Emergency medical services

Emergency medical services, also known as ambulance services or paramedic services (abbreviated to the initialism EMS, EMAS, EMARS or SAMU in some countries), are a type of emergency service dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves.^[1] Emergency medical services may also be locally known as a paramedic service, a first aid squad,^[2] FAST squad,^[3] emergency squad,^[4] rescue squad,^[5] ambulance squad,^[6] ambulance service,^[7] ambulance corps,^[8] or life squad.^[9]

The goal of most emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital. The term emergency medical service evolved to reflect a change from a simple system of ambulances providing only transport, to a system in which preliminary medical care is given on scene and during transport. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.^[10]

In most places in the world, the EMS is summoned by members of the public (or other emergency services, businesses, or authorities) via an emergency telephone number which puts them in contact with a control facility, which will then dispatch a suitable resource to deal with the situation.^[11]

In some parts of the world, the emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one; usually to facilitate the provision of a higher level or more specialized field of care but also to transfer patients from a specialized facility to a local hospital or nursing home when they no longer require the services of that specialized hospital, such as following successful cardiac catheterization due to a heart attack. In such services, the EMS is not summoned by members of the public but by clinical professionals (e.g. physicians or nurses) in the referring facility. Specialized hospitals that provide higher levels of care may include services such as neonatal intensive care (NICU),^[12] pediatric intensive care (PICU), state regional burn centres,^[13] specialized care for spinal injury and/or neurosurgery,^[14] regional stroke centers,^[15] specialized cardiac care^[16][17] (Cardiac catheterization),^[18] and specialized/regional trauma care.^[19]

In some jurisdictions, EMS units may handle technical rescue operations such as extrication, water rescue, and search and rescue.^[20] Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive ambulances, with no medical training.^[10] In contrast, most systems have personnel who retain at least basic first aid certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less commonly, physicians.

History

Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaritan. Luke 10:34 (NIV) - "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." Also during the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield.^[21]

The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte's chief surgeon.^[22][23] Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system.^[22][23][24] Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field.^[23] Larrey's projects for 'flying ambulances' were first approved by the Committee of Public Safety in 1794. Larrey subsequently entered Napoleon's service during the Italian campaigns in 1796, where his ambulances were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even developing a litter which could be carried by a camel for a campaign in Egypt.^[23]

In civilian ambulances, a major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832.^[25] The statement on the carriage, as printed in The Times, said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other".^[24] This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.

The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865.^[24] This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine.

In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London.^[26] It was modelled on a military-style command and discipline structure.

The earliest emergency medical service was reportedly the rescue society founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ring Theater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide.^[27]

Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899.^[24] This was followed in 1900 by New York City, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2 hp motors on the rear axle.^[24]

American historians claim that the world's first component of civilian pre-hospital care on scene began in 1928, when "Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad in the nation." Canadian historians dispute this with the city of Toronto claiming "The first formal training for ambulance attendants was conducted in 1892."

During World War One, further advances were made in providing care before and during transport – traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures.^[28] Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Prior to World War II, there were some areas where a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses - the only available vehicle that could carry a recumbent patient - and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.^[29][30]

Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.

Advances in the 1960s, especially the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances.^[31] In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the USA during that time was Accidental Death and Disability: The Neglected Disease of Modern Society. This report is commonly known as The White Paper.^[32] These studies, along with the White Paper report, placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. In the USA prior to the 1970s, ambulance service was largely unregulated. While some areas ambulances were staffed by advanced first-aid-level responders, in other areas, it was common for the local undertaker, having the only transport in town in which one could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. The government reports resulted in the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.

In 1971 a progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a "superb white paper" that "jolted and wakened the entire structure of organized medicine. This report is created as a "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services". Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting.^[33] Such advancements included Dr. R Adams Cowley creating the country's first statewide EMS program, in Maryland.^[34]

Service providers

Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.

• Government Ambulance Service

Operating separately from (although alongside) the fire and police service of the area, these ambulances are funded by local, provincial or national government. In some countries, these only tend to be found in big cities, whereas in countries such as United Kingdom almost all emergency ambulances are part of a national health system.^[35] In the United States, ambulance service provided by a local government are often referred to as "third service" EMS (the Fire Department, Police Department, and separate EMS forming an emergency services trio) by the employees of said service, as well as other city officials and residents. Government Ambulance Service also have to take Civil service exam just like government fire departments and police. In the United States certain Federal Government Agencies employ Emergency Medical Technicians at the BLS and ALS level such as the National Park Service and the Federal Bureau of Prisons.

