Dispatch System Delineation of National EMS provider practice scope of practice The dispatch center receives calls, categorizes them according to levels © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONpriority, provides fi rst-aid instructionsNOT FOR to callers, SALE and OR dispatches DISTRIBUTION the closest appropriate emergency service vehicle (e.g., police, Replaces the current national National EMS fi re), rescue personnel, and equipment. Many emergency ser- standard curricula education standards vice vehicles have vehicle locators so that the dispatcher can see the vehicle’s exact location in respect to the call. Dispatch serves © Jones & Bartlett Learning, LLC as a communication© Jones point& Bartlett through Learning,which an EMT LLC can call for NOTNational FOR EMS SALE OR DISTRIBUTIONNational EMS education additionalNOT resources. FOR The SALE dispatch OR center DISTRIBUTION may also relay infor- certification program accreditation mation from the scene of an incident to the receiving facility and advise the EMT on facility selection and availability of other Figure 1-4 The EMS education agenda for the future: a systems rescue personnel (Figure 1-5) . The dispatcher may also advise approach. A single agency for each function. Redrawn from the caller or bystanders on initial treatment steps to help the National Highway Traffi c Safety Administration: National EMS © Jones & Bartlett Learning, LLC © Jonespatient & Bartlettuntil the ambulance Learning, arrives. LLC agenda for the future, Washington, DC, 2005, US Department of A formal national training program has been developed to NOT FORTransportation. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION train dispatch personnel to deal with the complexities of their

Figure 1-5 © A computerizedJones & Bartlett dispatch workstationLearning, in LLCa commu- © Jones & Bartlett Learning, LLC nication center.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Figure 1-7 An EMT in the ﬁ eld communicates by a portable © Jones & Bartlett Learning, LLC © Jonesvoice radio. & Bartlett Cellular phones Learning, and landline LLC phones are also used NOT FOR SALE OR DISTRIBUTION NOTto communicateFOR SALE with OR dispatch DISTRIBUTION or medical direction.

as alerting the trauma team or preparing an isolation room for a patient with a possible infectious disease.

© Jones & Bartlett Learning, LLC LEARNING OBJECTIVE © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Differentiate the role and responsibilitiesNOT of FOR the EMT SALE from those OR of DISTRIBUTION other prehospital care providers.

Levels of Training Figure 1-6 Online medical direction. A physician at a hospital communication© Jones base station& Bartlett can speak Learning, directly with LLC the EMT A wide range ©of Jonesillnesses and& Bartlett injuries require Learning, emergency LLC care. about a patient’sNOT FORstatus andSALE give ordersOR DISTRIBUTION regarding treatment Every year approximatelyNOT FOR 16 millionSALE patients OR DISTRIBUTION in the United States and transport. are transported by ambulance to emergency departments, usually because of chest pain, shortness of breath, abdominal pain, injury from a motor vehicle crash or other accident, convul- sions, or general weakness. Persons presenting with imminent © Jonesjob. Emergency & Bartlett Medical Learning, Dispatch (EMD) LLC is now a recognized pro- © Joneschildbirth, & poisoning,Bartlett Learning,or uncontrolled LLC bleeding are examples NOT FORgram. SALEEMD professionals OR DISTRIBUTION are skilled coordinators of emergency NOTof theFOR types SALE of emergencies OR DISTRIBUTION for which immediate attention is care communication and play a vital role in EMS systems. required. For each patient category, distinct interventions can improve the patient’s chances for survival. Ambulance-to-Hospital Communication Systems Patients themselves should know the signs and symptoms of Many EMS systems provide communication from the fi eld illnesses that require immediate intervention and how to access personnel to the physician ©at Jonesa base hospital & Bartlett or medical Learning, di- the LLC EMSS. They also should know© some Jones basic &self-help Bartlett measures Learning, LLC rection center, often referredNOT to as FOR online SALE medical OR direction DISTRIBUTIONin the event that immediate help fromNOT bystanders FOR SALE is not available. OR DISTRIBUTION (Figure 1-6; see later discussion). These communication systems may include both voice and biotelemetric components. Lay Rescuers Field providers may consult medical direction for advice about Often the fi rst person to recognize an emergency condition is treatment and transportation decisions or to speak directly another member of the community. For certain conditions that with patients© Jones who are &refusing Bartlett care orLearning, transport to LLC the hospital render someone© Joneshelpless, actions& Bartlett by bystanders Learning, and those LLC fi rst ( Figure 1-7NOT). FOR SALE OR DISTRIBUTION to respond canNOT make FOR the critical SALE difference. OR DISTRIBUTION Simple knowledge, Biotelemetry allows transmission of ECG data from the pa- such as how to open an airway or control bleeding, may be all tient in the fi eld to the physician at the base hospital or medi- that is necessary to save a life. cal control facility. Cellular phones and radio transmission are When performed in a timely fashion, CPR and use of an au- used for both voice communication and biotelemetry. tomated external defi brillator (AED) may save thousands of lives © Jones Most & Bartlett hospitals Learning,have dedicated LLC phones or radio equipment © Joneseach year & ( Figure Bartlett 1-8) .Learning, Training in CPR LLC and other basic fi rst- NOT FORfor communication SALE OR DISTRIBUTIONwith EMTs in the fi eld. In some cases the NOTaid FORskills maySALE result OR in certifiDISTRIBUTION cation that permits laypeople to hospital makes special preparations for the EMT’s arrival, such serve as responders in the workplace or other environments.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Provider National Provider level 4 EMS core Provider level 1 Provider level 3 content level 2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Figure 1-9 Four levels of EMS providers. Provider level 1: Emergency Medical Responder (EMR); level 2: Emergency Medical Technician © Jones & Bartlett Learning, LLC (EMT); level© 3:Jones Advanced & EMT; Bartlett level 4: Paramedic.Learning, Redrawn LLC from Figure NOT 1-8 A FORlay responder SALE performs OR DISTRIBUTION one-person cardiopulmo- NOT FOR SALE OR DISTRIBUTION nary resuscitation (CPR). National Highway Traffi c Safety Administration: National EMS scope of practice model, Washington, DC, 2005, US Department of Transportation. REAL World © Jones &In Bartlett recognition Learning, of the importance LLC of bystander care, NHTSA has© Jones & Bartlett Learning, LLC developed a bystander care program entitled First There, First Education and Scope of Practice NOT FOR SALECare. This OR campaign DISTRIBUTION identifi es target audiences, develops outreachNOT FOR SALE OR DISTRIBUTION strategies for the general public, and provides tools for conducting The NHTSA provides a widely used national curriculum for local training to teach bystander care. various levels of EMT. A paradigm shift in EMS education, how- The program is designed to educate the public on fi ve life- ever, is now underway. The concept is simple: a core content of sustaining skills that can be used at a motor vehicle crash: (1) stop to knowledge and skills for EMS providers. The National EMS Core help, (2) call for help, (3)© assess Jones the victim, & Bartlett (4) start the Learning, breathing, LLCContent serves as the total ©domain Jones of knowledge& Bartlett from Learning, which LLC and (5) stop the bleeding.NOT The purposeFOR SALEis to teach OR the publicDISTRIBUTION that the National EMS Scope of PracticeNOT FORModel derivesSALE national OR DISTRIBUTION EMS bystander involvement can sustain a life until EMS arrives. provider levels. The National EMS Education Standards will de- rive educational objectives to guide EMS training in the future. The AHA’s bystander program is structured around the EMTs at various levels provide the foundation of EMS educa- “chain of survival” concept that defi nes four critical links for tion for the future. Currently, there are four national levels of bystanders© Jones treating & personsBartlett with Learning, heart attack, LLCstroke, choking, EMT described© Jones in the scope& Bartlett of practice Learning, document ( FigureLLC 1-9 ). and respiratoryNOT FOR and SALE cardiac ORarrest. DISTRIBUTION The four links include early Emergency NOT Medical FOR Responders SALE OR(First Responders).DISTRIBUTION Sometimes a access to 9-1-1, early CPR, early defi brillation, and early ad- community will plan for a formal response to the call for help vanced care. Bystanders are encouraged to deliver the fi rst three by training certain people to administer emergency care before links in the chain, including CPR and early defi brillation using EMTs in an ambulance arrive. For example, EMTs, Advanced an AED (see Chapter 12). EMTs, or paramedics may respond in fi rst-responder vehicles © Jones & BartlettThis type of Learning, program recognizes LLC that the time from collapse© Jones and &arrive Bartlett at a patient’s Learning, side before LLC the ambulance, shorten- NOT FORto SALE provision OR of DISTRIBUTIONcare plays an essential role in victim survival.NOT FORing the SALE time from OR the DISTRIBUTION emergency event to patient care. Other For example, the chances of survival for victims of cardiac ar- trained fi rst responders may include police offi cers, fi refi ghters, rest resulting from ventricular fi brillation decrease by 7% to industrial workers, teachers, coaches, and other volunteers. 10% for each minute that passes from the time of collapse until First responders, or emergency medical responders (EMRs), defi brillation is provided. Performance of CPR can extend that have a wider range of skills than most bystanders, including critical period by delivering© Jones oxygen to& theBartlett heart and Learning, brain until LLCmanagement of medical emergencies,© Jones childbirth,& Bartlett and Learning, specifi c LLC defi brillation is used to NOTrestore FORa normal SALE heart rhythm.OR DISTRIBUTION pediatric emergencies. First NOTresponders FOR are SALE often equipped OR DISTRIBUTION with Community education programs that provide the public oxygen, AEDs, and airway equipment and may respond in po- with basic fi rst-aid skills may be taught by several different lice cars, fi re apparatus, or special fi rst responder vehicles. community groups. Programs taught in school systems, scuba First responders may take a course following a national stan- diving training, Boy Scouts and Girl Scouts, and other organi- dard. The fi rst responder is trained to recognize emergencies, zations© Joneseducate a & signifi Bartlett cant cross Learning, section of LLCthe community. initiate care,© Jones and have & the Bartlett necessary Learning,skills to save a LLC life with the OtherNOT even FORmore basicSALE actions, OR suchDISTRIBUTION as recognizing the signs use of a minimumNOT FOR of equipment. SALE OR DISTRIBUTION of a heart attack and stroke, and calling 9-1-1 for help, are of- Emergency Medical Technician. There are hundreds of thou- ten taught in the mass media to reach even more people in the sands of registered EMTs nationwide and the numbers con- community. tinue to grow. They provide the foundation for prehospital care As an EMT, you should value the contribution made by by- ( Figure 1-10). DOT defi nes an emergency medical technician © Jones &standers Bartlett since Learning, they serve as LLCthe “bridge of life support” from© Jones (also & called Bartlett EMT-Basic Learning,) as someone LLC who has successfully com- NOT FORcollapse SALE to OR your DISTRIBUTIONarrival. You can also play an educational roleNOT by FORpleted SALE a training OR program DISTRIBUTION according to the NHTSA Emergency becoming a CPR, AED, and fi rst-aid instructor. Medical Technician National Standard Curriculum or is trained

