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ems

1. Chapter 1
EMS Systems

2. Preparatory
Integrates comprehensive knowledge of the
EMS system, safety/well-being of the
paramedic, and medical/legal and ethical
issues, which is intended to improve the
health of EMS personnel, patients, and the
community.
National EMS Education
Standard Competencies

3. Emergency Medical Services (EMS)
Systems
•EMS systems
•History of EMS
•Roles/responsibilities/professionalism of EMS
personnel
•Quality improvement
•Patient safety
National EMS Education
Standard Competencies

4. Research
•Impact of research on emergency medical
responder (EMR) care
•Data collection
•Evidence-based decision making
•Research principles to interpret literature and
advocate evidence-based practice
National EMS Education
Standard Competencies

5. Introduction
•The EMS system
is constantly
evolving.
–Originally, the
primary role was
transportation.
•As a paramedic,
you will encounter
many different
situations.
© Mark C. Ide

6. Introduction
•The public’s perception of you is based on:
–TV and articles
–Your treatment of their loved ones
•Continued education is a must.
•Treat everyone with respect and dignity.

7. The History of EMS
•1485
–First use of an
ambulance
–Transport only
•1800s
–First use of
ambulance/
attendant to care
for injuries on site
•1926
–Service started
similar to present
day
•1940s
–EMS turned over to
fire and police
departments
–No standards set

8. The 20th Century and Modern
Technology
•EMS made major
strides after WWII.
–Bringing hospital to
field gave patients
a better chance for
survival
–Korean War
•First use of a
helicopter
•M*A*S*H units
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9. The 20th Century and Modern
Technology
•1956
–Mouth-to-mouth resuscitation developed
•Late 1950s/early 1960s
–Focus shifted to bringing hospital to patients
–MICUs developed

10. The 20th Century and Modern
Technology
•1965: “The White Paper” released
–Findings included:
•Lack of uniform laws and standards
•Poor-quality equipment
•Lack of communication
•Lack of training

11. The 20th Century and Modern
Technology
•“The White Paper” findings outlined 10
critical points for EMS system
–Led to National Highway Safety Act
–Created US Department of Transportation
•1968
–Training standards implemented
–9-1-1 created

12. The 20th Century and Modern
Technology
•1969
–First true
paramedic
program
–Standards for
ambulance design
and equipment
•1970s
–NREMT began
Courtesy of Eugene L. Nagel and the Miami Fire Department

13. The 20th Century and Modern
Technology
•1970s (cont’d)
–1971: Emergency Care and Transportation of
the Sick and Injured published by the AAOS
–1973: Emergency Medical Services System Act
–1977: First National Standard Curriculum for
Paramedics developed by US DOT

14. The 20th Century and Modern
Technology
•1980s/1990s
–Number of trained personnel grew
–NHTSA developed 10 system elements to help
sustain EMS system
–Responsibility for EMS transferred to the states
–Major legislative initiatives

15. Licensure, Certification, and
Registration
•Certification examination:
–Ensures all health care providers have the
same basic level of knowledge and skill
–Once you pass certification you can apply for
state licensure.

16. Licensure, Certification, and
Registration
•Licensure:
–How states control
who practices
–Also known as
certification or
credentialing
–Unlawful to
practice without
licensure
•Holding a license
shows you:
–Completed initial
education
–Met the
requirements to
achieve the license
•Paramedics are
required to receive
medical direction.

17. Licensure, Certification, and
Registration
•You may be required to be registered and
licensed.
–Board of registration holds your:
•Education records
•State or local licensure
•Recertification

18. Licensure, Certification, and
Registration
•Reciprocity
–Certification granted from another state/agency
–Requirements:
•Hold a current state certification.
•Be in good standing.
•National Registry certification.

19. The EMS System
•A complex network of coordinated services
that provides care to the community
•The public needs to be taught how to:
•Recognize emergencies.
•Activate the EMS system.
•Provide basic care.