• Fire or Police Linked Service

In countries such as the United States, Japan, France, and parts of India; ambulances can be operated by the local fire or police service. Fire-based EMS is the most common model in the United States, where nearly all urban fire departments provide EMS service^[36] and a majority of emergency transport ambulance services in large cities are part of fire departments. It is somewhat rare for a police department in the United States to provide EMS or ambulance service, although many police officers have basic medical training.

• Volunteer Ambulance Service

Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service in some parts of the world on a volunteer basis^[37] (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance^[37] and the Order of Malta Ambulance Corps.^[38] These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of Australia, Ireland and most importantly Germany and Austria. First Aid Squads are common names for establishments of volunteer Emergency Medical Services. First Aid Squads receive support from the town and rely on fundraisers to stay in operation. Ambulance crews in First Aid Squads range from 2-5 people all of whom need to be state certified EMTs. Shifts range from 6-12 hours with some members pulling 24-hour shifts when needed. Some towns rely solely on volunteer ambulance service while others have township run or paid, private companies. In the United States, volunteer ambulances are more rare, but can still be seen in rural areas.

• Private Ambulance Service

Normal commercial companies with paid employees, but often on contract to the local or national government. Private companies may provide only the patient transport elements of ambulance care (i.e. nonurgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility impaired if they have for example fallen and just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events.^[39] In Latin America, private ambulance companies are often the only readily available EMS service

• Combined Emergency Service

these are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where size or budget does not warrant separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.

• Hospital Based Service

Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital. Most Advanced Life Support (Paramedic) services in the United States are this type of service.

• Charity Ambulance

This special type of ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the UK's 'Jumbulance' project.^[40]

• Company Ambulance

Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion.

Purpose

Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the six points, which are used to represent the six stages of high quality pre-hospital care, which are:^[41]

1. Early detection – members of the public, or another agency, find the incident and understand the problem
2. Early reporting – the first persons on scene make a call to the emergency medical services (911) and provide details to enable a response to be mounted
3. Early response – the first professional (EMS) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin
4. Good on-scene/ field care – the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.
5. Care in transit -– the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
6. Transfer to definitive care – the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Levels of care

Emergency Medical Service is provided by a variety of individuals, using a variety of methods. To some extent, these will be determined by country and locale, with each individual country having its own 'approach' to how EMS should be provided, and by whom. In some parts of Europe, for example, legislation insists that efforts at providing advanced life support (ALS) Mobile Intensive Care Units (MICU) services must be physician-staffed, while other permit some elements of that skill set to specially trained nurses, but have no paramedics. Elsewhere, as in North America, the UK and Australasia, ALS services are performed by paramedics, but rarely with the type of direct "hands-on" physician leadership seen in Europe. Increasingly, particularly in the UK and in South Africa, the role is being provided by specially trained paramedics who are independent practitioners in their own right. Beyond the national model of care, the type Emergency Medical Service will be determined by local jurisdictions and medical authorities, based upon the needs of the community, and the economic resources to support it.

A category of emergency medical service which is known as 'medical retrieval' or rendez vous MICU protocol in some countries (Australia, NZ, Great Britain, and Francophone Canada) refers to critical care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in regionalized systems of hospital care where intensive care services are centralized to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service in Scotland. In the United States, this is referred to as "Critical Care Transport" and qualifications for this role vary by state and can include an RN, Paramedic and/or EMT.

Generally speaking, the levels of service available will fall into one of three categories; Basic Life Support (BLS), Advanced Life Support (ALS), and Critical Care Transport (CCT) by traditional healthcare professionals, meaning nurses and/or physicians working in the pre-hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate Life Support (ILS), which is essentially a BLS provider with a moderately expanded skill set, may be present, but this level rarely functions independently, and where it is present may replace BLS in the emergency part of the service. When this occurs, any remaining staff at the BLS level is usually relegated to the non-emergency transportation function. Job titles typically include Emergency Medical Technician, Ambulance Technician, or Paramedic. These ambulance care givers are generally professionals or paraprofessionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it.^[42] In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.