Figure 1-10© An Jones EMT administers & Bartlett treatment Learning, to an injured LLC patient. Figure © 1-11 Jones A modern & Bartlett emergency Learning, department. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

within the new educational paradigm meeting the scope of prac- training is available through programs sponsored by hospitals, tice proposed by NHTSA and having the requisite knowledge of community colleges, and other agencies. the EMS core content. This is the course that you are taking Paramedics also may be used for critical care transport op- © Jonesnow & for Bartlett initial or refresher Learning, training. LLC © Joneserations. & In Bartlettthese types Learning, of services, EMS LLC providers are involved NOT FOR The SALE EMT curriculum OR DISTRIBUTION involves attending lectures and receiv- NOTprimarily FOR inSALE the transfer OR ofDISTRIBUTION acutely ill and injured patients from ing practical and clinical instruction in the assessment and man- one care center to another. Often EMS providers who function agement of the acutely ill or injured patient. The EMT provides in this role have additional training in specialized devices, such basic emergency medical care and transportation for critical as intravenous pumps (devices that deliver IV fl uids more pre- and emergent patients who access the EMS system. EMTs func- cisely) and balloon pumps (devices that enhance circulation in tion as part of a system under© Jones medical oversight& Bartlett and Learning,perform patients LLC with cardiovascular failure).© Jones Paramedics & Bartlett or critical careLearning, LLC interventions with basic equipmentNOT FOR on an SALE ambulance. OR DISTRIBUTIONEMTs nurses also are used in medical evacuationNOT FOR (medevac) SALE helicop-OR DISTRIBUTION may assist patients with their medications and, under medical ter programs. These programs often are designed to transport direction, may give medication such as aspirin to patients with critically ill patients from the scene of the emergency or a local chest pain and oral glucose to patients with low blood glucose. community hospital to specialized care facilities. In many communities, it is the EMT providing the large por- tion of out-of-hospital© Jones & care. Bartlett In rural Learning, areas, they may LLC represent The Healthcare© Jones System & Bartlett Learning, LLC the highestNOT level ofFOR EMS SALEcare. The OR EMT’s DISTRIBUTION care is based on assess- NOT FOR SALE OR DISTRIBUTION ment fi ndings. Their scope of practice is limited to basic skills that are effective and can be performed in an out-of-hospital Emergency Departments setting with medical oversight and limited training. Modern emergency departments (EDs) are vital centers of acute Advanced Emergency Medical Technician. The advanced emer- medical and trauma care that serve as the intersection between © Jonesgency & medicalBartlett technician Learning, (AEMT) LLC is also called the EMT- © Jonesthe prehospital & Bartlett and hospital Learning, phases of LLC care (Figure 1-11). In the NOT FORIntermediate SALE (EMT-I). OR DISTRIBUTION NOTED FORthe patient SALE is evaluated OR DISTRIBUTION and treated, and decisions are made With additional training, EMTs may function at a more ad- about the need for further care, including admission to the hos- vanced level. Various designations are used for advanced EMTs, pital, transfer to an operating room, or discharge home. Hospi- but the trend is toward standardizing certifi cation to three lev- tals may have specialty teams that respond quickly to patients els: the EMT, the advanced EMT, and the paramedic. with time-critical illness and injury, such as stroke, trauma, and Advanced training includes© Jones skills such & Bartlettas ECG interpreta- Learning,cardiac LLC conditions. © Jones & Bartlett Learning, LLC tion, advanced or alternativeNOT airway FOR management SALE OR (i.e., DISTRIBUTION ET The standards for EDs also haveNOT advanced FOR SALEover the ORpast 25DISTRIBUTION intubation, dual-lumen airway device), IV fl uid therapy, and years. Many communities have developed minimum standards administration of certain IV medications. for staff, space, equipment, and availability of specialists (e.g., Advanced EMT training is shorter and more focused than the neurosurgeons, orthopedists). The National EMSS Act of 1973 paramedic level. Advanced EMT programs are more often used stimulated much of this progress, citing hospital facilities as in rural volunteer© Jones EMS & systems, Bartlett where Learning, attending longer LLC training a key component© Jones of EMS &systems. Bartlett Currently, Learning, these standards LLC programsNOT may not FOR be feasible SALE and OR call volumesDISTRIBUTION are lower. are set by variousNOT organizations, FOR SALE including OR DISTRIBUTIONstate departments of Paramedic. The highest level of training for advanced health, The Joint Commission (TJC; formerly Joint Commis- EMTs is usually referred to as paramedic. A paramedic has sion on Accreditation of Healthcare Organizations [JCAHO]), completed a course that followed the standardized national and other professional organizations. curriculum as prescribed by NHTSA or meets the standards of The acutely ill or injured patient may be admitted to the hos- © Jonesthe new& Bartlett educational Learning, paradigm. A LLCparamedic performs advanced © Jonespital. Some & patientsBartlett may Learning, go directly from LLC the ED to the operating NOT FOR techniques, SALE such OR as DISTRIBUTIONECG interpretation, drug therapy, inva- NOTroom, FOR cardiac SALE catheterization OR DISTRIBUTION laboratory, or a critical care unit for sive airway techniques, and manual defi brillation. Paramedic additional treatments, monitoring, or both ( Figure 1-12 ). Various