20. The EMS System
•Patient outcomes determined by:

21. The EMS System
•Dispatchers
–Usually the public’s first contact
–Training level varies by state
•Scene may differ from what dispatcher
relays

22. The EMS System
•As a paramedic, you must:
–Develop care plan
–Decide on transport method
–Determine receiving facility
–Be active in your community.

23. Levels of Education
•EMS system functions from a federal to
local level
–Federal: National EMS Scope of Practice Model
–State: Licensure
–Local: Medical director decides day-to-day limits

24. Levels of Education
•The national guidelines designed to create
more consistent delivery of EMS nationally
–Medical director can only limit scope of practice
•2009: National EMS Education Standards
–NREMT provides a national standard for testing
and certification

25. The Dispatcher
•Plays a critical role
–Receives and
enters information
–Interprets it
–Relays it to
appropriate service
•Some locations
train EMDs
–Give prearrival
instructions
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26. Emergency Medical Responder
(EMR)
•Formerly “first
responder”
•Requirements vary
by state
•Should be able to:
–Recognize
seriousness of
condition.
–Provide basic care.
–Relay information.
© Matt Dunham/AP Photosages

27. EMT
•Formerly EMT-B
•Primary provider
level in many EMS
systems
•EMT certification
precedes paramedic
education
•Most populous level
in the system
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28. Advanced EMT (AEMT)
•Formerly EMT-I
•Initially developed in 1985
–Major revision in 1999
•Trained in:
•More advanced pathophysiology
•Some advanced procedures

29. Paramedic
•Highest level to be nationally certified
–1999: Major revisions to curriculum greatly
increased level of training and skills
•Even if independently licensed, you must:
–Function under guidance of physicians.
–Be affiliated with a paramedic-level service.

30. Paramedic Education
•Initial education
–Most states base education programs on the
National EMS Education Standards.
•Outline minimum knowledge needed for practice
–States require varying hours of education.
•National average: 1,000-1,500 hours

31. Paramedic Education
•Continuing
education
–Most states require
proof of hours.
–Attend conferences
and seminars.
–Read EMS journals.
–Get everyone
involved in postrun
critiques.
•The responsibility for
continuing education
rests with you.

32. Additional Types of Transports
•Specialty center
–Require in-house
staffs of specialists
–Transport time can
be slightly longer.
–Know:
•Location of centers
•Protocol for direct
transport
•Interfacility
–Use for:
•Nonambulatory
patients
•Patients who require
medical monitoring
–Other medical
professionals may
accompany patient.

33. Working With Other
Professionals
•Hospital staff
–Become familiar with the hospital.
–You may consult with staff by using the radio
through established procedures.
–The best patient care occurs when emergency
care providers have close rapport.

34. Working With Other
Professionals
•Public safety
agents
–Some have EMS
training
•Can better perform
certain functions
than you
–Interagency
cooperation
benefits patient
© Mark C. Ide

35. Working With Other
Professionals
•Continuity of care
–The community has expectations of EMS
–Focus on prevention
–You will interact with many professional groups
•Understand your role, as well as theirs.

36. National EMS Group
Involvement
•Many national and
state organizations
exist and invite
paramedic
membership.
–Impact EMS future
–Provide access to
resources
–Promote uniformity

37. Professionalism
•You have responsibilities as a health care
professional.
•You will be measured by:
–Standards, competencies, and education
requirements
–Performance parameters
–Code of ethics

38. Professionalism
•You are in a highly visible role in your
community.
•You must:
–Instill confidence.
–Establish and maintain credibility.
–Show concern for your patients.

39. Professionalism
•Your appearance is of utmost importance.
–Has more impact than you may think
•Present a professional image and treat
colleagues with respect.
–Arguing with colleagues is inappropriate.
–Raise issues at the appropriate time and place.

