Emergency medical services in the United States
Encyclopedia
Emergency Medical Services in the United States, (herein, EMS
) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the federal
government, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual state
governments, which often require higher standards from the services they oversee.
Wide differences in population density
, topography
, and other conditions can call for different types of EMS systems; consequently, there is often significant variation between the Emergency Medical Services provided in one state and those provided in another.
s. While most services are, to some degree, publicly-funded, the factor which often differentiates services is the manner in which they are operated. EMS systems may be directly operated by the community, or they may fall to a third-party provider, such as a private company. The most common operating models in the U.S. include:
department. In small communities that lack a large population or tax-base, such a service may not be able to operate unless it is staffed by community volunteers. In these cases, the volunteer squad may receive some funding from municipal taxes, but is generally heavily reliant on voluntary donation
s to cover operating expenses. This provides a significant challenge for volunteer groups, since the training
standards for staff must be met, and the vehicle and equipment standards adhered to, while the group does all or most of its own fundraising
. Without the presence of dedicated volunteers, however, many small communities in America might be without local EMS systems and would either have no service at all or be forced to rely on service from more distant communities.
Another operating model for publicly-operated EMS is what is generally referred to in the industry as the 'third service' option. In this option, rather than being an integral part of (or in some cases, an 'add-on' to) one of the traditional 'emergency' services (fire and police), the service is organized as a separate, free-standing, municipal
department, with organization that may be similar to, but operated independently from, either the fire or police departments,. In a variant of this model, the EMS system may be recognized as a legitimate third emergency service, but provided under a contractual agreement with another organization, such as a private company or a hospital, instead of direct operation. This model is sometimes referred to as the 'public utility' model. This may be a cost-saving measure, or it may be because the community feels that they lack the resident expertise to deal with medical oversight and control issues, and the legal requirements that typically surround an Emergency Medical Service.
In yet another model for publicly-operated EMS, the system may be integrated into the operations of another municipal emergency service, such as the local fire department
or police department. This integration may be partial or complete. In the case of partial integration, the EMS staff may share quarters, administrative services, and even command and control with the other service. In the case of full integration, the EMS staff may be fully cross-trained to perform the entry-level function of the other emergency service, whether firefighting or policing. Many communities perceive this as providing 'added value' to the community, since municipal workers are fulfilling more than one function, and are less likely to be idle.
aircraft or perform training or medical quality assurance, it is extremely uncommon to see a physician deliberately responding to the scene of an emergency.
services in the United States can be operated by a variety of sources. Some services are hospital-operated, while others may be operated by Federal
, State
or local government
; or through a variety of departments, including local or State police
, the United States Park Service, or Fire Departments. Such services may be operated directly by any of these EMS systems, or they may be contracted to a third-party provider, such as an aircraft charter company. In addition, it is not uncommon for U.S. military helicopters to be pressed into service providing air ambulance support. The vast distances covered by the U.S. mean that while helicopters may be the preferred form of service delivery for 'on-scene' emergencies, fixed wing aircraft, including small jets
, are often used for transfers from rural hospitals to tertiary care sites. These aircraft are typically staffed by a mix of personnel including physicians, nurses, and paramedics, and in some cases, by all three. Publicly operated air ambulance service is supplemented by emergency and non-emergency air transport service, which may be provided by dedicated air ambulance companies, or by aircraft charter
companies as a 'sideline' business operation.
services in the United States began in Cincinnati and New York City in 1865 and 1869, respectively. Hospital intern
s rode in horse drawn carriages designed specifically for transporting the sick and injured.
The first volunteer rescue squads organized around 1920 in Roanoke
, Virginia, Palmyra, New Jersey
, and along the New Jersey
coast. Gradually, especially during and after World War II, hospitals and physicians faded from prehospital practice, yielding in urban areas to centrally coordinated programs. These were often controlled by the municipal hospital or fire department. Sporadically, funeral home hearses, which had been the common mode of transport, were being replaced by fire department, rescue squad and private ambulances.
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 a person could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. However, after the release of the National Highway Traffic Safety Administration
's study, "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in the EMS trade as the White Paper
) a concerted effort was undertaken to improve emergency medical care in the pre-hospital setting.
In the late 1960s, Dr. R Adams Cowley
was instrumental in the creation of the country's first statewide EMS program, in Maryland. The system was called the Division of Emergency Medical Services (now known as the Maryland Institute for Emergency Medical Services and Systems). Also in 1969, Cowley obtained a military
helicopter to assist in rapidly transporting patients to the Center for the Study of Trauma (now known as the R Adams Cowley Shock Trauma Center
), a specialized hospital that he had started for the purpose of treating shock
. This service was not only the first statewide EMS program, but also the beginning of modern emergency medical helicopter transport in the United States.
The first civilian
hospital-based medical helicopter program in the U.S., Flight For Life
Colorado, began in 1972 with a single Alouette III helicopter
, based at St. Anthony Central Hospital in Denver, Colorado.
National EMS standards for the US are determined by the U.S. Department of Transportation and modified by each state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Committees (usually in rural areas) or by other committees, or even individual EMS providers. In addition, the National Registry of Emergency Medical Technicians, an independent body, was created in 1970 at the recommendation of President Richard M. Nixon in an effort to provide a nationally accepted certification for providers and a nationwide consensus on protocols. Currently, National Registry certification is accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.
A significant event in the development of modern standards of care in the U.S. was a report published in 1966 by the National Academy of Sciences entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", commonly referred to as "the White Paper." In this study, it became apparent that many of the deaths occurring every day were unnecessary, and could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments.