Figure © 1-12 Jones Surgery & in Bartlett an operating Learning, room may LLCbe part of Figure 1-13© Jones Patients &may Bartlett be admitted Learning, to a critical LLCcare unit. additional NOT emergency FOR SALE treatment. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

types of critical care or intensive care units exist for patients with Liaison with Other Public Safety Workers different problems, such as cardiac, respiratory, surgical, pediat- The EMT interacts with various public safety personnel at the ric, and high-risk obstetric and neonatal ( Figure 1-13 ). scene of a call. Police, fi re service, public utility workers, and © Jones & Bartlett Learning, LLC © Jonesstate & and Bartlett federal law Learning, enforcement LLC offi cers are key resources at general medical or trauma emergencies, crime or motor vehicle NOT FOR SALE REAL OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION World crash scenes, mass casualty incidents, and behavioral emergen- Of all patients transported to emergency departments, 14% arrive cies. Become familiar with the resources in your region and by ambulance. For patients under 15 years of age, 3.8% arrive by how to contact them when needed. Understand and respect ambulance. For patients over 75 years, 40.9% are transported by the roles, responsibilities, and authority of various resources at ambulance. © Jones & Bartlett Learning, LLCemergency scenes. © Jones & Bartlett Learning, LLC Can you think of reasons for such a difference at these extremes Many systems provide a tiered response to certain calls. For of age? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Data from Institute of Medicine: EMS at the crossroads, Washington, example, police or fi re service personnel may be dispatched DC, 2006. as fi rst responders to provide immediate care (e.g., AED use, bleeding control) before arrival of the ambulance. Police offi - cers often assume responsibility for notifi cation of family, se- Specialty© Jones Referral & CentersBartlett Learning, LLC curing valuables© Jones or property, & Bartlett and assisting Learning, with violent LLC patients Some NOT patients FOR have SALE unique needsOR DISTRIBUTION that require the care of spe- or other behavioralNOT FOR emergencies. SALE OR DISTRIBUTION cially trained individuals, using highly specialized equipment. When multiple agencies are needed at an emergency incident, Specialty referral services include trauma centers, burn centers, the roles and command function are assigned by the nature of pediatric intensive care, neonatal (newborn) centers, cardiac the incident. In general, police take charge at any crime scene centers, and hyperbaric centers for victims of diving injuries or or where crowd or traffi c control may be needed. Fire personnel © Jones &poisoning Bartlett with Learning, carbon monoxide. LLC EMTs may transport certain© Jones would & takeBartlett charge Learning,at a fi re scene. LLCAn EMT’s primary concern is NOT FORpatients SALE directly OR DISTRIBUTION to a specialty referral center, at times bypassingNOT FORpatient SALE care. The OR EMT DISTRIBUTION must know the roles of the various agen- other hospitals. cies in the region so that all can work in a coordinated and a safe, effective manner. An incident management system, also known Hospital Personnel as an “incident command system,” has been established to al- The EMT is part of a larger team of personnel who care for the low for clear lines of authority and responsibilities at the scene patient at each phase of© the Jones EMSS. &These Bartlett individuals Learning, also can LLCof an emergency when many© agencies Jones respond & Bartlett and must Learning, work LLC serve as a resource for information,NOT FOR feedback SALE aboutOR DISTRIBUTION a patient’s together to resolve the emergencyNOT situation FOR SALE (see Chapter OR 28).DISTRIBUTION condition, and continuing education. Mutual respect and ap- preciation of each team member’s contribution are essential to Local Emergency Medical Services System promote effective communication and continuity of care. The To perform optimally for the patient, EMTs should become hospital team members include the following: familiar with the components of their local EMSS. All the • The © physician, Jones who& Bartlett is responsible Learning, for the overall LLC management components© Jones just described & Bartlett are part Learning, of everyday LLCEMT prac- of theNOT patient FOR in the SALE prehospital OR DISTRIBUTIONand hospital phases of care. tice. FamiliarityNOT FORwith theSALE access OR and DISTRIBUTION communication system • The nurse, who coordinates care in the ED, operating room, is an essential fi rst step. Knowing the levels of training allows critical care units, and other general medical-surgical units in the EMT to interact appropriately with fi rst responders and addition to directing patient care duties. advanced-level EMTs who may also arrive at the scene. Treat- • Other health professionals, such as physician assistants, nurse ment, triage (sorting according to medical need), and transport © Jones &practitioners, Bartlett Learning, respiratory LLCtherapists, radiology technicians,© Jones protocols & Bartlett should be Learning, learned and LLCcarried in the vehicle, because NOT FOR SALEand a host OR of personnelDISTRIBUTION who tend to the various needs ofNOT the FORthey describe SALE the OR key DISTRIBUTION patient care decisions and interaction with patient in the hospital. medical direction. Familiarity with the designations of specialty

Figure 1-14© EMTs Jones using & personal Bartlett protective Learning, equipment LLC © Jones & Bartlett Learning, LLC during CPR.NOT FOR SALE OR DISTRIBUTION Figure 1-15 A high-effiNOT FOR ciency SALE particulate OR air DISTRIBUTION (HEPA) respirator is an important defense against diseases spread by airborne transmission, such as tuberculosis, chickenpox, measles, receiving hospitals is necessary when critical patients with spe- and smallpox. From Chapleau W, Pons P: Emergency medical cial needs, such as for burn or trauma center care, are identifi ed technician, St Louis, 2007, Mosby-Elsevier. © Jonesin the & fi Bartletteld. EMTs Learning,must know the LLC initial steps to take when as- © Jones & Bartlett Learning, LLC NOT FORsisting SALE at a disaster. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Orientation sessions and review of policies and protocols assist The choice of a particular piece of equipment depends on the the EMT in gathering this important information. Continuing ed- circumstances of a given call. For example, gloves are used ucation and studying current local and state EMS updates allow the routinely when exposure to blood or body fl uids may occur, EMT to retain essential information and stay abreast of change. such as when bandaging a minor wound. Goggles are used when © Jones & Bartlett Learning,there LLC is a potential for an eye splash© Jones of blood or& bodyBartlett fl uid. ThisLearning, LLC LEARNING OBJECTIVES NOT FOR SALE OR DISTRIBUTIONcan happen during suctioning NOTor administration FOR SALE of positive- OR DISTRIBUTION • Describe the roles and responsibilities of the EMT related to per- pressure ventilation. A special mask is used if tuberculosis or sonal safety. another airborne pathogen is suspected (see Chapter 2). • Discuss the roles and responsibilities of the EMT toward the safety of Prevention is the key in matters of safety. Developing good the crew, the patient, and bystanders. habits early in your clinical experience ensures the safest pos- © Jones & Bartlett Learning, LLC sible approach.© You Jones will learn & Bartlett more about Learning, the specifi cs ofLLC safety NOT FOR SALE OR DISTRIBUTION later in this chapterNOT and FOR in Chapter SALE 2. OR DISTRIBUTION Roles and Responsibilities of the EMT Patient Assessment The work of an EMT is diversifi ed and provides challenge and Assessment is one of your primary responsibilities as an EMT. gratifi cation. As an EMT, you will function in several roles that It involves the systematic collection and analysis of information © Jonescall for& Bartlettmedical, technical, Learning, clerical, LLC and social interaction skills. © Jonesreceived &through Bartlett a patient Learning, history, vitalLLC signs, and a physical NOT FORMany SALEof these skillsOR DISTRIBUTIONwill be acquired during classroom training NOTexamination FOR SALE (Figure OR 1-16 DISTRIBUTION). Become a skilled observer who can sessions. Other skills will develop during clinical fi eld experi- recognize problems quickly and respond accordingly. ence under the supervision of senior EMTs or instructors. Patient assessment is probably the most diffi cult skill to master as an EMT because it involves many different areas of Primary Responsibilities knowledge. You will learn to obtain a concise history from a © Jones & Bartlett Learning,patient LLC who may be in severe pain,© confused,Jones &or Bartletthysterical. ThisLearning, LLC Personal Safety and SafetyNOT of Others FOR SALE OR DISTRIBUTIONwill require patience and much NOTpractice. FOR You SALEwill learn OR which DISTRIBUTION Primary concern for safety is the fi rst and most important step facts are relevant to each type of chief complaint and how to on every call. Scene safety is the fi rst part of patient assessment. avoid unnecessary questioning that wastes time. The use of cones and fl ares, proper positioning of emergency vehicles, and wearing refl ective clothing at the scene are all basic Patient Care Based on Assessment Findings defenses against© Jones personal & Bartlett injury. Other Learning, conditions LLCthat may be Your training ©will Jones prepare &you Bartlett to respond Learning, to a variety of LLC critical consideredNOT include FOR hazardous SALE materials OR DISTRIBUTION or toxic gases, aggressive problems, rangingNOT from FOR immobilization SALE OR of DISTRIBUTIONa fractured leg to re- animals, violent patients or bystanders, and electrical hazards. suscitation of a cardiac arrest victim ( Figure 1-17). In some cases, The risk of exposure to communicable disease is real and time may not allow a prolonged analysis because many true emer- should be taken seriously. The primary defenses against dis- gencies require treatment while assessment continues. Signifi cant ease transmission are personal protective equipment (PPE) loss of blood or complete airway blockage requires a refl ex reac- © Jonesand &handwashing Bartlett ( Learning,Figure 1-14). Gloves,LLC eye protection, gowns, © Jonestion that &you Bartlett can develop Learning, only with intensive LLC classroom and clini- NOT FORand high-effi SALE ciency OR DISTRIBUTIONparticulate air (HEPA) respirator masks NOTcal practice.FOR SALE Other treatments OR DISTRIBUTION you will learn include CPR, oxygen are examples of basic PPE carried by an EMT (Figure 1-15). therapy, assisting at childbirth, management of poisoning and

