History of EMS
Past, Present, Future
Jeff Dostalek
EMS Instructor, NREMT-P
Introduction
EMS System Development
History of EMS
Role of the Paramedic today versus the “ambulance
driver” of yesterday
Paramedic professional responsibilities to enhance their
ability to provide quality service
Licensure, Certification, Credentialing
Objectives
Describe benefits of continuing education
Medical Direction
List the benefits of professional association membership
Introduction
The public perception of you is based on
– TV and articles
– Your treatment of their loved ones
Continuing education is a must
Treat everyone with respect and dignity
How far have we come
EMS System Development
• 1485
First use of an
ambulance.
Transport only
• 1926
• Service started similar to
present day
• 1800s
First use of and
ambulance/attendant to
care for injured on site
• 1940
• EMS turned over to fire and
police department
• No set standard of care
The 20th Century and Modern
Technology
EMS Made major strides after WWII
– Bringing hospital to filed gave patients a better
chance for survival
– Korean War
First use of helicopter
M*A*S*H* Units
The 20th Century and Modern
Technology
1956
– Mouth-to-Mouth resuscitation developed
Late 1950s/early 1960s
– Focused shifted to bring hospitals to patients
– MICU developed
The 20th Century and Modern
Technology
1965: “The White Paper” released
– Finding included:
Lack of uniform laws and standards
Poor-quality equipment
Lack of communication
Lack of training
The 20th Century and Modern
Technology
“The White Paper: finding outlined 10
critical points for EMS Systems
– Led to national Highway Safety Act
– Created US Department of Transportation
1968
– Training Standards implemented
– 9-1-1 created
The 20th Century and Modern
Technology
1969
– First true Paramedic program
– Standards for ambulance design and
equipment
1970
– NREMT began
The 20th Century and Modern
Technology
1970s (cont’d)
– 1971: Emergency Care and Transportation of
the Sick and Injured published by AAOS
– 1973: Emergency Medical Services Act
– 1977: First National Standard Curriculum for
Paramedics developed by US DOT
The 20th Century and Modern
Technology
1980s/1990s
– Number of trained personnel grew
– NHTA developed 10 system elements to help
sustain EMS System
– Responsibility for EMS transferred to the
stated
– Major legislative initiatives
Licensure, Certification, and
Registration
Certification examination
– Ensure all health care providers have the
same basic level of knowledge and skill
– Once you pass certification you can apply for
state licensure
Licensure, Certification, and
Registration
Licensure
– How states control
who practice
– Also known as
certification or
credentialing
– Unlawful to practice
without license
Holding a license
shows you:
– Completed initial
education
– Met the requirement to
achieve the license
Licensure, Certification, and
Registration
Reciprocity
– Certification granted from another
State/agency
– Requirements:
Hold a current state certification
Be in good standing
National Registry certification
The EMS System
Network of coordinated services that
provide care to the community
The public needs to be taught how to:
– Recognize emergencies
– Activate the EMS System
– Provide basic care
The EMS System
Patient outcomes are determined by:
– Bystander care
– Dispatch
– Response
– Pre-hospital care
– Transportation
– ER Care
– Definitive care and Rehabilitation
The EMS System
Dispatcher
– Usually the publics first contact
– Training level varies from State to State
Scene may differ from what dispatcher
relays
The EMS System
As a paramedic, you must:
– Develop care plan
– Decide on transportation mode
– Determine receiving facility
– Be active in your community
Levels of Education
EMS System function from a federal to
local level
– Federal: National EMS Scope of Practice
Model
– State: Licensure
– Local: Medical Director decides day to day
limits
Levels of Education
The national guideline designed to create
more consistent delivery of EMS
nationally.
2009: national EMS Education Standard
– NREMT provides a national standard for
testing and certification
The Dispatcher
Plays a critical role
– Receives and enters
information
– Interprets it
– relays it to appropriate
service
– Pre-arrival instructions
Emergency Medical Responder
(EMR)
Formerly “First
responder”
Requirements vary by
state
Should be able to:
– Recognize
seriousness of
condition
– Provide basic first aid
– Relay information
EMT
Formerly EMT Basic
Primary provider level
in many systems
Most populous level
in the system
Advance EMT (AEMT)
Formerly EMT-I
Trained in:
– More advanced Pathophysiology
– Some advanced procedures
Initially developed in 1985
– Major revision in 1999
Paramedic
Highest Level to be nationally
certified
– 1999: Major revision to
curriculum to increase level of
training and skills
Even if independently licensed,
you must:
– Function under the guidance
of physician
– Be affiliated with a paramedic
level service
Paramedic Education
Initial education
– Most states based on National EMS
Education Standards
– States require varying hours of educations
national Average: 1,000-1,500 hours
Paramedic Education
Continuing Education
– Most states require
proof of hours
– Attend conferences
and seminars
– Read EMS journals
– Get involved in post
run review
Continuing Education
Maintenance of core knowledge and skills
Expansion of knowledge and skills
Awareness of advances in profession
Forms of CEU are many
Working With Other
Professionals
Hospital Staff
– Become familiar with the hospital;
– The best patient care occurs when
emergency care providers have a close
rapport with staff
ASK QUESTIONS
Health Care Professional
Conform to professional standards
Provide quality patient care
Instill pride in the profession
Strive for high standards
Earn respect of others
Societal expectations on & off duty
Position of public trust
Unprofessional conduct tarnishes the profession, the
service, and you
Image and Behavior
Working With Other
Professionals
Public safety agents
– Some have EMS
Training
Can better perform
certain functions than
you
– Interagency
cooperation benefits
patients
Working With Other
Professionals
Continuity of care
– the community has expectation of EMS
– Focus on prevention
– You will interact with many professional
groups
Understand your role, as well as others
EMS Group Involvement
National, state, regional, and local
Development, education, implementation and setting
standards for EMS
NREMT: verifies competency and reciprocity
Wisconsin:
– DHS
EMS Advisory Board
– WEMSA
STAC / RTAC
– PSOW
WTCS
– WPS,Inc.