In particular, in the US state of California
, in Seattle
, Washington state (see Medic One
), and in Miami, projects began to include paramedic
s in the EMS responses in the early 1970s. Groups in Pittsburgh, Pennsylvania
, Charlottesville, Virginia
and Portland, Oregon
were also early pioneers in pre-hospital emergency medical training. Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the NBC
television series, Emergency!
which, in part, followed the adventures of two Los Angeles County Fire Department
paramedics as they responded to various types of medical emergency
. James O. Page
served as the series technical adviser and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.
, based in Greenwood Village, Colorado. The second-largest US EMS provider is Rural/Metro Corporation
, based in Scottsdale, Arizona; Rural/Metro Corporation also provides EMS services to parts of Latin America. Like AMR, Rural/Metro provides other transportation services, such as non-emergency transport and "coach", or wheelchair, transportation.
Many colleges and universities now also have their own EMS agencies for their campuses. Collegiate EMS programs vary somewhat from university to university; however, most agencies are fully staffed by student volunteers. Agencies might operate what is called a Quick Response Service (which does not transport patients but acts as a first responder to scenes) providing initial patient assessment and care, or they might operate certified ambulance services staffed with EMTs or Paramedics. Some groups limit services to within their campus, while others extend services to the surrounding community. Services provided by college and university agencies may include ambulance services, mass-casualty incident response, aero-medical services, and search-and-rescue teams.
While Fire Service in the US is rated based on ISO
classes, and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. This often forces EMS to depend on emotional pleas for funds during difficult financial times.
The original lines that delineated an EMT from a Paramedic and a Paramedic from a doctor are becoming increasingly blurred. Skills that were once reserved for physicians are now routinely performed by paramedics, and skills once reserved for paramedics, such as defibrillation, are now routinely performed by Basic Emergency Medical Technician
s (EMTs). However, there is wide variation among states, and even among counties within states, of what type of care providers at different levels are allowed to provide. In addition to these variations, some states and counties allow for add-ons, such as defibrillation
or IV therapy
, which enable workers at a lower level to learn and use additional skills that would not normally be within the scope of practice
of their qualification level (for example, an EMT-Basic is not generally permitted to start an IV, but after successfully completing an IV add-on course, he or she would then be able to do so.) Add-on skills are generally more common in rural areas where definitive care is further away geographically and immediate interventions by EMTs are beneficial for patient care.
A basic listing of qualification levels, not taking into account variations and add-ons, is the following:
EMTs other than EMT-Bs are typically identified based on their level of certification. For example, an EMT-P is generally called a paramedic in the field, and not an EMT. The title EMT, when used alone, therefore generally refers to an EMT-B.
In addition to the Paramedic level, Critical Care Paramedics specialize in the management of critical trauma and medical patients during interfacility ground and aeromedical transports. Skills performed by CCPs include ventilator management, IV pump infusion maintenance, aortic balloon pump monitoring, and specialized hemodynamic monitoring, although in some states some of these skills are performed by Paramedic level providers due to a lack of a separate level of licensure or classification as "Critical Care". Other specialty certifications and levels include ToxMedic, which has intense, hands on training in the treatment and dealing with hazardous materials exposure and poisoning; the Wilderness Paramedic program, which trains rural and wildland-area paramedics in some definitive care measures, preventive medicine, and care beyond that of the Golden Hour for critically injured and ill patients; Tactical or NarcMedic, which trains paramedics in police raid and search tactics to provide care under hostile fire and to assist special response teams; and Flight Paramedic, which builds on the Critical Care Paramedic curriculum by incorporating flight-specific knowledge and treatment. Pediatric and Neonatal Critical Care Paramedic also exists, but the program is new and hard to find.
Reciprocity - that is, recognition of one state's EMT certification being valid in another state - between states is somewhat limited, and after 30 years of operation by the National Registry of Emergency Medical Technicians
, only about 40 states provide unlimited recognition of the NREMT certifications. In reality, there are at least 40 types of certification for EMS personnel within the United States, and many of these are recognized by no more than a single state. This creates significant challenges for the career mobility of many EMS providers, as they must often re-sit certification examinations each time they move from one state to another.
, or board-certified physician
who oversees the policies and protocols of a particular EMS system or organization. Both the medical director and the actions he or she undertakes are often referred to as "Medical Control".
Equipment and procedures are necessarily limited in the pre-hospital environment, and EMS professionals are trained to follow a formal and carefully designed decision tree
(more commonly referred to as a "protocol") which has been approved by Medical Control. This protocol helps ensure a consistent approach to the most common types of emergencies the EMS professional may encounter. Medical Control may take place on-line, with the EMS personnel having to contact the physician for direction delegation
for all Advanced Life Support (ALS
) procedures, or off-line
, with EMS personnel performing some or all of their ALS procedures on the basis of protocols or 'standing orders'.
AD (Additional Duty) versions of both Type I and Type III designs are also defined. They include increased GVWR, storage and payload capacity.
Large American cities like New York and Los Angeles tend to have many distinct ambulance services, each with its own paint scheme and using all of the ambulance types mentioned above. Pedestrians and drivers in such cities must be alert for ambulances of many shapes, sizes, and colors. Most ambulances certified for emergency response in the U.S. are marked with the Star of Life
for ready identification by the public.