©Figure Jones 1-16 &An Bartlett EMT performs Learning, patient assessment. LLC Figure 1-18© The Jones patient & is Bartlett secured to Learning, an immobilization LLC device. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Figure 1-19 An EMT presents a patient history to the emergency physician, providing details gathered from the time of fi rst con- © Jones & Bartlett Learning, LLC tact, which© can Jones play a major& Bartlett role in diagnosis Learning, and treatment. LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 1-17 An EMT performs cardiopulmonary resuscitation. you take on a great responsibility. Although the law allows certain exemptions while you are operating an emergency vehicle, you are overdose, treatment of shock states, and psychological fi rst aid. still responsible for maintaining control of the vehicle at all times. Knowing when to transport a patient and when to choose a special You must be familiar with the best possible routes in your © Jones &institution Bartlett (e.g., Learning, burn center) LLCis also important. © Jonesarea. & You Bartlett should know Learning, the traffi c LLC patterns at all times of the day NOT FOR SALE OR DISTRIBUTION NOT FORand the SALE alternate OR routes DISTRIBUTION in the event that your original route is Lifting and Moving obstructed. Many patients you encounter will be injured and require care- The safe and appropriate transport of your patient is another ful handling. A victim with a suspected spinal injury should be aspect of emergency vehicle operation. Contrary to popular be- immobilized to prevent further injury during transport (Figure lief, most patients do not benefi t from a frantic ride to the hos- 1-18). As an EMT, you© will Jones become & familiar Bartlett with Learning, a variety of LLCpital with lights fl ashing and© siren Jones blaring. & Bartlett Learning, LLC spinal immobilization NOTmethods, FOR splinting, SALE different OR DISTRIBUTION types of When you arrive at the EDNOT with FORyour patient, SALE you OR should DISTRIBUTION be stretchers, and rapid removal techniques. ready to transfer care of the patient to the ED staff. You may need The needs of patients vary widely, from an elderly patient who to continue certain aspects of care, such as resuscitation, until needs a stair chair to be helped to the ambulance, to a seriously the nurse, physician, or other healthcare professional assumes injured patient who must be rapidly extricated from a burning responsibility. You should present a brief report that highlights automobile.© Jones As an & EMT, Bartlett you become Learning, an expert LLC in movement, key aspects© ofJones the assessment & Bartlett and treatment Learning, performed LLC in the matchingNOT a particularFOR SALE strategy OR with DISTRIBUTION the needs of a patient. You fi eld (Figure NOT 1-19 FOR). SALE OR DISTRIBUTION should carefully learn and practice these techniques during and after your EMT course. Record Keeping Accurate records play an important role in the management of Transport and Transfer of Care the patient because they become the reference point for infor- © Jones &If yourBartlett rapid responseLearning, to a call LLC results in a preventable injury© to Jones mation & Bartlett after your Learning,departure from LLC the hospital ( Figure 1-20). NOT FORyourself, SALE your OR partner, DISTRIBUTION or a patient, you have defeated your pur-NOT FORPrehospital SALE assessment OR DISTRIBUTION fi ndings and the chronology of prehos- pose. When you get behind the wheel of an emergency vehicle, pital events and treatments are very important because they

Prehospital Care Report

© Jones & AgencyBartlett Learning,Unit # LLCTrip # ©Type Jones of incident & Bartlett Learning, LLCDate of service NOT FOR SALE OR DISTRIBUTION Medical TraumaNOT FORNo patient SALE Refusal OR # DISTRIBUTION of Patients / / Incident location Pt. destination Transport by Attendant Certification level Attendant Certification level Driver Certification level

Patient’s age Sex F M Chief complaint Mechanism of injury Narrative © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

NOT FOR SALEPrevious medical OR history DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Medications

Allergies Charted by Patient Vital Signs Blood Pulse © JonesRespirations & BartlettPupils Learning,Movement of extremities LLC Glasgow Pulse oximeter © JonesCardiac rhythm& Bartlett Learning, LLC Time pressure rate Rhythm rate Rhythm/quality LR R - arm - L R - leg - L Eyes Verbal Motor SaO2 O2LPM / NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION / /

NOT FOR SALEIV Therapy OR DISTRIBUTION NOTMedications FOR SALE OR DISTRIBUTION

Time Solution Site Size Rate Initials S/U Medication Dose Route Time Time Time Time Order from Response to treatment

Tone Responding On scene ALS on Departed Arr hosp In service

City, State, Zip Relationship

Hospital notification Assistance Call outcome

Med channel #______Base physician Police Fire Response code 2 3 Transported to facility © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Cellular Amb dispatch Sheriff Other Transport code 2 3 Care transferred in field NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Landline Other State Patrol Air Life Flight for Life Helicopter transport Cancelled Figure 1-20 A prehospital care report. Modiﬁ ed from HealthONE EMS Patient Care Report, courtesy HealthONE EMS, Englewood, Colo.

symptoms can be caused by serious conditions such as carbon © Jones & Bartlett Learning, LLC © Jonesmonoxide & Bartlett poisoning Learning, or serious infections LLC (e.g., meningitis, an- NOT FOR SALE OR DISTRIBUTION NOT FORthrax). SALE Intoxication OR DISTRIBUTIONcan often mask a serious underlying injury. Once again, you should focus on the patient.

Other Responsibilities © Jones & Bartlett Learning, LLC Public Education © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAn important responsibilityNOT of the EMTFOR is SALEto educate OR the DISTRIBUTION public and help prevent injuries. Programs such as community CPR classes can go a long way in increasing the chance of survival of a heart attack victim. Bicycle helmet and safety programs help prevent injuries. © Figure Jones 1-21 & An Bartlett EMT should Learning, show compassion. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ExtricationNOT FOR SALE OR DISTRIBUTION Although extrication is not a primary EMT responsibility, are the only source of documentation from the scene. When sometimes you may be called on to gain access to and free peo- you leave the hospital, physicians and nurses will refer to the ple trapped in automobiles. This activity is usually the function prehospital care report to retrieve essential information. You of specialized rescue personnel within EMS, police department, © Jones &should Bartlett develop Learning, good habits andLLC record pertinent data from© the Jones or fi &re department.Bartlett Learning, However, when LLC these units are not imme- NOT FORtime SALE of the OR initial DISTRIBUTION patient encounter until arrival at the hospital. NOT FORdiately SALE available, OR or DISTRIBUTIONwhen regional systems incorporate these Many EMS systems are using electronic prehospital care reports functions into the EMT’s protocols, you must be prepared to whereas others are still using handwritten forms. Regardless of bring about a safe and effi cient rescue. In most situations, you the type of program your system uses, your documentation will perform “light extrication,” or extrication with the use of must be thorough, chronological, and clear. Accuracy is another basic tools, such as screwdrivers, crowbars, and hacksaws. necessary ingredient in© effective Jones documentation. & Bartlett Learning,Times, vital LLCIf “heavy extrication” is assigned© Jones through & Bartlett regional protocols, Learning, LLC sign values, and other NOTdiagnostic FOR fi ndings SALE should OR beDISTRIBUTION recorded specialized programs are usuallyNOT conducted FOR SALE to teach OR the DISTRIBUTIONproper carefully to aid in further assessment of the patient. Your re- use of the larger and more powerful devices typically used by porting of vital signs provides a baseline that can help track the rescue personnel. progress or deterioration of the patient’s condition. Before extrication can occur, you may need to gain control of the scene. This may mean setting up visual warning devices Patient© Jones Advocacy & Bartlett Learning, LLC on a highway© Jones or choosing & Bartlett someone Learning, to direct traffi LLC c or crowd At theNOT moment FOR of encounter,SALE OR you DISTRIBUTION become the primary health- control. NOT FOR SALE OR DISTRIBUTION care representative for the patient during the prehospital phase of care. Patients may not be familiar with the EMSS and depend Communications on you, the EMT, for advice about the best course of action The proper use of the radio or other communication device is for their problem. Often your actions or advice may be guided part of your training. Radio communications should be short © Jones &by Bartlettprotocols or Learning, directives regarding LLC patient care, hospital selec-© Jonesand &clear. Bartlett The radio Learning, is a useful tool LLC for mobilizing essential re- NOT FORtion, SALE decisions OR regardingDISTRIBUTION who can ride with the patient in NOTthe FORsources, SALE notifying OR hospital DISTRIBUTION personnel of the arrival of an acutely ambulance, and many other issues. ill patient, and documenting unusual circumstances that may It is important to treat patients as a whole and to consider all have medicolegal implications later. For example, a patient aspects of their condition, their ability to care for themselves, who leaves the scene against your advice and without a proper notifi cation of family members, and other social and psychologi- signature on a release form can be documented by relaying cal issues. A good rule for© theJones EMT is& to Bartlett treat the patient Learning, as you LLCthe information to the dispatcher© Jones or medical & Bartlett control. Learning, Many LLC would want a family memberNOT to FOR be treated SALE under OR similar DISTRIBUTION condi- systems record all conversationsNOT toFOR provide SALE another OR form DISTRIBUTION of tions. Sometimes such treatment means “going that extra mile” by docu mentation. contacting a family member or advising the nurse at the hospital Importantly, you also must learn to be an effective commu- of the need for social service intervention. As a patient advocate, nicator with patients, family members, and hospital personnel. your attitude and actions shift from a purely clinical point of view to a more© Jones humanistic & Bartlett approach toLearning, patient care (LLC Figure 1-21 ). Vehicle and© Jones Equipment & BartlettMaintenance Learning, LLC AtNOT times, FOR patients SALE may present OR DISTRIBUTION with seemingly minor com- Vehicles NOTand equipment FOR SALE that are OR well DISTRIBUTION maintained last longer plaints. Although these may not be emergent problems, stay and perform better for you and the patient. It is frustrating and aware and do not jump to conclusions. Adopting a “help- dangerous to attempt resuscitation or another task, only to dis- based” approach rather than a “thrill-seeking” focus will help cover that essential equipment is not serviceable or is missing. prevent burnout and poor patient care. What initially may seem Proper inspection and maintenance of the vehicle and restock- © Jones &minor Bartlett may easily Learning, become serious.LLC Back pain and headaches© Jones ing equipment& Bartlett are Learning, roles of every LLCEMT (Figure 1-22). Cleaning NOT FORcan SALE be caused OR by DISTRIBUTION serious vascular problems, such as dissectionNOT FORthe ambulance SALE OR and equipmentDISTRIBUTION is part of a planned program of of the aorta or a hemorrhage (bleeding) in the brain. Flulike infection control and respect for EMT and patient safety.