40. Professionalism
•Attributes of professionalism:

41. Professionalism
•Attributes of professionalism (cont’d):

42. Professionalism
•More health care locations are using
paramedic services, including:
–Administering vaccinations
–Serving as home health nurses
–Performing special transports

43. Roles and Responsibilities
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44. Roles and Responsibilities
•Teach the
community about
prevention of injury
and illness.
–Appropriate use of
EMS
–CPR training
–Influenza and
pandemic issues
–Campaign for EMS
system
Courtesy of Captain David Jackson, Saginaw
Township Fire Department

45. Medical Direction
•Paramedics carry out advanced skills
–Must take direction from medical directors
•Medical directors may perform many roles:
–Educate and train
–Recommend new personnel or equipment
–Develop protocols, guidelines, and quality
improvement programs

46. Medical Direction
•Roles of the medical director (cont’d):
–Provide input for patient care
–Interface between EMS and other agencies
–Advocate for EMS
–Serve as “medical conscience”

47. Medical Direction
•Medical directors also provide online and off-line
medical control.

48. Improving System Quality
•Continuous quality improvement (CQI)
–Tool to continually evaluate care
–Quality control
–Process of assessing current practices, looking
for ways to improve
–Dynamic process

49. Improving System Quality
•Review ambulance
runs when possible.
•Focus of CQI is
improving care
•CQI can be a peer
review.
–Be professional
–Should be a
constructive process

50. Improving System Quality
•CQI programs help
prevent problems
by:
–Evaluating day-to-
day operations
–Identifying
possible stress
points
•Look for ways to
eliminate human
error.
–Ensure adequate
lighting
–Limit interruptions
–Store medications
properly

51. Improving System Quality
•Ways to eliminate human error (cont’d)
–Be careful when handing patients off.
–Three main sources of errors:
•Rules-based failure
•Knowledge-based failure
•Skills-based failure

52. Improving System Quality
•Ways to eliminate human error (cont’d)
–Agencies need clear protocols.
–Be aware of your environment.
–Ask yourself “Why am I doing this?”
–Use cheat sheets.
–Be conscientious of protocols.

53. EMS Research
•EMS has been drawn toward evidence-
based practice.
–Protocols should be based on scientific findings.
•Research should be performed by properly
educated researchers.
–More education centers now offer an EMS
track.

54. The Research Process
•Identify problem, procedure, or question.
•Develop research agenda by specifying:
–Questions to be answered
–Methods to gather data
•Stick to the research agenda.

55. The Research Process
•Determine the research domain.
–Area of research
–Domains: clinical, systems, or education
•Research may be performed within a
research consortium.

56. Funding
•Researchers should use an IRB when a
project begins.
•All research requires funding.
–Any type of support is considered funding.
•Researchers must:
–Disclose sources of funding.
–Maintain transparency of research methods.

57. Types of Research
•Qualitative
–Focuses on
questions within
surrounding events
and concurrent
processes
–Often used when
quantitative
research does not
provide answers
–Majority of research
•Quantitative
–Based on numeric
data
–Three types:
•Experimental
–Scientific
approach
•Nonexperimental
–Descriptive
•Survey

58. Types of Research
•Retrospective
–Examines available data
–May be used to:
•Develop educational sessions for EMS personnel
•Plan public education and prevention strategies
–In large studies, data often collected from
widespread databases
•Techniques can be used at the local level

59. Types of Research
•Other types of research:
–Prospective
–Cohort
–Case study
–Cross-sectional design
–Longitudinal design
–Literature review

60. Research Methods
•Identify the group(s) necessary for research.
•Ways to select subjects for research:
–Systematic sampling
–Alternative time frame sampling
–Convenience sampling
•Parameters should be identified.

61. Research Methods
•Studies can be:
–Blinded
•Subjects not told
project specifics
•Single-, double-,
or triple-blinded
–Unblinded
•Participants
advised of all
aspects
•Research statistics
can be:
–Descriptive
•Observations
made
•No attempts made
to alter event
–Inferential
•Hypothesis used
to prove one
finding

62. Ethical Considerations
•The IRB monitors whether a study is
conducted ethically and ensures:
–Protection of participants
–Appropriate conduct
•Benefits must outweigh risks.
•Conflicts of interest must be identified.