Ambulances may be supplemented or supported by vehicles that lack the capacity to transport a patient. The most common of these vehicles is known by several names, including 'Response Car'. Response cars are often equipped with much of the same equipment carried by an ambulance, but, since they are SUVs or large cars, they are often faster and nimbler. Response cars are staffed by one or more medical providers, and are used variously as a source of additional (or more skilled) manpower, as a supervisor's vehicle, or as a first response vehicle, enabling medical treatment to begin before the arrival of the ambulance.
in the United States is 9-1-1
. The number works for all three emergency services. In most cases, a 9-1-1 call will be answered at a central facility, usually referred to as a Public Safety Answering Point, and operated, in most cases, by the police. The needs of the caller are identified, and the call is routed to the dispatcher for the emergency service(s) required.
While some small communities continue to use 'low-tech' approaches to dispatch, in many places in the U.S. the technology is quite advanced. Advanced technologies in use may include electronic mapping, Global Positioning System
(GPS) or its first cousin Automatic vehicle location
(AVL). The use of decision support software such as AMPDS is also common, as are surveillance
'add-ons'. As a result, many dispatchers are trained to a high level in their own right, triaging incoming calls by severity, and providing advice or medical guidance by telephone prior to the arrival of the ambulance or rescue squad on the scene. Some are certified as EMTs or paramedics in their own states, and increasingly, are becoming certified as Emergency Medical Dispatchers.
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the federal
Federal government of the United States
The federal government of the United States is the national government of the constitutional republic of fifty states that is the United States of America. The federal government comprises three distinct branches of government: a legislative, an executive and a judiciary. These branches and...
government, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual state
U.S. state
A U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...
governments, which often require higher standards from the services they oversee.
Wide differences in population density
Population density
Population density is a measurement of population per unit area or unit volume. It is frequently applied to living organisms, and particularly to humans...
, topography
Topography
Topography is the study of Earth's surface shape and features or those ofplanets, moons, and asteroids...
, and other conditions can call for different types of EMS systems; consequently, there is often significant variation between the Emergency Medical Services provided in one state and those provided in another.
Land Ambulance
EMS delivery in the US can be based on various modelPrototype
A prototype is an early sample or model built to test a concept or process or to act as a thing to be replicated or learned from.The word prototype derives from the Greek πρωτότυπον , "primitive form", neutral of πρωτότυπος , "original, primitive", from πρῶτος , "first" and τύπος ,...
s. While most services are, to some degree, publicly-funded, the factor which often differentiates services is the manner in which they are operated. EMS systems may be directly operated by the community, or they may fall to a third-party provider, such as a private company. The most common operating models in the U.S. include:
Publicly-operated EMS
In one of the more common publicly-operated models, an EMS system is operated directly by the municipality it services. The services themselves may be provided by a local government, or may be the responsibility of the regional (or state) government. Municipality-operated services may be funded by service fees and supplemented by property taxes. In many such cases, the EMS system is considered to be too small to operate independently, and is organized as a branch of another municipal department, such as the Public HealthPublic health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
department. In small communities that lack a large population or tax-base, such a service may not be able to operate unless it is staffed by community volunteers. In these cases, the volunteer squad may receive some funding from municipal taxes, but is generally heavily reliant on voluntary donation
Donation
A donation is a gift given by physical or legal persons, typically for charitable purposes and/or to benefit a cause. A donation may take various forms, including cash, services, new or used goods including clothing, toys, food, and vehicles...
s to cover operating expenses. This provides a significant challenge for volunteer groups, since the training
Training
The term training refers to the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relate to specific useful competencies. It forms the core of apprenticeships and provides the backbone of content at institutes of...
standards for staff must be met, and the vehicle and equipment standards adhered to, while the group does all or most of its own fundraising
Fundraising
Fundraising or fund raising is the process of soliciting and gathering voluntary contributions as money or other resources, by requesting donations from individuals, businesses, charitable foundations, or governmental agencies...
. Without the presence of dedicated volunteers, however, many small communities in America might be without local EMS systems and would either have no service at all or be forced to rely on service from more distant communities.
Another operating model for publicly-operated EMS is what is generally referred to in the industry as the 'third service' option. In this option, rather than being an integral part of (or in some cases, an 'add-on' to) one of the traditional 'emergency' services (fire and police), the service is organized as a separate, free-standing, municipal
Local government
Local government refers collectively to administrative authorities over areas that are smaller than a state.The term is used to contrast with offices at nation-state level, which are referred to as the central government, national government, or federal government...
department, with organization that may be similar to, but operated independently from, either the fire or police departments,. In a variant of this model, the EMS system may be recognized as a legitimate third emergency service, but provided under a contractual agreement with another organization, such as a private company or a hospital, instead of direct operation. This model is sometimes referred to as the 'public utility' model. This may be a cost-saving measure, or it may be because the community feels that they lack the resident expertise to deal with medical oversight and control issues, and the legal requirements that typically surround an Emergency Medical Service.
In yet another model for publicly-operated EMS, the system may be integrated into the operations of another municipal emergency service, such as the local fire department
Fire department
A fire department or fire brigade is a public or private organization that provides fire protection for a certain jurisdiction, which typically is a municipality, county, or fire protection district...
or police department. This integration may be partial or complete. In the case of partial integration, the EMS staff may share quarters, administrative services, and even command and control with the other service. In the case of full integration, the EMS staff may be fully cross-trained to perform the entry-level function of the other emergency service, whether firefighting or policing. Many communities perceive this as providing 'added value' to the community, since municipal workers are fulfilling more than one function, and are less likely to be idle.