Others ?
Primary Responsibilities
Preparation
Response to scene
Scene assessment
Patient assessment
Recognition of injury or illness
Management
Appropriate disposition
Patient transport and transfer of care
Documentation
Return to service
Professionalism
Standards of conduct and performance
established by the profession
You will be measured by:
– Standard, competencies, and education requirments
– Performance parameters
– Adherence to a “Code of Ethics”
Professionalism
You are in a highly visible role in your
community
You must:
– Instill confidence
– Establish and maintain credibility
– Show concern for your patients
Professionalism
Your appearance is of utmost importance
Present a professional image and treat
colleagues with respect.
– Arguing with colleagues is inappropriate
– Raising issues at the appropriate time and
place
Professional Attributes of the Paramedic
Integrity
Empathy
Self-motivation
Appearance and Personal Hygiene
Self confidence
Excellent communications
Time management
Teamwork
Diplomacy
Respect
Patient Advocacy
Careful delivery of service
Roles and Responsibilities
Teach the community
about injury
prevention and illness
– Appropriate use of
EMS
– CPR Training
– Influenza and
pandemic issues
– Campaign for EMS
system
Medical Direction
paramedic carry out advanced skills
– Must take direction from medical directors
Medical Director may perform many roles
– Educate and train
– Recommend new personnel or equipment
– Develop protocols, guidelines, and QA
Medical Direction
Roles of the Medical Director (cont)
– Provide input for patient care
– Interface between EMS and other agencies
– Advocate for EMS
Medical Direction
(Medical Control)
Online
– Provides immediate
and specific patient
care resources
– Allows for continues
quality improvement
– Can render on-scene
care assistance
Offline
– Allows for the
development of:
Protocols or guidelines
Standing orders
Procedures
Training
Improving System Quality
Goal: evaluating and improving patient care
Continuous Quality Improvement
Quality Assurance
Improving System Quality
Continues quality improvement (CQI)
– Tools to continually evaluate care
– Quality Control
– Process of assessing current practice looking
for ways to improve
– Dynamic Process
Improving System Quality
Review ambulance
runs when possible
Focus of CQI is
improving care
CQI can be peer
review:
– Be professional
– Should be a
constructive process
Improving System Quality
CQI programs helps
prevent problems by:
– Evaluating day-to-day
operations
– Identify possible stress
points
Look for ways to
eliminate human
error:
– Ensure adequate
lighting
– Store medications
properly
Improving System Quality
Ways to eliminate human error
– Be careful when handing patients off
– Three sources of errors
Rules-based failure
Knowledge-based failure
Skills-based failure
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 sheet
– Be conscientious of protocols
Patient Safety
1996 Institute of Medicine
– Launched efforts to improve patient safety
and quality of care.
– At least 44,000 and may up to 98,000 people
die in hospital each year as a result of
medical errors
Highest Risk for EMS
Ambulance Crashes
Dropping Patients
Hand-off
Communication issues
Medication issues
Poor sterile technique
Airway issues
Spinal Immobilization
Preventing Medical Errors
Look-alike, Sound-alike Medication
Patient identification
Communication on hand-off
Perform correct procedures
Medication accuracy
Pulling tubes and line
Using proper technique
Proper Hand hygiene
Preventing Medical Error in EMS
Environmental methods
– Clear-established protocols
– Sufficient lighting for procedures and
assessment
– Performing patient care duties with minimal
interruptions
– Organizing and packaging drugs
– Securing equipment in patient care
compartments.
Preventing Medical Error in EMS
(cont’d)
Individual methods
– Reflection in actions
– Question assumptions
– Reflection bias
– Use decisions aids
– Ask for help
Summary
Ambulance corps were developed in WW
II to transport and rapidly care for solders
Helicopter implemented during the Korean
War
Summary
1966 the National Academy of Sciences
and the National Research Council
released the “The White Paper”
Paramedics must be licensed before
performing any function
Summary
Standards for pre-hospital care are
regulated by state law and State EMS
offices
Four levels of training
– First Responder
– EMT
– Advance EMT
– Paramedic
Summary
Paramedics should be familiar with:
– Roles of other health care providers
– Continuing education requirements
– Medical Control
– Code of ethics
– Professional attributes of a health care
provider
– Quality Assurance
– Patient safety consideration
EMS Star of Life
Detection
Reporting
Response
On Scene Care
Care in Transit
Transfer to Definitive
Care