© Jones & Bartlett Learning, LLC © Jones Box 1-1& Bartlett Emergency Learning, Medical Technician’s LLC Oath NOT FOR SALE OR DISTRIBUTION NOTBe FOR it pledged SALE as an OR Emergency DISTRIBUTION Medical Technician, I will honor the physical and judicial laws of God and man. I will follow that regimen which, according to my ability and judgment, I consider for the benefi t of patients and abstain from whatever is deleteri- ous and mischievous, nor shall I suggest any such counsel. Into whatever homes I enter, I will go into them for the benefi t of © Jones & Bartlett Learning, LLConly the sick and injured, never ©revealing Jones what & I Bartlettsee or hear Learning, in LLC NOT FOR SALE OR DISTRIBUTIONthe lives of men unless required NOTby law. FOR SALE OR DISTRIBUTION I shall also share my medical knowledge with those who may benefi t from what I have learned. I will serve unselfi shly and continuously in order to help make a better world for all A mankind. While I continue to keep this oath unviolated, may it be © Jones & Bartlett Learning, LLC granted to me© to Jones enjoy life, & and Bartlett the practice Learning, of the art, respected LLC NOT FOR SALE OR DISTRIBUTION by all men, inNOT all times. FOR Should SALE I trespass OR DISTRIBUTIONor violate the oath, may the reverse be my lot. So help me God. © 1994, National Association of Emergency Medical Technicians (NAEMT). Written by Charles Gillespie, MD.

© Jones & Bartlett Learning, LLC © Jonesfact that &you Bartlett often are Learning, judged by your LLC appearance, and dress NOT FOR SALE OR DISTRIBUTION NOTappropriately. FOR SALE OR DISTRIBUTION The attitude of the EMT is even more important than the outer appearance. You should show an interest in your job and possess a sensitive awareness of your environment and the needs of others around you. The provision of medical care is a B © Jones & Bartlett Learning,giving LLC profession and should not© be Jones taken lightly. & Bartlett The attributes Learning, LLC Figure 1-22 A, Restocking ofNOT the vehicle. FOR B, SALE Inspecting OR DISTRIBUTIONof quality we seek to deliver areNOT well articulated FOR SALE in a report OR DISTRIBUTIONby the engine. the Institute of Medicine on quality in America’s health care (Box 1-2). You should put the patient’s needs fi rst while protecting and Professional Attributes of the EMT preserving the safety of bystanders, other rescuers, and yourself. © Jones & Bartlett Learning, LLC You are not useful© Jones to others & ifBartlett you become Learning, a victim yourself. LLC A As a medicalNOT professional, FOR SALE you have OR a DISTRIBUTIONunique and special body fi rst step in arrivalNOT at FORthe scene SALE of every OR emergency DISTRIBUTION is to ensure of knowledge that is to be used for the benefi t of society. You scene safety. EMTs must maintain awareness of the safety of are expected to demonstrate skill and knowledge for the good of the environment throughout the call, from arrival to transport the patient. You also are expected to promote high standards of to the hospital. Evolving or escalating hazards can range from behavior and medical practice within the profession. Also, as a street traffi c, violence, fi re scenes, and emotionally disturbed © Jonesprofessional, & Bartlett you are Learning, expected to LLCadd to the body of knowledge © Jonespatients and& Bartlett family members Learning, to communicable LLC diseases. NOT FORto continue SALE to advanceOR DISTRIBUTION progress in emergency medicine. NOT FOR SALE OR DISTRIBUTION The term that probably best embodies these basic values is professionalism. The dictionary describes professionalism as “acting requisite to the body of knowledge which defi nes the service and abilities of the professional …according to the oath of the profession.” Although© the Jones term professional & Bartlett is used Learning, more LLC © Jones & Bartlett Learning, LLC loosely now, the expectationsNOT of behavior FOR SALEcan easily OR be under-DISTRIBUTION NOT FOR SALE OR DISTRIBUTION stood by reading a traditional medical oath. Box 1-1 provides the EMT’s oath. Appearance and Attitude A professional© Jones appearance & Bartlett and attitude Learning, help evoke LLC a sense of © Jones & Bartlett Learning, LLC confi denceNOT in the FOR patient SALE and family OR DISTRIBUTIONmembers (Figure 1-23). NOT FOR SALE OR DISTRIBUTION Because emergency care providers have little time to establish rapport with their patients, the sight of an EMT in a clean and appropriate uniform helps establish a sense of respect and trust. Of course, wearing a uniform may not always be possible Figure 1-23 A properly attired EMT inspires confi dence. (e.g., a volunteer EMT responding from home or work). Be- © Jones & Bartlett Learning, LLC © Jones From Aehlert & BartlettB: Paramedic Learning, today: above and LLC beyond, St Louis, 2010, cause you often need to gain a stranger’s cooperation and trust NOT FOR SALE OR DISTRIBUTION NOTMosby-Elsevier. FOR SALE OR DISTRIBUTION quickly in EMS, however, you should take advantage of the