Basic life support (BLS)

First responder

An emergency worker (Police Officer, Firefighter, Ambulance Volunteer) whose duties include provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, cardio-pulmonary resuscitation (CPR), and automated external defibrillator (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an emergency call. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before an ambulance can arrive and to then assist the ambulance crew.^[43]

Ambulance driver

Most jurisdictions require two licensed prehospital providers to operate a licensed ambulance. Some jurisdictions separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid certificate), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.^[44]

Ambulance care assistant

Ambulance Care Assistants (ACAs) have varying levels of training across the world. In many countries, such staff are usually only required to perform patient transport duties (which can include stretcher or wheelchair cases), rather than acute care. However, there remain both countries and individual jurisdictions in which economics will not support ALS service, and the efforts of such individuals may represent the only EMS available. Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic.^[45][46]

Emergency medical technician

Emergency medical technicians, also known as Ambulance Technicians in the UK and EMT in the United States. In the United States, EMT is usually made up of 3 levels. EMT-B, EMT-I (EMT-A in some states) and EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. EMTs are usually able to perform a wide range of emergency care skills, such as Automated defibrillation, care of spinal injuries and oxygen therapy.^[47][48] In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs, more advanced airway procedures, CPAP, and limited cardiac monitoring.^[49] Most advanced procedures and skills are not within the national scope of practice for an EMT.^[50] As such most states require additional training and certifications to perform above the national curriculum standards.^[51][52] In the US, an EMT certification requires intense courses and training in field skills. A certification expires after two years and holds a requirement of taking 48 CEUs (continuing education credits). 24 of these credits must be in refresher courses while the other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric care, specific traumas, etc.

Emergency medical dispatcher

An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

Advanced life support (ALS)

Paramedic

A paramedic has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform endotracheal intubation), cardiac monitoring, tracheal intubation, pericardiocentesis, cardioversion, needle decompression and other skills such as performing a cricothyrotomy.^[53] The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment.^[54] In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution.^[55] In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care,^[56] Flight Paramedic Certification (FP-C),^[57] and Critical Care Emergency Medical Transport Program certification.^[58]

Critical care paramedic

Recently studies have looked at new level of pre-hospital care.^[59][60] What has developed is the critical care paramedic, also called an advanced practice Paramedic in some parts of United States and Canada. These providers represent a higher level of licensure above that of the DOT or respective paramedic level curriculum.^[58] The training, permitted skills, and certification requirements vary from one jurisdiction to the next. These providers transport critically ill or injured patients from one hospital to a receiving hospital with higher level of care (ie.. cardiac catheterization, trauma services or specialized ICU services) not available at referring facility.

These paramedics receive additional training beyond normal EMS medicine. The Board for Critical Care Transport Certification (BCCTPC®) has developed a certification exam for flight and ground critical care paramedics ^[61][62] Some educational facilities that provide this training are UMBC Critical Care Emergency Medical Transport Program^[63] or "Cleveland Clinic CICP program". . Individual services such as "Wake County EMS".  and "MedStar EMS".  have developed 'in-house' advanced practice paramedic providers. These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are Dopamine, Dobutamine, Propofol, blood and blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tubes.

Paramedic practitioner / emergency care practitioner

In the United Kingdom and South Africa, some serving paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics. An emergency care practitioner is a position sometimes referred to as a 'super paramedic' and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training,^[64] and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

Wilderness emergency medical technician

Some paramedics and emergency medical technicians, known as Wilderness Emergency Medical Technicians, utilize expanded scope of practice protocols that are operationalized when in wilderness (remote, austere, or resource-deficient) environments. Wilderness EMS Systems (WEMS) have been developed to deliver a standard and professional medical response to wilderness areas. Examples include the national-level agencies such as the National Ski Patrol in the United States as well as local responding agencies. Like traditional EMS providers, all WEMS providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the Wilderness Medical Society and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course,^[65] which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011.^[66] Common procedures utilized by WEMS providers that exceed traditional EMS scope of care include joint reduction, catheterization, antibiotic administration, selective spinal immobilization, and different training and protocols involving CPR cessation and wilderness skills. A multitude of organizations provide WEMS training, including private schools,^{[67][68][69][70][71]} non-profit organizations such as the Appalachian Center for Wilderness Medicine ^[72] and the Wilderness EMS Institute,^[73] military branches, community colleges and universities,^[74][75] EMS-college-hospital collaborations,^[76] and others.