Private/for profit EMS
Ambulance services operating on a private/for profit basis have a long history in the U.S. Often, particularly in smaller communities, ambulance service was seen by the community as a lower priority than police or fire services, and certainly nothing that should require public funding. Until the professionalization of emergency medical services in the early 1970s, one of the most common providers of ambulance service in the United States was a community's local funeral home. This occurred essentially by default, as hearses were the only vehicles at the time capable of transporting a person lying down. Funeral home ambulance operations were sometimes supplemented by 'mom and pop' operations, which weren't affiliated with funeral homes but rather operated on much the same basis as a taxi service. There were no national standards for ambulance services and staff generally had little, if any, medical training or equipment, leading to a high pre-hospital mortality rate. Such companies continue to operate this way in some locations, providing non-emergency transport services, fee-for-service emergency service, or contracted emergency ambulance service to municipalities, as in the public utility model. During the late 1970s and early 1980s, more than 200 private ambulance companies in the U.S. were gradually merged into large regional companies, some of which continue to operate today. As this trend continued, the result was a few remaining private companies, a handful of regional companies, and two very large multinational companies which currently dominate the entire industry. These services continue to operate in some parts of the U.S., either on a fee-for-service basis to the patient, or by means of contracts with local municipalities. Such contracts usually result in a fee-for-service operation which is funded by the municipality on a supplementary basis, in exchange for formal guarantees of adequate performance on such issues as staffing, skill sets, resources available, and response times.Model of care
The Emergency Medical Service system in the United States typically follows the Anglo-American model (bringing the patient to the hospital), as opposed to the Franco-German model (bringing the hospital to the patient) of service delivery. Apart from a handful of doctors who work on MedevacMEDEVAC
Medical evacuation, often termed Medevac or Medivac, is the timely and efficient movement and en route care provided by medical personnel to the wounded being evacuated from the battlefield or to injured patients being evacuated from the scene of an accident to receiving medical facilities using...
aircraft or perform training or medical quality assurance, it is extremely uncommon to see a physician deliberately responding to the scene of an emergency.
Air Ambulance
Air ambulanceAir ambulance
An air ambulance is an aircraft used for emergency medical assistance in situations where either a traditional ambulance cannot reach the scene easily or quickly enough, or the patient needs to be transported over a distance or terrain that makes air transportation the most practical transport....
services in the United States can be operated by a variety of sources. Some services are hospital-operated, while others may be operated by Federal
Federal government of the United States
The federal government of the United States is the national government of the constitutional republic of fifty states that is the United States of America. The federal government comprises three distinct branches of government: a legislative, an executive and a judiciary. These branches and...
, State
U.S. state
A U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...
or local government
Local government
Local government refers collectively to administrative authorities over areas that are smaller than a state.The term is used to contrast with offices at nation-state level, which are referred to as the central government, national government, or federal government...
; or through a variety of departments, including local or State police
State police
State police are a type of sub-national territorial police force, particularly in Australia and the United States. Some other countries have analogous police forces, such as the provincial police in some Canadian provinces, while in other places, the same responsibilities are held by national...
, the United States Park Service, or Fire Departments. Such services may be operated directly by any of these EMS systems, or they may be contracted to a third-party provider, such as an aircraft charter company. In addition, it is not uncommon for U.S. military helicopters to be pressed into service providing air ambulance support. The vast distances covered by the U.S. mean that while helicopters may be the preferred form of service delivery for 'on-scene' emergencies, fixed wing aircraft, including small jets
Jet aircraft
A jet aircraft is an aircraft propelled by jet engines. Jet aircraft generally fly much faster than propeller-powered aircraft and at higher altitudes – as high as . At these altitudes, jet engines achieve maximum efficiency over long distances. The engines in propeller-powered aircraft...
, are often used for transfers from rural hospitals to tertiary care sites. These aircraft are typically staffed by a mix of personnel including physicians, nurses, and paramedics, and in some cases, by all three. Publicly operated air ambulance service is supplemented by emergency and non-emergency air transport service, which may be provided by dedicated air ambulance companies, or by aircraft charter
Charter
A charter is the grant of authority or rights, stating that the granter formally recognizes the prerogative of the recipient to exercise the rights specified...
companies as a 'sideline' business operation.
History
Civilian ambulanceAmbulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
services in the United States began in Cincinnati and New York City in 1865 and 1869, respectively. Hospital intern
Intern
Internship is a system of onthejob training for white-collar jobs, similar to an apprenticeship. Interns are usually college or university students, but they can also be high school students or post graduate adults seeking skills for a new career. They may also be as young as middle school or in...
s rode in horse drawn carriages designed specifically for transporting the sick and injured.
The first volunteer rescue squads organized around 1920 in Roanoke
Roanoke
Roanoke may refer to:*Roanoke , Carolina Algonquian-speaking tribe in eastern North Carolina*Roanoke , an American ship *Roanoke Colony, a former English colony that mysteriously disappeared...
, Virginia, Palmyra, New Jersey
Palmyra, New Jersey
Palmyra is a Borough in Burlington County, New Jersey, United States. As of the 2000 United States Census, the borough population was 7,091.Palmyra was originally incorporated as a township by an Act of the New Jersey Legislature on April 19, 1894, from portions of Cinnaminson Township and Riverton...
, and along the New Jersey
New Jersey
New Jersey is a state in the Northeastern and Middle Atlantic regions of the United States. , its population was 8,791,894. It is bordered on the north and east by the state of New York, on the southeast and south by the Atlantic Ocean, on the west by Pennsylvania and on the southwest by Delaware...
coast. Gradually, especially during and after World War II, hospitals and physicians faded from prehospital practice, yielding in urban areas to centrally coordinated programs. These were often controlled by the municipal hospital or fire department. Sporadically, funeral home hearses, which had been the common mode of transport, were being replaced by fire department, rescue squad and private ambulances.
