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Chapter 1Chapter 1
EMS Systems
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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 CompetenciesNational EMS Education Standard Competencies
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Emergency Medical Services (EMS) Systems
– EMS systems
– History of EMS
– Roles/responsibilities/professionalism of EMS personnel
– Quality improvement
– Patient safety
National EMS Education Standard CompetenciesNational EMS Education Standard Competencies
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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 CompetenciesNational EMS Education Standard Competencies
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IntroductionIntroduction
• The EMS system is constantly evolving.– Originally, the
primary role was transportation.
• As a paramedic, you will encounter many different situations.
© Mark C. Ide
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IntroductionIntroduction
• 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.
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The History of EMSThe 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
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The 20th Century and Modern Technology
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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The 20th Century and Modern Technology
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
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The 20th Century and Modern Technology
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
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The 20th Century and Modern Technology
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
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The 20th Century and Modern Technology
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
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The 20th Century and Modern Technology
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
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The 20th Century and Modern Technology
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
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Licensure, Certification, and Registration
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.
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Licensure, Certification, and Registration
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.
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Licensure, Certification, and Registration
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
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Licensure, Certification, and Registration
Licensure, Certification, and Registration
• Reciprocity– Certification granted from another state/agency
– Requirements:
• Hold a current state certification.
• Be in good standing.
• National Registry certification.
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The EMS SystemThe 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.
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The EMS SystemThe EMS System
• Patient outcomes determined by:
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The EMS SystemThe EMS System
• Dispatchers– Usually the public’s first contact
– Training level varies by state
• Scene may differ from what dispatcher relays
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The EMS SystemThe EMS System
• As a paramedic, you must:– Develop care plan
– Decide on transport method
– Determine receiving facility
– Be active in your community.
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Levels of EducationLevels 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
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Levels of EducationLevels 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
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The DispatcherThe 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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Emergency Medical Responder (EMR)
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
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EMTEMT
• 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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Advanced EMT (AEMT)Advanced EMT (AEMT)
• Formerly EMT-I
• Initially developed in 1985– Major revision in 1999
• Trained in:• More advanced pathophysiology
• Some advanced procedures
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ParamedicParamedic
• 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.
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Paramedic EducationParamedic 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
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Paramedic EducationParamedic 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.
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Additional Types of TransportsAdditional 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.
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Working With Other Professionals
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.
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Working With Other Professionals
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
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Working With Other Professionals
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.
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National EMS Group Involvement
National EMS Group Involvement
• Many national and state organizations exist and invite paramedic membership.– Impact EMS future
– Provide access to resources
– Promote uniformity
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ProfessionalismProfessionalism
• You have responsibilities as a health care professional.
• You will be measured by:– Standards, competencies, and education
requirements
– Performance parameters
– Code of ethics
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ProfessionalismProfessionalism
• You are in a highly visible role in your community.
• You must:– Instill confidence.
– Establish and maintain credibility.
– Show concern for your patients.
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ProfessionalismProfessionalism
• 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.
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ProfessionalismProfessionalism
• Attributes of professionalism:
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ProfessionalismProfessionalism
• Attributes of professionalism (cont’d):
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ProfessionalismProfessionalism
• More health care locations are using paramedic services, including: – Administering vaccinations
– Serving as home health nurses
– Performing special transports
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Roles and ResponsibilitiesRoles and Responsibilities
© D
an M
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Roles and ResponsibilitiesRoles 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
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Medical DirectionMedical 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
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Medical DirectionMedical 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”
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Medical DirectionMedical Direction
• Medical directors also provide online and off-line medical control.
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Improving System QualityImproving 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
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Improving System QualityImproving 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
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Improving System QualityImproving 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
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Improving System QualityImproving 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
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Improving System QualityImproving 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.
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EMS ResearchEMS 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.
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The Research ProcessThe 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.
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The Research ProcessThe Research Process
• Determine the research domain.– Area of research
– Domains: clinical, systems, or education
• Research may be performed within a research consortium.
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FundingFunding
• 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.
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Types of ResearchTypes 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
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Types of ResearchTypes 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
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Types of ResearchTypes of Research
• Other types of research:– Prospective
– Cohort
– Case study
– Cross-sectional design
– Longitudinal design
– Literature review
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Research MethodsResearch 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.
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Research MethodsResearch 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
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Ethical ConsiderationsEthical 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.
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Ethical ConsiderationsEthical 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.
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Evaluating Medical ResearchEvaluating 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.
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Evaluating Medical ResearchEvaluating 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.
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Evidence-Based PracticeEvidence-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.
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Evidence-Based PracticeEvidence-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
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Evidence-Based PracticeEvidence-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
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Evidence-Based PracticeEvidence-Based Practice
• Level IV– Lowest level
– Reviews of:• Descriptive studies
• Expert opinion
• Uncontrolled studies
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Evidence-Based PracticeEvidence-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.
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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• 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.
SummarySummary
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CreditsCredits
• 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.
• ,