Traditional healthcare professions

Registered nurses

The use of registered nurses (RNs) in the pre-hospital setting is common in many countries. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed,^[77] as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure that is above the Paramedic. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT.^[78] In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs.^[79][80] And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain.^[81] In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols,^[82] while SAMU-SMUR units are staffed by physicians and nurses^[83]

Physician

There are many places in Europe, most notably in France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain where the model of EMS is different, and physicians take a more direct, 'hands-on' approach to pre-hospital care. In France, Italy, and Spain, response to high-acuity emergency calls is physician-led, as with the French SMUR teams. Paramedics do not exist within those systems, and most ALS is performed by physicians. In the German-speaking countries, paramedics do exist, but special physicians (called Notarzt) respond directly to high-acuity calls, supervising the paramedics ALS procedures directly. In these countries, paramedics may perform many procedures under their "Notfallkompetenz" ("emergency competence"), meaning that they may autonomously perform treatments, such as defibrillation or administering drugs, if there is no physician on scene, and a life-threatening condition is present, otherwise they may only act on the physician's instructions.^[84] Some systems - most notably air ambulances in the UK.^[85][86] will employ physicians to take the clinical lead in the ambulance; bringing a full range of additional skills such as use of medications that are beyond the paramedic skill set. The response of physicians to emergency calls is routine in many parts of Europe, but is uncommon in the UK, where physicians are generally tasked to high priority calls on a voluntary basis. Within the UK a sub-speciality of Pre-Hospital Care is being developed for Doctors, which would allow training programs and consultant posts to be developed in this one area of practice.

This 'hands-on' approach is less common in the United States. While one will occasionally see a physician with an ambulance crew on an emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained paramedics, or performing routine medical quality assurance. In some jurisdictions adult or pediatric critical care transports sometimes use physicians, but generally only when it appears likely that the patient may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during transport.

Physicians are leaders of medical retrieval teams in many western countries, where they may assist with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when longer transport times are involved. In these cases the physician's role is extended to ensure the highest level of care is provided throughout the transport and diagnosis of serious medical conditions.

Prehospital delivery of care

Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization. This variation may lead to large differences in levels of care and expected scope of practice.

The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was often the case in a historical context, and is still true in the developing world, where operators as diverse as taxi drivers^[10] and undertakers may operate this service.

Most developed countries now provide a government funded emergency medical service, which can be run on a national level, as is the case in the United Kingdom, where a national network of ambulance trusts operate an emergency service, paid for through central taxation, and available to anyone in need,^[87] or can be run on a more regional model, as is the case in the United States, where individual authorities have the responsibility for providing these services.

Ambulance services can be stand alone organisations, but in some cases, the emergency medical service is operated by the local fire^[88] or police^[89] service. This is particularly common in rural areas, where maintaining a separate service is not necessarily cost effective. This can lead, in some instances, to an illness or injury being attended by a vehicle other than an ambulance, such as fire truck.^[90][91][92] In some locales, firefighters are the first responders to calls for emergency medical aid, with separate ambulance services providing transportation to hospitals when necessary.^[93]

Some charities or non-profit companies also operate emergency medical services, often alongside a patient transport function.^[37] These often focus on providing ambulances for the community, or for cover at private events, such as sports matches. The Red Cross provides this service in many countries across the world on a volunteer basis (and in others as a Private Ambulance Service), as do some other smaller organizations such as St John Ambulance.^[37] and the Order of Malta Ambulance Corps.^[94] In some countries, these volunteer ambulances may be seen providing support to the full-time ambulance crews during times of emergency, or simply to help cover busy periods.^[95]

There are also private ambulance companies, with paid employees, but often on contract to the local or national government. Many private companies provide only the patient transport elements of ambulance care (i.e. nonurgent), although in some places these private services are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy or to respond to non-emergency home calls. Private companies are often contracted by private clients to provide event specific cover, as is the case with voluntary EMS crews.

Many colleges and universities, especially in the United States, maintain their own EMS organizations. These organizations operate at capacities ranging from first response to ALS transport. Campus EMS in the United States is overseen by the National Collegiate Emergency Medical Services Foundation.