by one state of the validity of the EMT certifi cation granted Box 1-2 Six Quality Aims of Institute of Medicine (IOM)© Jonesby another. & Bartlett The National Learning, Registry LLC of EMTs also maintains CE © Jones & Bartlett Learning,“Quality Chasm” LLC Report NOT FOR SALE OR DISTRIBUTION NOT FORrequirements SALE thatOR encourage DISTRIBUTION the professional development of • Health care should be: EMTs nationwide. EMTs can be registered at either the basic or • Safe —Avoiding injuries to patients from the care that is in- the advanced level. tended to help them. • Effective —Providing services based on scientifi c knowledge to National Association of Emergency Medical Technicians all who could benefi ©t, andJones refraining & Bartlettfrom providing Learning, services LLCThe NAEMT is an organization© Jones that represents & Bartlett EMTs through-Learning, LLC to those not likely toNOT benefi t.FOR SALE OR DISTRIBUTIONout the United States. It wasNOT founded FOR in 1975 SALE with OR the supportDISTRIBUTION • Patient centered—Providing patient care that is respectful to of the National Registry and other national organizations and and responsive of individual patient preferences, needs, and val- leaders to serve as a national voice for prehospital providers. ues, and ensuring that patient values guide all clinical decisions. The NAEMT maintains three societies that serve other subdivi- • Timely —Reducing waits and sometimes harmful delays for sions of prehospital care: the National Society of EMS Admin- both those who receive and those who give care. • Effi© cient Jones —Avoiding & Bartlett waste, including Learning, waste LLCof equipment, istrators, the© Jones National & Society Bartlett of Instructor Learning, Coordinators, LLC and supplies,NOT FORideas, and SALE energy. OR DISTRIBUTION the NationalNOT Society FOR of EMT-Paramedics.SALE OR DISTRIBUTION • Equitable —Providing care that does not vary in quality be- The NAEMT works for legislative change in EMS, provides cause of personal characteristics such as gender, ethnicity, continuing education, represents EMTs in other national or- geographic location, and socioeconomic status. ganizations, provides job placement for EMTs, and in general, From IOM Committee on Quality of Health Care in America: Crossing the quality chasm: works for the development and recognition of EMTs nation- © Jones &a newBartlett health system Learning, for the 21st century, Washington,LLC DC, 2001, National Academies Press,© Joneswide. & Among Bartlett the CELearning, efforts offered LLC by NAEMT are an annual NOT FOR ppSALE 5-6. OR DISTRIBUTION NOT FORnational SALE educational OR DISTRIBUTION conference and Prehospital Trauma Life Support (PHTLS), a CE trauma program.

LEARNING OBJECTIVE American Heart Association • State the specifi c statutes and regulations in your state regarding the In cooperation with other healthcare organizations, the AHA EMS system. © Jones & Bartlett Learning, LLCestablishes CPR and emergency© Jones cardiovascular & Bartlett care guidelines Learning, LLC NOT FOR SALE OR DISTRIBUTIONfor both hospital and prehospitalNOT FOR providers. SALE Approximately OR DISTRIBUTION every 5 years, the AHA publishes the International Guidelines Maintenance of Up-to-Date Knowledge for CPR and Emergency Cardiovascular Care, which provides and Skills recommendations for CPR performance and cardiac protocols Your EMT training is the foundation of your EMS education. used in prehospital care. Each ©state Jones establishes & Bartlett license Learning,or certifi cation LLC requirements © Jones & Bartlett Learning, LLC for theNOT practicing FOR SALEEMT that OR may DISTRIBUTION include written, practical, LEARNINGNOT OBJECTIVE FOR SALE OR DISTRIBUTION and clinical requirements. Although there are variations, the • Defi ne quality improvement, and discuss the EMT’s role in the NHTSA curricula and the scope of practice documents usually process. provide the framework for programs throughout the United States. Different states or other countries may also add various © Jones &training Bartlett modules Learning, that enhance LLC the local or regional provision© Jones Quality & Bartlett Improvement Learning, LLC NOT FORof SALE prehospital OR care, DISTRIBUTION such as specialized trauma programs, emer-NOT FOR SALE OR DISTRIBUTION gency vehicle operation, extrication training, hazardous materi- The effectiveness of any organization depends on a continuing pro- als training, domestic preparedness, and other programs. cess of evaluation and change called quality improvement (QI). Recertifi cation is usually required every 2 to 3 years (al- EMS quality improvement is defi ned in the National Standard though the interval may be longer) and may involve ongoing Curriculum for Emergency Medical Technicians as “a system of in- continuing education (CE)© Jones requirements, & Bartlett challenge Learning, testing, or LLCternal and external reviews and© auditsJones of all & aspects Bartlett of an EMSLearning, sys- LLC attendance at a formalizedNOT refresher FOR program. SALE ContinuingOR DISTRIBUTION edu- tem so as to identify those aspectsNOT needing FOR improvement SALE OR to DISTRIBUTION assure cation takes many forms: attendance at local, state, and national that the public receives the highest quality of prehospital care.” conferences; reading EMS journals; and attending call review. Quality improvement takes many forms and may include Several national organizations contribute to EMS education. As the following: an EMT, you should also be familiar with the specifi c statutes • Reviewing prehospital documentation to ensure appropriate and regulations© Jones related & Bartlett to EMS inLearning, your state. LLC record keeping.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Reviewing NOT ambulance FOR SALE runs to determineOR DISTRIBUTION the type of care pro- National Registry of Emergency Medical Technicians vided and the quality of care. The National Registry of EMTs was developed to establish a • Gathering feedback from patients and hospital personnel on high-quality and standardized competency level for all levels the quality of care. of EMTs. The National Registry provides written and practical • Providing continuing education. © Jones &testing Bartlett and a Learning,continuing education LLC program at the basic ©and Jones • Ensuring & Bartlett preventive Learning, maintenance LLC of the emergency vehicle NOT FORadvanced SALE levels.OR DISTRIBUTION This registry is used by many states to provideNOT FORand SALE equipment. OR DISTRIBUTION reciprocity to EMTs and paramedics. Reciprocity is recognition • Maintaining personal skills.

As an EMT, you should be an active participant in the QI © Jonesprocess & Bartlettby helping Learning, with audits and LLC maintaining a positive at- © Jones Offl ine & Medical Bartlett Direction Learning, LLC NOT FORtitude SALEabout feedback. OR DISTRIBUTION Viewing QI feedback as a mechanism for NOTOffl FOR ine medical SALE direction OR DISTRIBUTION is medical guidance from the physi- personal growth rather than criticism provides the best atmo- cian to the EMT in the form of written protocols, policies, or sphere for ongoing individual and system development. procedures to guide patient triage, transportation, and transport decisions. Offl ine medical direction is accomplished without direct voice-to-voice contact. Rather, it is determined in LEARNING OBJECTIVE © Jones & Bartlett Learning,advance LLC by the medical director© of Jones the EMSS & orBartlett a regional Learning, or LLC • Defi ne medical direction, and discuss the EMT’s role in the process. NOT FOR SALE OR DISTRIBUTIONstate medical advisory committee.NOT A protocolFOR SALE may consist OR DISTRIBUTIONof standing orders, a requirement to contact medical direction via Medical Direction radio or telephone, or both. Standing orders are the aspects of the protocol that the EMT initiates without a requirement to Medical direction is defi ned as the accountability for the medi- contact medical direction. Some protocols, such as administra- cal conduct© ofJones EMS personnel & Bartlett by a physician Learning, knowledgeable LLC in tion of a certain© medication,Jones & mayBartlett require Learning, contact with medicalLLC prehospitalNOT emergency FOR care.SALE The OR type DISTRIBUTION of care provided in the direction beforeNOT treatment. FOR Another SALE aspect OR DISTRIBUTIONof medical direction fi eld should be carefully considered and judged to be medically is the responsibility for review of the QI program. prudent by physicians who are expert in emergency medicine. Depending on the size of the service, more than one physician Scenario Follow-up may share in accepting this responsibility. © JonesEvery & Bartlett ambulance Learning, service or rescue LLC squad must have physician © JonesThe motor & vehicleBartlett crash Learning, victim had ultrasoundLLC at the bedside, NOT FORmedical SALE direction. OR State DISTRIBUTION laws address the practice of medicine and NOTwhich FOR identifi SALE ed free OR blood DISTRIBUTION near the spleen. Emergency computed delegate responsibility to physician extenders, such as EMTs, para- tomography (CT) scan of the head and neck revealed no head in- medics, and physician assistants. The relationship of the EMT to jury or neck fracture. The patient was brought emergently to the medical direction is best understood by reference to the medical operating room, where the bleeding from the spleen was stopped, practice act in your state. In general, however, the EMT might be an otherwise fatal injury. considered to be a designated© agent Jones of the medical& Bartlett director Learning, and the LLCMany people in diverse roles responded© Jones to this & individual. Bartlett A fellow Learning, LLC care rendered an extension ofNOT the medical FOR director’s SALE authority.OR DISTRIBUTION motorist, who had read a “First There,NOT First FOR Care” poster,SALE saw OR the carDISTRIBUTION The type of medical direction can vary. The term medical over- off the road, called the dispatch center for help, went to the patient’s sight has been offered by the National Association of EMS Physi- side, and remained there until help arrived. Police and rescue person- cians in reference to system-wide responsibility. Within an EMSS, nel arrived to secure the scene and help extricate the victim. Both there may be many individuals who assume responsibilities for an emergency medical responder (EMR) and an emergency medical medical direction.© Jones From & theBartlett ground Learning,up, it would start LLC with the technician (EMT)© caredJones for the& Bartlettpatient. The Learning,EMT identifi ed LLCthat the ambulanceNOT service FOR medical SALE director, OR who DISTRIBUTION takes responsibility for patient met criteriaNOT for FORdirect transport SALE to OR a trauma DISTRIBUTION center. This com- the medical conduct of that service’s EMTs. Within a region, med- munity had organized in advance to identify hospitals willing and able ical directors from the hospitals and ambulance services may join to deliver emergency, lifesaving care to injured patients. together to promote uniform treatment protocols. Other physi- Who saved this life? Without all the partners and prior planning, cians may provide online medical direction for particular patients it may have been lost. The credit goes to all who developed and © Jonesfrom & a medicalBartlett control Learning, console, often LLC located in a regional hospi- © Jonesparticipated & Bartlettin this emergency Learning, medical serviceLLC system (EMSS). NOT FORtal where SALE physicians OR DISTRIBUTIONfamiliar with the EMS system offer 24-hour NOT FOR SALE OR DISTRIBUTION direct contact with the EMTs regarding patient care issues. Some systems only provide this service for advanced EMS providers. Summary An EMS system medical director may assume responsibility for the medical conduct of the system as a whole. Medical directors of EMTs work in cooperation with many people in providing training programs assume responsibility© Jones for& theBartlett clinical accuracyLearning, timely LLC and effective medical care.© JonesOther workers & Bartlett include Learning, lay LLC of the educational offerings, provideNOT FORcritical SALEinput regarding OR DISTRIBUTION prac- rescuers, dispatchers, fi rst responders,NOT FORfi re and SALE police person-OR DISTRIBUTION tical skills, and help to oversee and arrange for clinical rotations. nel, and physicians and nurses in receiving hospitals. As an EMT, you must be familiar with your primary responsibili- Online Medical Direction ties, which include personal safety and the safety of others, pa- Online medical direction involves the direct, real-time contact tient assessment, prompt patient care, safe transportation and by telephone© Jones or radio & with Bartlett a physician Learning, who guides LLC treatment, transfer, appropriate© Jones documentation, & Bartlett and Learning, record keeping, LLC and transport,NOT and triage FOR decisions SALE atOR the DISTRIBUTION scene. The EMT might communicationNOT of fi ndingsFOR withSALE medical OR directors DISTRIBUTION and hospital contact medical direction for a treatment order, such as whether personnel. Most important is your responsibility as a patient to assist a patient in administration of the patient’s nitroglyc- advocate. You may be the fi rst medical professional the patient erin for chest pain. The EMT might contact medical direction encounters in an EMSS. A caring and empathetic attitude is an for assistance in triage of multiple casualties at the scene. Other essential characteristic of an effective EMT. You should review © Jonesuses &of Bartlettonline medical Learning, direction LLC include a physician resource © Jonesthe following & Bartlett learning checklistLearning, to reinforce LLC and help retain the NOT FORfor patients SALE who OR are DISTRIBUTION refusing medical assistance but who are NOTinformation FOR SALE you learned OR DISTRIBUTION in this chapter. Good luck in your believed to have critical illnesses that warrant emergency care. EMS work!