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 a person could lie down, to operate both the local furniture store (where he would make coffins as a sideline) and the local ambulance service. However, after the release of the National Highway Traffic Safety Administration
National Highway Traffic Safety Administration
The National Highway Traffic Safety Administration is an agency of the Executive Branch of the U.S. government, part of the Department of Transportation...
's study, "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in the EMS trade as the White Paper
The White Paper
Accidental Death and Disability: The Neglected Disease of Modern Society, more commonly known as The White Paper, was an influential report published in 1966 by the National Academy of Sciences that is considered a landmark in the development of the emergency medical services system in the United...
) a concerted effort was undertaken to improve emergency medical care in the pre-hospital setting.
In the late 1960s, Dr. R Adams Cowley
R Adams Cowley
R Adams Cowley was an American surgeon considered a pioneer in emergency medicine and the treatment of shock trauma. He is also known for being one of the first to perform open-heart surgery and invented both a surgical clamp that bears his name and a prototype pacemaker that was used by Dwight D...
was instrumental in the creation of the country's first statewide EMS program, in Maryland. The system was called the Division of Emergency Medical Services (now known as the Maryland Institute for Emergency Medical Services and Systems). Also in 1969, Cowley obtained a military
Military
A military is an organization authorized by its greater society to use lethal force, usually including use of weapons, in defending its country by combating actual or perceived threats. The military may have additional functions of use to its greater society, such as advancing a political agenda e.g...
helicopter to assist in rapidly transporting patients to the Center for the Study of Trauma (now known as the R Adams Cowley Shock Trauma Center
R Adams Cowley Shock Trauma Center
R Adams Cowley Shock Trauma Center is a free-standing trauma hospital in Baltimore, Maryland and is part of the University of Maryland Medical Center. It was the first facility in the world to treat shock...
), a specialized hospital that he had started for the purpose of treating shock
Hypovolemia
In physiology and medicine, hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma...
. This service was not only the first statewide EMS program, but also the beginning of modern emergency medical helicopter transport in the United States.
The first civilian
Civilian
A civilian under international humanitarian law is a person who is not a member of his or her country's armed forces or other militia. Civilians are distinct from combatants. They are afforded a degree of legal protection from the effects of war and military occupation...
hospital-based medical helicopter program in the U.S., Flight For Life
Flight For Life
Flight for Life is a prehospital care service with many bases of operation across the United States. Flight for Life is primarily known for its emergency medical helicopter transport, but also operates a fleet of land vehicles and fixed wing aircraft for the transport of critically ill patients to...
Colorado, began in 1972 with a single Alouette III helicopter
Helicopter
A helicopter is a type of rotorcraft in which lift and thrust are supplied by one or more engine-driven rotors. This allows the helicopter to take off and land vertically, to hover, and to fly forwards, backwards, and laterally...
, based at St. Anthony Central Hospital in Denver, Colorado.
National EMS standards for the US are determined by the U.S. Department of Transportation and modified by each state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Committees (usually in rural areas) or by other committees, or even individual EMS providers. In addition, the National Registry of Emergency Medical Technicians, an independent body, was created in 1970 at the recommendation of President Richard M. Nixon in an effort to provide a nationally accepted certification for providers and a nationwide consensus on protocols. Currently, National Registry certification is accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.
A significant event in the development of modern standards of care in the U.S. was a report published in 1966 by the National Academy of Sciences entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", commonly referred to as "the White Paper." In this study, it became apparent that many of the deaths occurring every day were unnecessary, and could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments.
In particular, in the US state of California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
, in Seattle
Seattle, Washington
Seattle is the county seat of King County, Washington. With 608,660 residents as of the 2010 Census, Seattle is the largest city in the Northwestern United States. The Seattle metropolitan area of about 3.4 million inhabitants is the 15th largest metropolitan area in the country...
, Washington state (see Medic One
Medic One
The Seattle & King County Emergency Medical Services System is a fire-based two-tier response system providing prehospital basic and advanced life support services....
), and in Miami, projects began to include paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
s in the EMS responses in the early 1970s. Groups in Pittsburgh, Pennsylvania
Pittsburgh, Pennsylvania
Pittsburgh is the second-largest city in the US Commonwealth of Pennsylvania and the county seat of Allegheny County. Regionally, it anchors the largest urban area of Appalachia and the Ohio River Valley, and nationally, it is the 22nd-largest urban area in the United States...
, Charlottesville, Virginia
Charlottesville, Virginia
Charlottesville is an independent city geographically surrounded by but separate from Albemarle County in the Commonwealth of Virginia, United States, and named after Charlotte of Mecklenburg-Strelitz, the queen consort of King George III of the United Kingdom.The official population estimate for...
and Portland, Oregon
Portland, Oregon
Portland is a city located in the Pacific Northwest, near the confluence of the Willamette and Columbia rivers in the U.S. state of Oregon. As of the 2010 Census, it had a population of 583,776, making it the 29th most populous city in the United States...
were also early pioneers in pre-hospital emergency medical training. Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the NBC
NBC
The National Broadcasting Company is an American commercial broadcasting television network and former radio network headquartered in the GE Building in New York City's Rockefeller Center with additional major offices near Los Angeles and in Chicago...
television series, Emergency!