Strategies for delivering care

The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit or the German "Notarzt"-System (preclinical emergency physician). The use of helicopters was pioneered in the Korean war, when time to reach a medical facility was reduced from 8 hours to 3 hours in World War II, and again to 2 hours by the Vietnam war.^[96]

The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and the victim is transported as fast as possible to a trauma centre.^[97]

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient.^[98] Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab.^[99] The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent.^[100] In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.^[101]

Models of care

Although a variety of differing philosophical approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician-led and the other led by pre-hospital specialists such as emergency medical technicians or paramedics (which may, or may not have accompanying physician oversight). These models are typically identified by their locations of origin.^[102]

The Franco-German model is physician-led, with doctors responding directly to all major emergencies requiring more than simple first aid. In some cases in this model, such as France, paramedics, as they exist in the Anglo-American model, are not used, although the term 'paramedic' is sometimes used generically, and those with that designation have training that is similar to an U.S. EMT-B.^[103] The team's physicians and in some cases, nurses, provide all medical interventions for the patient, and non-medical members of the team simply provide the driving and heavy lifting services. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is sharply restricted in terms of scope of practice; often not permitted to perform Advanced Life Support (ALS) procedures unless the physician is physically present, or in cases of immediate life-threatening conditions.^[84] Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.

The second care structure, termed the Anglo-American model, utilizes pre-hospital allied health staff, such as emergency medical technicians and paramedics, to staff ambulances, which may be classified according to the varying skill levels of the crews. In this model it is rare to find a physician actually working routinely in the pre-hospital setting, although they may be utilised on complex or major injuries or illnesses. In this system, a physicians involvement is most likely to be the provision of medical oversight for the work of the ambulance crews, which may be accomplished in terms of off-line medical control, with protocols or 'standing orders' for certain types of medical procedures or care, or on-line medical control, in which the technician must establish contact with the physician, usually at the hospital, and receive direct orders for various types of medical interventions. In some cases, such as in the UK, South Africa and Australia, a paramedic may be an autonomous health care professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient.^[104]

In this model, patients may still be treated at the scene up to the skill level of the attending crew, and subsequently transported to definitive care, but in many cases the reduced skill set of the ambulance crew and the needs of the patient indicate a shorter interval for transport of the patient than is the case in the Franco-German model.

Clinical governance

Paramedics in countries that follow the Anglo-American model normally function under the authority (medical direction) of one or more physicians charged with legally establishing the emergency medical directives for a particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of a State Medical Board examination (U.S.) or the National Registry of Emergency Medical Technicians (U.S.). In England, and in some parts of Canada, credentialing may occur by means of a College of Paramedicine.^[105] In these cases, paramedics are regarded as a self-regulating health profession. The final common method of credentialing is through certification by a Medical Director and permission to practice as an extension of the Medical Director's license to practice some medical acts. The authority to practice in this semi-autonomous manner is granted in the form of standing order protocols (off-line medical control) and in some cases direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with clinical decision-making authority using standing orders or protocols.

In some parts of the world, those in the paramedical professional role are only permitted to practice many of their advanced skills while assisting a physician who is physically present, or they face cases of immediately life-threatening emergencies.^[84] In many other parts in the world, most notably in France, Belgium, Luxembourg, Italy, and Spain, but also in Brazil and Chile. All MICU skills in the pre-hospital setting are performed by physicians and nurses and an On-line Permanent medical supervision is done by the SAMU. In certain other jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners capable of prescribing medications.^[106] In other jurisdictions, such as Australia and Canada, this expanded scope of practice is under active consideration and discussion.^[107]

Organization in different countries

See also

• In case of emergency, a programme that enables EMS workers to identify victims and contact their next of kin to obtain important medical information
• Public utility model, a model for organizing Emergency Medical Services
• Battlefield medicine
• Wilderness medicine
• Mass Gathering Medicine
• Good Samaritan law
• CEN 1789
• The White Paper (Official title "Accidental Death and Disability: The Neglected Disease of Modern Society" - a 1966 report that prompted the development of organized EMS in the United State)
• Medical amnesty policy
• Star of Life
• List of EMS provider credentials

References^[108]

Further reading

• Planning Emergency Medical Communications: Volume 2, Local/Regional Level Planning Guide, (Washington, D.C.: National Highway Traffic Safety Administration, US Department of Transportation, 1995).

External links

Wikimedia Commons has media related to Prehospital care.

• Emergency Medical Services at DMOZ
• "Emergency Medical Services in the European Union: report of an assessment project co-ordinated by the European Union"
• World Health Organization: Department of Violence and Injury Prevention "Prehospital Trauma Care Systems"