Learning Checklist interventions with basic equipment typically found on an ambulance, under medical oversight, linking the patient ✓ An emergency medical© servicesJones system & Bartlett (EMSS) isLearning, the planned LLC from the scene to the emergency© Jones healthcare & Bartlett system. Learning, LLC confi guration of communityNOT FOR resources SALE and personnelOR DISTRIBUTION neces- ✓ An advanced emergencyNOT medical FOR technician SALE (AEMT) OR DISTRIBUTION pro- sary to provide immediate medical care to patients with sud- vides basic and limited advanced care, including administra- den or unexpected illness or injury. tion of certain drugs. ✓ Although most growth and development of EMS systems oc- ✓ A paramedic is an allied health professional whose primary curred over the past 40 years, several key historical events focus is to provide advanced emergency medical care for helped© Jones to shape & EMS Bartlett over the Learning, last century: LLC critical© and Jones emergent & patients.Bartlett Paramedics Learning, possess LLC complex ✓ NOT During FOR the Napoleonic SALE OR Wars, DISTRIBUTION army surgeon Baron Dom- knowledgeNOT and FOR skills SALE necessary OR to DISTRIBUTION perform basic and ad- inique-Jean Larrey introduced his ambulance volantes. vanced interventions with equipment found on an ambu- ✓ Horse-drawn ambulances were introduced during the lance, under medical oversight. Civil War, under the direction of Dr. Jonathan Letterman. ✓ Primary responsibilities of the EMT include personal safety ✓ During the Korean War in the 1950s, helicopters were and safety of others, patient assessment, lifting and moving, © Jones & Bartlettused to Learning,rapidly evacuate LLC the wounded to mobile army© Jones transport & Bartlett and transferLearning, of care, LLC record keeping, and patient NOT FOR SALEsurgical OR hospitals DISTRIBUTION (MASH units). NOT FORadvocacy. SALE OR DISTRIBUTION ✓ One of the fi rst hospital-based ambulance services was ✓ Other responsibilities of the EMT include extrication, com- initiated by Cincinnati General Hospital in the mid- munications, and vehicle and equipment maintenance. 1860s. The fi rst motorized ambulance is said to have ✓ EMTs should dress appropriately to instill confi dence, show been provided by Michael Reese Hospital of Chicago and interest in their job, and possess a sensitive awareness of their St. Vincent’s Hospital© Jones in 1899. & Bartlett Learning, LLCenvironment and the needs© Jonesof others &around Bartlett them. Learning, LLC ✓ CPR and portableNOT defi brillators FOR SALE were introduced OR DISTRIBUTION in the ✓ EMTs should maintain NOT up-to-date FOR knowledgeSALE OR and DISTRIBUTION skills 1960s. through continuing education and refresher training. ✓ Introduction of biotelemetry in the late 1960s allowed for ✓ EMTs play several important roles in quality assurance, advanced life support. including reviewing prehospital documentation to ensure ✓ Medical societies played a signifi cant part in the devel- accuracy, reviewing ambulance runs to ensure that the ©opment Jones of EMSS,& Bartlett including Learning, the National LLC EMT Training prehospital© Jones care was & appropriate,Bartlett Learning, gathering feedback LLC from NOTCurriculum FOR currentlySALE ORused. DISTRIBUTION The curriculum was an out- patientsNOT and hospitalFOR SALE personnel OR on DISTRIBUTION the quality of care, pre- growth of work by these physician groups in the 1960s. ventive maintenance of the vehicle and equipment, and ✓ In 1966 the National Academy of Sciences published the maintaining personal skills. landmark paper Accidental Death and Disability: the Ne- ✓ Medical direction is the oversight of clinical patient care by a glected Disease of Modern Society. physician. © Jones & Bartlett✓ In 1973, Learning, federal legislation LLC provided funding for the ©de- Jones ✓ Online & Bartlett medical Learning, direction involves LLC the direct, real-time con- NOT FOR SALEvelopment OR DISTRIBUTION of EMSS throughout the United States. NOT FORtact SALE by telephone OR DISTRIBUTIONor radio with a physician who directs treat- ✓ The EMS Agenda for the Future is a modern document ment, transport, and triage decisions at the scene or while en that defi nes 14 elements of an effective EMS system. route to the hospital. ✓ The EMS Education Agenda for the Future, the National ✓ Offl ine medical direction is medical guidance from the phy- EMS Core Content, the National EMS Scope of Practice sician to the EMT in the form of written protocols, policies, Model, and the National© Jones EMS & EducationBartlett Standards Learning, en- LLCor procedures that guide© patient Jones triage, & Bartletttransportation, Learning, and LLC compass multipleNOT steps FOR intended SALE to enhance OR DISTRIBUTION effective transport decisions. NOT FOR SALE OR DISTRIBUTION EMS education and practice. ✓ The National Highway Traffi c Safety Administration Key Terms (NHTSA) provides leadership for EMS on a federal level. ✓ Emergency medical responders (EMRs, or fi rst responders), Advanced emergency medical technician (AEMT) An AEMT such© Jonesas police &and Bartlett fi refi ghters, Learning, are often equipped LLC with oxy- provides© basicJones and limited& Bartlett advanced Learning, care, including LLC adminis- gen,NOT automated FOR SALEdefi brillators, OR DISTRIBUTION and airway equipment and tration NOTof certain FOR drugs SALE under medical OR DISTRIBUTION oversight to critical and may respond in fi rst-responder cars or police or fi re vehicles. emergent patients who access the EMS system. Also called They possess knowledge and skills to provide lifesaving in- EMT-Intermediate (EMT-I). terventions while awaiting additional EMS response and can Biotelemetry Method by which biological data are transferred assist higher level personnel on the scene. from one location to another by radio or telephone. © Jones & ✓ BartlettEmergency Learning, medical technicians LLC (EMTs) provide basic emer-© Jones & Bartlett Learning, LLC NOT FOR SALEgency medical OR DISTRIBUTION care and transportation for critical and emer-NOT FOR SALE OR DISTRIBUTION gent patietns who access the EMS system. They perform