Emergency!
Emergency! is an American television series that combines the medical drama and action-adventure genres. It was produced by Mark VII Limited and distributed by Universal Studios...
which, in part, followed the adventures of two Los Angeles County Fire Department
Los Angeles County Fire Department
The Los Angeles County Fire Department , serves unincorporated parts of Los Angeles County, as well as 58 cities and towns that choose to have the county provide fire and EMS services, including La Habra. It should not be confused with the Los Angeles City Fire Department, which serves the city of...
paramedics as they responded to various types of medical emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
. James O. Page
James O. Page
James O. Page, JD , was recognized as a leading authority on United States emergency medical services . Page served in the Los Angeles County Fire Department for 16 years rising to the rank of Battalion Chief. In 1973 he was appointed as the first director of North Carolina's statewide EMS system...
served as the series technical adviser and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.
Staffing
Ambulances in the United States must be staffed with a minimum of 2 personnel. The level of crew certification varies depending on the jurisdiction the ambulance is operating in. In most areas, the bare minimum is an EMT-Basic to provide patient care and a First Responder to assist and drive the unit. This set-up would be classified as a Basic Life Support Unit (BLS) due to the fact that the highest ranking provider cannot perform Advanced Life Support (ALS) interventions. If patient condition warrants, an ALS provider may be summoned to assist and meet the ambulance en-route to the hospital. Other staffing combinations include 1 EMT-Basic and 1 Paramedic (the most common arrangement), or 2 Paramedics, which are classified in most areas as an Advanced Life Support Unit (ALS). Unlike in Europe, Emergency Physicians do not regularly practice in the field, and only crew ambulances for specialty situations, such as extreme-low-weight infant transports, ECMO or cardiac bypass transports, or unusual situations such as crush injuries necessitating field amputation, or mass casualty/disaster situations.Funding and manpower models
Outside of large cities, EMS is most often provided by volunteers; however, due to the increasing intensity of training, EMS is becoming more of a paid profession. Even agencies that were once strictly volunteer have begun supplementing their ranks with compensated members in order to keep up with booming call volumes. As of 2004, the largest "Private Enterprise" provider of contract EMS services in North America is AMR, or American Medical ResponseAmerican Medical Response
American Medical Response, Inc. or is an American provider of emergency and non-emergency medical transportation, operating in 38 states and the District of Columbia. It employs around 17,000 personnel and has a fleet of 4,400 vehicles...
, based in Greenwood Village, Colorado. The second-largest US EMS provider is Rural/Metro Corporation
Rural Metro
Rural/Metro Corporation is a for-profit emergency services organization — the second-largest in the country — providing emergency medical transportation, non-emergency general medical transportation to healthcare facilities and health management organizations, fire protection services, including...
, based in Scottsdale, Arizona; Rural/Metro Corporation also provides EMS services to parts of Latin America. Like AMR, Rural/Metro provides other transportation services, such as non-emergency transport and "coach", or wheelchair, transportation.
Many colleges and universities now also have their own EMS agencies for their campuses. Collegiate EMS programs vary somewhat from university to university; however, most agencies are fully staffed by student volunteers. Agencies might operate what is called a Quick Response Service (which does not transport patients but acts as a first responder to scenes) providing initial patient assessment and care, or they might operate certified ambulance services staffed with EMTs or Paramedics. Some groups limit services to within their campus, while others extend services to the surrounding community. Services provided by college and university agencies may include ambulance services, mass-casualty incident response, aero-medical services, and search-and-rescue teams.
While Fire Service in the US is rated based on ISO
International Organization for Standardization
The International Organization for Standardization , widely known as ISO, is an international standard-setting body composed of representatives from various national standards organizations. Founded on February 23, 1947, the organization promulgates worldwide proprietary, industrial and commercial...
classes, and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. This often forces EMS to depend on emotional pleas for funds during difficult financial times.
Training and certification
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
s (EMTs). However, there is wide variation among states, and even among counties within states, of what type of care providers at different levels are allowed to provide. In addition to these variations, some states and counties allow for add-ons, such as defibrillation
Defibrillation
Defibrillation is a common treatment for life-threatening cardiac arrhythmias, ventricular fibrillation and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator...
or IV therapy
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
, which enable workers at a lower level to learn and use additional skills that would not normally be within the scope of practice
Scope of Practice
Scope of Practice is a terminology used by national and state/provincial licensing boards for various professions that defines the procedures, actions, and processes that are permitted for the licensed individual. The scope of practice is limited to that which the law allows for specific education...
of their qualification level (for example, an EMT-Basic is not generally permitted to start an IV, but after successfully completing an IV add-on course, he or she would then be able to do so.) Add-on skills are generally more common in rural areas where definitive care is further away geographically and immediate interventions by EMTs are beneficial for patient care.
A basic listing of qualification levels, not taking into account variations and add-ons, is the following:
- Emergency medical responderEmergency medical responderEmergency medical responders are people who are specially trained to provide out-of-hospital care in medical emergencies. There are many different types of emergency medical responders, each with different levels of training, ranging from first aid and basic life support to advanced life support...
(EMR): EMRs, many of whom are volunteers, render very basic first aid, including oxygen administration, to patients. An EMR, with the help of an EMT, can assume care for a patient while that patient is being transported. - Emergency Medical TechnicianEmergency medical technicianEmergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
(EMT): EMT is used two different ways, one more specific than the other. In general, an EMT is a person who has been certified (or licensed, in some states) to provide a stated level of care based on written protocolsGuideline (medical)A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
. However, EMTs may be divided into several groups based on their level of certification and permitted skillsParamedicA paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
:- EMT Basic (EMT-B)
- EMT Intermediate (EMT-I) (Some states no longer recognize this as a certification level.)
- EMT ParamedicParamedicA paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
(EMT-P)
EMTs other than EMT-Bs are typically identified based on their level of certification. For example, an EMT-P is generally called a paramedic in the field, and not an EMT. The title EMT, when used alone, therefore generally refers to an EMT-B.
In addition to the Paramedic level, Critical Care Paramedics specialize in the management of critical trauma and medical patients during interfacility ground and aeromedical transports. Skills performed by CCPs include ventilator management, IV pump infusion maintenance, aortic balloon pump monitoring, and specialized hemodynamic monitoring, although in some states some of these skills are performed by Paramedic level providers due to a lack of a separate level of licensure or classification as "Critical Care". Other specialty certifications and levels include ToxMedic, which has intense, hands on training in the treatment and dealing with hazardous materials exposure and poisoning; the Wilderness Paramedic program, which trains rural and wildland-area paramedics in some definitive care measures, preventive medicine, and care beyond that of the Golden Hour for critically injured and ill patients; Tactical or NarcMedic, which trains paramedics in police raid and search tactics to provide care under hostile fire and to assist special response teams; and Flight Paramedic, which builds on the Critical Care Paramedic curriculum by incorporating flight-specific knowledge and treatment. Pediatric and Neonatal Critical Care Paramedic also exists, but the program is new and hard to find.
Reciprocity - that is, recognition of one state's EMT certification being valid in another state - between states is somewhat limited, and after 30 years of operation by the National Registry of Emergency Medical Technicians
National Registry of Emergency Medical Technicians
The National Registry of Emergency Medical Technicians is a US certification agency covering prehospital medical providers.- History :NREMT was established in 1970 in response to President Lyndon Johnson's Committee on Highway Traffic Safety recommended a national certifying agency for Emergency...
, only about 40 states provide unlimited recognition of the NREMT certifications. In reality, there are at least 40 types of certification for EMS personnel within the United States, and many of these are recognized by no more than a single state. This creates significant challenges for the career mobility of many EMS providers, as they must often re-sit certification examinations each time they move from one state to another.
Medical control
EMS providers work under the authority and indirect supervision of a medical directorMedical director
As laboratory director,means that you are responsible for the overall operation and administration of the laboratory, including the employment of competentqualified personnel. Even though you have the option to delegate some...
, or board-certified physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
who oversees the policies and protocols of a particular EMS system or organization. Both the medical director and the actions he or she undertakes are often referred to as "Medical Control".
Equipment and procedures are necessarily limited in the pre-hospital environment, and EMS professionals are trained to follow a formal and carefully designed decision tree
Decision tree
A decision tree is a decision support tool that uses a tree-like graph or model of decisions and their possible consequences, including chance event outcomes, resource costs, and utility. It is one way to display an algorithm. Decision trees are commonly used in operations research, specifically...
(more commonly referred to as a "protocol") which has been approved by Medical Control. This protocol helps ensure a consistent approach to the most common types of emergencies the EMS professional may encounter. Medical Control may take place on-line, with the EMS personnel having to contact the physician for direction delegation
Delegation
Delegation is the assignment of authority and responsibility to another person to carry out specific activities. However the person who delegated the work remains accountable for the outcome of the delegated work. Delegation empowers a subordinate to make decisions, i.e...
for all Advanced Life Support (ALS
ALS
ALS refers to amyotrophic lateral sclerosis, also known as Lou Gehrig's diseaseIt may also refer to:-Medicine:* Advanced life support, a level of medical training* Anterolateral system, part of the nervous system...
) procedures, or off-line
Off-line
The terms "online" and "offline" have specific meanings in regard to computer technology and telecommunications. In general, "online" indicates a state of connectivity, while "offline" indicates a disconnected state...
, with EMS personnel performing some or all of their ALS procedures on the basis of protocols or 'standing orders'.
Ambulances
Ambulances in the United States are defined by federal KKK-1822 Standards requirements, which define several categories of ambulances. In addition, most states have additional requirements according to their individual needs.- Type I Ambulances are based on the chassis-cabs of light duty pickup-trucks,
- Type II Ambulances are based on modern passenger/cargo vans.
- Type III Ambulances are based on chassis-cabs of light duty vans,
AD (Additional Duty) versions of both Type I and Type III designs are also defined. They include increased GVWR, storage and payload capacity.
Large American cities like New York and Los Angeles tend to have many distinct ambulance services, each with its own paint scheme and using all of the ambulance types mentioned above. Pedestrians and drivers in such cities must be alert for ambulances of many shapes, sizes, and colors. Most ambulances certified for emergency response in the U.S. are marked with the Star of Life
Star of Life
The Star of Life is a blue, six-pointed star, outlined with a white border which features the Rod of Asclepius in the center, originally designed and governed by the U.S. National Highway Traffic Safety Administration...
for ready identification by the public.
Ambulances may be supplemented or supported by vehicles that lack the capacity to transport a patient. The most common of these vehicles is known by several names, including 'Response Car'. Response cars are often equipped with much of the same equipment carried by an ambulance, but, since they are SUVs or large cars, they are often faster and nimbler. Response cars are staffed by one or more medical providers, and are used variously as a source of additional (or more skilled) manpower, as a supervisor's vehicle, or as a first response vehicle, enabling medical treatment to begin before the arrival of the ambulance.
Dispatch
In the United States, there are as many methods of dispatching EMS resources as there are approaches to providing EMS service. In some larger communities, EMS may be self-dispatching. Where EMS is operated as a division of the Police or Fire Departments, it will generally be dispatched by those organizations. Dispatching may occur through state-licensed EMS dispatch centers, which are operated by one service but provide dispatch to several counties. In large centers, such as New York City, the statutory EMS provider (in the case of NYC, the FDNY) will dispatch not only their own vehicles, but also EMS resources belonging to hospitals, private companies, and even volunteers, within their own community. The national emergency numberEmergency telephone number
Many countries' public telephone networks have a single emergency telephone number, sometimes known as the universal emergency telephone number or occasionally the emergency services number, that allows a caller to contact local emergency services for assistance. The emergency telephone number may...
in the United States is 9-1-1
9-1-1
9-1-1 is the emergency telephone number for the North American Numbering Plan .It is one of eight N11 codes.The use of this number is for emergency circumstances only, and to use it for any other purpose can be a crime.-History:In the earliest days of telephone technology, prior to the...
. The number works for all three emergency services. In most cases, a 9-1-1 call will be answered at a central facility, usually referred to as a Public Safety Answering Point, and operated, in most cases, by the police. The needs of the caller are identified, and the call is routed to the dispatcher for the emergency service(s) required.
While some small communities continue to use 'low-tech' approaches to dispatch, in many places in the U.S. the technology is quite advanced. Advanced technologies in use may include electronic mapping, Global Positioning System
Global Positioning System
The Global Positioning System is a space-based global navigation satellite system that provides location and time information in all weather, anywhere on or near the Earth, where there is an unobstructed line of sight to four or more GPS satellites...
(GPS) or its first cousin Automatic vehicle location
Automatic vehicle location
Automatic vehicle location is a means for automatically determining the geographic location of a vehicle and transmitting the information to a requester....
(AVL). The use of decision support software such as AMPDS is also common, as are surveillance
Surveillance
Surveillance is the monitoring of the behavior, activities, or other changing information, usually of people. It is sometimes done in a surreptitious manner...
'add-ons'. As a result, many dispatchers are trained to a high level in their own right, triaging incoming calls by severity, and providing advice or medical guidance by telephone prior to the arrival of the ambulance or rescue squad on the scene. Some are certified as EMTs or paramedics in their own states, and increasingly, are becoming certified as Emergency Medical Dispatchers.
Response times
There is no official Federal or State standard for response times in the United States. Response time standards frequently do exist in the form of contractual obligations between communities and EMS provider organizations, however. As a result, there is typically considerable variation between standards in one community and another. New York City, for example, mandates a 10 minute response time on emergency calls, while some communities in California have moved response time standards to 12–15 minutes. It is generally accepted within the field that an 'ideal' response time for emergency calls would be within eight minutes, ninety-percent of the time, but this objective is rarely achieved, and current research results question the validity of that standard. As call volumes increase and resources and funding fail to keep pace, even large EMS systems such as Pittsburgh, Pennsylvania and Augusta, Georgia struggle to meet these standards. Individuals who live in rural areas far from emergency services also may expect a longer wait due to the distance involved. This issue is further complicated by differing performance measurement methodologies. Some services count response time beginning at the moment that the telephone call is answered and running until an ambulance or response resource arrives at the scene, while others measure only the time from the notification of EMS personnel of the call, which is considerably shorter. Another issue which arises in urban areas is that the response time 'clock' almost universally stops when the unit arrives in front of the address; in large office or apartment buildings, actually accessing the patient may take several minutes longer, but this is not considered in response time calculation or reporting.See also
- AmbulanceAmbulanceAn ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
- Emergency Medical ServicesEmergency medical servicesEmergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
- Emergency Medical DispatcherEmergency medical dispatcherAn Emergency medical dispatcher is a professional telecommunicator, tasked with the gathering of information related to medical emergencies, the provision of assistance and instructions by voice, prior to the arrival of Emergency Medical Services, and the dispatching and support of EMS resources...
- Certified first responderCertified first responderA certified first responder is a person who has completed a course and received certification in providing pre-hospital care for medical emergencies. They have more skill than someone who is trained in basic first aid but they are not a substitute for advanced medical care rendered by emergency...
- Emergency medical technicianEmergency medical technicianEmergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
- Emergency medical responder levels by state
- Paramedics in the United StatesParamedics in the United StatesThe paramedic is an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system. This individual possesses the complex knowledge and skills necessary to provide patient care and...
- ParamedicParamedicA paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
- Emergency medicineEmergency medicineEmergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
- The White PaperThe White PaperAccidental Death and Disability: The Neglected Disease of Modern Society, more commonly known as The White Paper, was an influential report published in 1966 by the National Academy of Sciences that is considered a landmark in the development of the emergency medical services system in the United...
- 9-1-19-1-19-1-1 is the emergency telephone number for the North American Numbering Plan .It is one of eight N11 codes.The use of this number is for emergency circumstances only, and to use it for any other purpose can be a crime.-History:In the earliest days of telephone technology, prior to the...
External links
- History of Emergency Medical Services
- HISTORY OF EMERGENCY MEDICAL SERVICES (EMS)
- National Registry of Emergency Medical Technicians
- National Association of Emergency Medical Technicians
- National Volunteer Fire Council - EMS/Rescue Section
- National Highway Traffic Safety Agency, Office of Emergency Medical Services
- The Difference Between an EMT and a Paramedic