63. Ethical Considerations
•All subjects must:
–Give consent.
–Know their rights
will be protected.
–Participate
voluntarily.
–Be informed of all
potential risks.
–Be free to
withdraw at any
time.

64. Evaluating Medical Research
•When evaluating research, look for certain
criteria to determine the research quality.
–Know what questions to answer.
•Read every part of the research.
•Consider the type of journal.

65. Evaluating Medical Research
•Peer review helps ensure quality.
–Subject-matter experts review material prior to
publication
•Internet sites can be valid tools.
•Studies must follow a structured process.
•There will always be limitations.

66. Evidence-Based Practice
•Care should focus on procedures that have
proven useful in improving patient
outcomes.
–Evidence-based practice will have a growing
role in EMS.
•Stay up to date on health care advances.
–Make sure you understand new research
results.

67. Evidence-Based Practice
•Level I
–Highest-quality
evidence
–Multiple studies
–Large sample size
–Randomization
–Uses multiple
techniques
–Significant positive
effect outcome
•Level II
–Single, randomly
controlled trial, or
–Multiple trials with
small sample sizes,
or
–Large, randomly
controlled studies
–Moderate effect on
patient outcome

68. Evidence-Based Practice
•Level III
–Level IIIA: Well-designed trial without
randomization
–Level IIIB: Evidence from causal comparison and
case or cohort studies
–Level IIIC: Evidence gathered from single
experiments

69. Evidence-Based Practice
•Level IV
–Lowest level
–Reviews of:
•Descriptive studies
•Expert opinion
•Uncontrolled studies

70. Evidence-Based Practice
•Research determines the effectiveness of
treatment.
–Can help identify which procedures,
medications, and treatments do and do not work
•When following a new study, measure the
results with your CQI program.

71. •Ambulance corps were developed during
World Wars I and II to transport and rapidly
care for soldiers.
•Helicopters were used to rapidly remove
soldiers from the battlefield during the
Korean and Vietnam Wars.
Summary

72. •In 1966 the National Academy of Science
and the National Research Council released
“The White Paper” outlining 10 points.
–The National Highway Safety Act and the US
Department of Transportation were created as a
result.
•Paramedics must be licensed (also known
as certification or credentialing) before
performing any functions.
Summary

73. •Standards for prehospital emergency care,
and the people who provide it, are regulated
under state law by a state office of EMS.
•There are four levels of training: emergency
medical responder, emergency medical
technician, advanced emergency medical
technician, and paramedic.
•Paramedics may be involved in interfacility
transports and transports to specialty
centers.
Summary

74. •Paramedics should be familiar with the roles
and responsibilities of other health care
providers and public safety agencies.
•Continuing education programs expose
paramedics to new research findings and
refresh their skills and knowledge.
•A physician medical director authorizes
EMS providers to provide care in the field
through off-line or online medical direction.
Summary

75. •There are expected standards and a code
of ethics for all paramedics.
•There are many professional attributes that
a paramedic is expected to have, including
but not limited to integrity, empathy,
teamwork, patient advocacy, and time
management skills.
Summary

76. •Some of the primary paramedic
responsibilities include preparation,
response, scene management, patient
assessment and care, management and
disposition, patient transfer and report,
documentation, and return to service.
•Paramedics evaluate their care through
quality control and continuous quality
improvement.
Summary

77. •Research establishes a consensus of what
EMS personnel should or should not do.
Research may be quantitative or qualitative.
•There are many ethical considerations
when conducting research. Researchers
must always obtain consent from subjects,
inform them of the research parameters,
and protect their rights and welfare.
Summary

78. •Paramedics should know how to evaluate
the quality of research, including how to
recognize peer-reviewed literature and how
to find quality research on the Internet.
•Review medical literature as it becomes
available, and stay up to date on changing
guidelines.
Summary

79. Credits
•Chapter opener: © Mark C. Ide
•Backgrounds: Purple—Courtesy of Rhonda Beck;
Green—Jones & Bartlett Learning; Blue—Courtesy
of Rhonda Beck; Lime—© Photodisc
•Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.