© JonesEmergency & Bartlett medical Learning, responder (EMR) LLC Often arriving before the © Jones 3. Of the & following,Bartlett which Learning, is the leading LLC cause of trauma deaths? NOT FORambulance, SALE EMRsOR suchDISTRIBUTION as police and fi refi ghters are equipped NOT FORa. Electrocution SALE OR DISTRIBUTION with oxygen, automated defi brillators, and airway equipment b. Motor vehicle crashes and may respond in fi rst-responder cars or police or fi re ve- c. Falls hicles. They possess knowledge and skills to provide lifesaving d. Burn injuries interventions while awaiting additional EMS response and can assist higher-level personnel© onJones the scene. & Bartlett Learning, 4.LLC An EMT is caring for a patient© Jones with cardiac & Bartlett chest pain Learning,and LLC Emergency medical technicianNOT (EMT) FOR EMTs SALE provide basicOR DISTRIBUTIONemer- wants to administer aspirin toNOT the patient. FOR The SALE EMT mustOR callDISTRIBUTION gency medical care and transportation for critical and emergent and consult with a physician before the aspirin can be admin- patients who access the EMS system. They perform interven- istered. This is best described by which of the following? tions with basic equipment typically found on an ambulance a. Offl ine medical direction under medical oversight, linking the patient from the scene to b. Quality assurance the emergency© Jones healthcare & Bartlett system. Learning, LLC c. Online© medical Jones direction & Bartlett Learning, LLC Medical directionNOT FOR The active SALE participation OR DISTRIBUTION of physicians oversee- d. TelemetryNOT FOR SALE OR DISTRIBUTION ing medical care in an EMS system; includes protocol development, needs assessment of the system, education, quality Match the following descriptions with the EMS system improvement, and outcome studies, as well as online medical role (a-e). direction. Also called “medical control.” Column A Column B © JonesOffl ine& Bartlettmedical direction Learning, The accountability LLC by a physician for © Jones 5. The &intersection Bartlett of Learning, hospital and LLC a. Emergency medical NOT FOREMS SALE providers OR through DISTRIBUTION the use of protocols, quality improve- NOT FORprehospital SALE care. OR DISTRIBUTIONresponder ment activities, educational endeavors, and other measures to 6. Trained individual who provides b. Emergency depart- ensure effective fi eld care. initial life-sustaining care (AED, ment Online medical direction The accountability of fi eld care by a CPR) with minimal equipment. c. Critical care unit physician though the use of radio or telephone communica- 7. Responsible for prioritizing calls, d. Emergency medical tions. © Jones & Bartlett Learning, LLCcommunicating with EMS ©pro- Jonesdispatcher & Bartlett Learning, LLC Paramedic Allied health professionalNOT FOR whose SALE primary focusOR DISTRIBUTIONis viders, and giving phone instruc-NOT FOR e. EMT SALE OR DISTRIBUTION to provide advanced emergency medical care for critical and tions to bystanders. emergent patients. Paramedics possess complex knowledge 8. Usually the fi rst medical person and skills necessary to perform basic and advanced interven- to see the patient. tions with equipment found on an ambulance, under medical 9. Which of the following best defi nes the physician’s involve- oversight.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ment and participation in all phases of the EMS system to Personal protectiveNOT FOR equipment SALE (PPE) OR VarietyDISTRIBUTION of safety equip- NOT FOR SALE OR DISTRIBUTION ment ranging from gloves, goggles, clothing, and masks to ensure quality care? self-contained breathing apparatus (SCBA) designed to protect a. Categorization the EMT at the scene. b. Standardization Quality improvement (QI) Methods of ensuring a high level of c. Systemization d. Medical direction © Jonespatient & Bartlett care. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT For FOR Further SALE Review OR DISTRIBUTION Review Questions

1. Which of the following is a system of resources and person- In the Student Workbook nel necessary to provide immediate care to ill and injured • Multiple-choice questions patients? © Jones & Bartlett Learning, • LLC Matching questions © Jones & Bartlett Learning, LLC a. Emergency medical servicesNOT FOR system SALE OR DISTRIBUTION• Fill in the blank questions NOT FOR SALE OR DISTRIBUTION b. Ambulance service • Short answer questions c. “Enhanced 9-1-1” dispatching system • True/false questions d. Hospital emergency service • Case scenario questions • Crossword puzzle 2. Which © ofJones the following & Bartlett most affected Learning, the early LLC growth and © Jones & Bartlett Learning, LLC developmentNOT FOR of prehospital SALE ORemergency DISTRIBUTION care? On EvolveNOT FOR SALE OR DISTRIBUTION a. Disaster drills b. Outpatient clinics • Weblinks c. War • Lecture notes d. Laboratory animal research • Exercises © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones Learning& Bartlett ObjectivesLearning, LLC © Jones • Defi & Bartlettne quality improvement,Learning, LLCand discuss the EMT’s role in NOT FOR SALE OR DISTRIBUTION NOT FORthe SALE process. OR DISTRIBUTION Cognitive Objectives • Defi ne medical direction, and discuss the EMT’s role in the process. • Defi ne emergency medical services (EMS) system. • Differentiate the roles and responsibilities of the EMT from Affective Objectives those of other prehospital care providers. © Jones & Bartlett Learning, LLC Assess areas of personal attitude© Jones and conduct& Bartlett of the Learning, EMT. LLC Describe the roles and responsibilities of the EMT related to • • NOT FOR SALE OR DISTRIBUTIONCharacterize the variousNOT methods FOR used SALE to access OR the DISTRIBUTION EMS personal safety. • system in your community. • Discuss the roles and responsibilities of the EMT toward the safety of the crew, patient, and bystanders. • State the specifi c statutes and regulations in your state regarding© Jones the EMS & system.Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

References

George Washington Medical Faculty Associates: AED program: AED FAQ’s, National Highway Traffi c Safety Administration: National EMS Core Content, © Jones & Washington,Bartlett DC, Learning, 2007. LLC © JonesWashington, & Bartlett DC, 2005 Learning, US Department LLC of Transportation. NOT FOR Gillespie SALE C: EmergencyOR DISTRIBUTION Medical Technician’s Oath, 1994, National AssociationNOT FOR National SALE Highway OR Traffi cDISTRIBUTION Safety Administration: National EMS scope of practice of Emergency Medical Technicians (NAEMT). model , DOT HS 810 657, Washington, DC, February 2007, US Department Institute of Medicine: Committee on the Future of Emergency Care in the of Transportation. United States Health System: EMS at the crossroads, Washington, DC, 2006 , National Highway Traffi c Safety Administration: US Department of Health and National Academies Press. Human Services, Public Health Services, Health Resources and Services Ad- Institute of Medicine: Committee on Quality of Health Care in America: Cross- ministration, Maternal and Child Health Bureau: EMS agenda for the future, ing the quality chasm: a new© health Jones system & for Bartlettthe 21st century Learning,, Washington, LLCWashington, DC, 1996 , US Department© Jones of Transportation & Bartlett. Learning, LLC DC, 2001 , National Academies Press. National Highway Traffi c Safety Administration: US Department of Health and McCaig L F , Burt C W : National NOT Hospital FOR Ambulatory SALE MedicalOR DISTRIBUTION Care Survey: Human Services, Public Health NOTServices, FORHealth Resources SALE and OR Services DISTRIBUTION Ad- 2003 emergency department summary—advance data from Vital and Health ministration, Maternal and Child Health Bureau: Emergency medical services Statistics 358, Hyattsville, Md, 2005 , National Center for Health Statistics. education agenda for the future: a systems approach, Washington, DC, 2000 , Miniño AM, et al: National Vital Statistics Report 55(19):8, 2007. US Department of Transportation. National Academy of Sciences– National Research Council: Accidental death and disability: the neglected disease of modern society, Washington, DC, 1966 , National © Jones Academy Press& Bartlett. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION