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History of EMSHistory of EMSPast, Present, FuturePast, Present, Future
Jeff Dostalek Jeff Dostalek EMS Instructor, NREMT-PEMS Instructor, NREMT-P
IntroductionIntroduction
EMS System DevelopmentEMS System Development
History of EMS History of EMS
Role of the Paramedic today versus the “ambulance Role of the Paramedic today versus the “ambulance driver” of yesterdaydriver” of yesterday
Paramedic professional responsibilities to enhance their Paramedic professional responsibilities to enhance their ability to provide quality serviceability to provide quality service
Licensure, Certification, CredentialingLicensure, Certification, Credentialing
ObjectivesObjectives
Describe benefits of continuing educationDescribe benefits of continuing education
Medical DirectionMedical Direction
List the benefits of professional association membershipList the benefits of professional association membership
IntroductionIntroduction
The public perception of you is based onThe public perception of you is based on– TV and articlesTV and articles– Your treatment of their loved onesYour treatment of their loved ones
Continuing education is a mustContinuing education is a must
Treat everyone with respect and dignityTreat everyone with respect and dignity
How far have we comeHow far have we come
EMS System DevelopmentEMS System Development
• 14851485• First use of an First use of an
ambulance.ambulance.• Transport onlyTransport only
• 1800s1800s• First use of and First use of and
ambulance/attendant to ambulance/attendant to care for injured on sitecare for injured on site
• 19261926• Service started similar to Service started similar to
present daypresent day
• 19401940• EMS turned over to fire and EMS turned over to fire and
police departmentpolice department• No set standard of careNo set standard of care
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
EMS Made major strides after WWIIEMS Made major strides after WWII
– Bringing hospital to filed gave patients a better Bringing hospital to filed gave patients a better chance for survivalchance for survival
– Korean WarKorean WarFirst use of helicopterFirst use of helicopterM*A*S*H* UnitsM*A*S*H* Units
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
19561956– Mouth-to-Mouth resuscitation developedMouth-to-Mouth resuscitation developed
Late 1950s/early 1960sLate 1950s/early 1960s– Focused shifted to bring hospitals to patientsFocused shifted to bring hospitals to patients– MICU developedMICU developed
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
1965: “The White Paper” released1965: “The White Paper” released
– Finding included:Finding included:Lack of uniform laws and standardsLack of uniform laws and standards
Poor-quality equipmentPoor-quality equipment
Lack of communicationLack of communication
Lack of trainingLack of training
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
““The White Paper: finding outlined 10 The White Paper: finding outlined 10 critical points for EMS Systemscritical points for EMS Systems– Led to national Highway Safety ActLed to national Highway Safety Act– Created US Department of TransportationCreated US Department of Transportation
19681968– Training Standards implementedTraining Standards implemented– 9-1-1 created9-1-1 created
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
19691969– First true Paramedic programFirst true Paramedic program– Standards for ambulance design and Standards for ambulance design and
equipmentequipment
19701970– NREMT beganNREMT began
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
1970s (cont’d)1970s (cont’d)– 1971: Emergency Care and Transportation of 1971: Emergency Care and Transportation of
the Sick and Injured published by AAOSthe Sick and Injured published by AAOS
– 1973: Emergency Medical Services Act1973: Emergency Medical Services Act
– 1977: First National Standard Curriculum for 1977: First National Standard Curriculum for Paramedics developed by US DOTParamedics developed by US DOT
The 20The 20thth Century and Modern Century and ModernTechnologyTechnology
1980s/1990s1980s/1990s– Number of trained personnel grewNumber of trained personnel grew– NHTA developed 10 system elements to help NHTA developed 10 system elements to help
sustain EMS Systemsustain EMS System– Responsibility for EMS transferred to the Responsibility for EMS transferred to the
statedstated– Major legislative initiativesMajor legislative initiatives
Licensure, Certification, and Licensure, Certification, and RegistrationRegistration
Certification examinationCertification examination– Ensure all health care providers have the Ensure all health care providers have the
same basic level of knowledge and skillsame basic level of knowledge and skill– Once you pass certification you can apply for Once you pass certification you can apply for
state licensurestate licensure
Licensure, Certification, and Licensure, Certification, and RegistrationRegistration
LicensureLicensure– How states control How states control
who practicewho practice– Also known as Also known as
certification or certification or credentialingcredentialing
– Unlawful to practice Unlawful to practice without licensewithout license
Holding a license Holding a license shows you:shows you:– Completed initial Completed initial
educationeducation– Met the requirement to Met the requirement to
achieve the licenseachieve the license
Licensure, Certification, and Licensure, Certification, and RegistrationRegistration
ReciprocityReciprocity– Certification granted from another Certification granted from another
State/agencyState/agency– Requirements:Requirements:
Hold a current state certificationHold a current state certification
Be in good standingBe in good standing
National Registry certificationNational Registry certification
The EMS SystemThe EMS System
Network of coordinated services that Network of coordinated services that provide care to the communityprovide care to the community
The public needs to be taught how to:The public needs to be taught how to:– Recognize emergenciesRecognize emergencies– Activate the EMS SystemActivate the EMS System– Provide basic careProvide basic care
The EMS SystemThe EMS System
Patient outcomes are determined by:Patient outcomes are determined by:– Bystander careBystander care– DispatchDispatch– ResponseResponse– Pre-hospital carePre-hospital care– TransportationTransportation– ER CareER Care– Definitive care and RehabilitationDefinitive care and Rehabilitation
The EMS SystemThe EMS System
DispatcherDispatcher– Usually the publics first contactUsually the publics first contact– Training level varies from State to StateTraining level varies from State to State
Scene may differ from what dispatcher Scene may differ from what dispatcher relaysrelays
The EMS SystemThe EMS System
As a paramedic, you must:As a paramedic, you must:– Develop care planDevelop care plan– Decide on transportation modeDecide on transportation mode– Determine receiving facilityDetermine receiving facility– Be active in your communityBe active in your community
Levels of EducationLevels of Education
EMS System function from a federal to EMS System function from a federal to local levellocal level– Federal: National EMS Scope of Practice Federal: National EMS Scope of Practice
ModelModel
– State:State: LicensureLicensure
– Local: Medical Director decides day to day Local: Medical Director decides day to day limitslimits
Levels of EducationLevels of Education
The national guideline designed to create The national guideline designed to create more consistent delivery of EMS more consistent delivery of EMS nationally.nationally.
2009: national EMS Education Standard2009: national EMS Education Standard– NREMT provides a national standard for NREMT provides a national standard for
testing and certificationtesting and certification
The DispatcherThe Dispatcher
Plays a critical rolePlays a critical role– Receives and enters Receives and enters
informationinformation– Interprets itInterprets it– relays it to appropriate relays it to appropriate
serviceservice– Pre-arrival instructionsPre-arrival instructions
Emergency Medical ResponderEmergency Medical Responder(EMR)(EMR)
Formerly “First Formerly “First responder”responder”
Requirements vary by Requirements vary by statestate
Should be able to:Should be able to:– Recognize Recognize
seriousness of seriousness of conditioncondition
– Provide basic first aidProvide basic first aid– Relay informationRelay information
EMTEMT
Formerly EMT BasicFormerly EMT Basic
Primary provider level Primary provider level in many systemsin many systems
Most populous level Most populous level in the systemin the system
Advance EMT (AEMT)Advance EMT (AEMT)
Formerly EMT-IFormerly EMT-I
Trained in:Trained in:– More advanced PathophysiologyMore advanced Pathophysiology– Some advanced proceduresSome advanced procedures
Initially developed in 1985Initially developed in 1985– Major revision in 1999Major revision in 1999
ParamedicParamedicHighest Level to be nationally Highest Level to be nationally certifiedcertified
– 1999: Major revision to 1999: Major revision to curriculum to increase level of curriculum to increase level of training and skillstraining and skills
Even if independently licensed, Even if independently licensed, you must:you must:
– Function under the guidance Function under the guidance of physicianof physician
– Be affiliated with a paramedic Be affiliated with a paramedic level servicelevel service
Paramedic EducationParamedic Education
Initial educationInitial education
– Most states based on National EMS Most states based on National EMS Education StandardsEducation Standards
– States require varying hours of educationsStates require varying hours of educationsnational Average: 1,000-1,500 hoursnational Average: 1,000-1,500 hours
Paramedic EducationParamedic Education
Continuing EducationContinuing Education– Most states require Most states require
proof of hoursproof of hours
– Attend conferences Attend conferences and seminarsand seminars
– Read EMS journalsRead EMS journals
– Get involved in post Get involved in post run reviewrun review
Continuing EducationContinuing Education
Maintenance of core knowledge and skillsMaintenance of core knowledge and skills
Expansion of knowledge and skillsExpansion of knowledge and skills
Awareness of advances in professionAwareness of advances in profession
Forms of CEU are manyForms of CEU are many
Working With Other Working With Other ProfessionalsProfessionals
Hospital StaffHospital Staff– Become familiar with the hospital;Become familiar with the hospital;
– The best patient care occurs when emergency The best patient care occurs when emergency care providers have a close rapport with staffcare providers have a close rapport with staff
ASK QUESTIONSASK QUESTIONS
Health Care ProfessionalHealth Care Professional
Conform to professional standardsConform to professional standardsProvide quality patient careProvide quality patient careInstill pride in the professionInstill pride in the professionStrive for high standardsStrive for high standardsEarn respect of othersEarn respect of othersSocietal expectations on & off dutySocietal expectations on & off dutyPosition of public trustPosition of public trustUnprofessional conduct tarnishes the profession, the Unprofessional conduct tarnishes the profession, the service, and youservice, and youImage and BehaviorImage and Behavior
Working With OtherWorking With OtherProfessionalsProfessionals
Public safety agentsPublic safety agents– Some have EMS Some have EMS
TrainingTrainingCan better perform Can better perform certain functions than certain functions than youyou
– Interagency Interagency cooperation benefits cooperation benefits patientspatients
Working With Other Working With Other ProfessionalsProfessionals
Continuity of careContinuity of care– the community has expectation of EMSthe community has expectation of EMS
– Focus on preventionFocus on prevention
– You will interact with many professional You will interact with many professional groupsgroups
Understand your role, as well as othersUnderstand your role, as well as others
EMS Group InvolvementEMS Group Involvement
National, state, regional, and localNational, state, regional, and local
Development, education, implementation and setting Development, education, implementation and setting standards for EMSstandards for EMS
NREMT: verifies competency and reciprocityNREMT: verifies competency and reciprocity
Wisconsin: Wisconsin: – DHSDHS EMS Advisory BoardEMS Advisory Board– WEMSAWEMSA STAC / RTACSTAC / RTAC– PSOWPSOW WTCSWTCS– WPS,Inc.WPS,Inc. Others ?Others ?
Primary ResponsibilitiesPrimary Responsibilities
PreparationPreparationResponse to sceneResponse to sceneScene assessmentScene assessmentPatient assessmentPatient assessmentRecognition of injury or illnessRecognition of injury or illnessManagementManagementAppropriate dispositionAppropriate dispositionPatient transport and transfer of carePatient transport and transfer of careDocumentationDocumentationReturn to serviceReturn to service
ProfessionalismProfessionalism
Standards of conduct and performance Standards of conduct and performance established by the professionestablished by the profession
You will be measured by:You will be measured by:– Standard, competencies, and education requirmentsStandard, competencies, and education requirments– Performance parametersPerformance parameters– Adherence to a “Code of Ethics”Adherence to a “Code of Ethics”
ProfessionalismProfessionalism
You are in a highly visible role in your You are in a highly visible role in your communitycommunity
You must:You must:– Instill confidenceInstill confidence– Establish and maintain credibilityEstablish and maintain credibility– Show concern for your patientsShow concern for your patients
ProfessionalismProfessionalism
Your appearance is of utmost importance Your appearance is of utmost importance
Present a professional image and treat Present a professional image and treat colleagues with respect.colleagues with respect.– Arguing with colleagues is inappropriateArguing with colleagues is inappropriate– Raising issues at the appropriate time and Raising issues at the appropriate time and
placeplace
Professional Attributes of the ParamedicProfessional Attributes of the Paramedic
IntegrityIntegrityEmpathyEmpathySelf-motivationSelf-motivationAppearance and Personal HygieneAppearance and Personal HygieneSelf confidenceSelf confidenceExcellent communicationsExcellent communicationsTime managementTime managementTeamworkTeamworkDiplomacyDiplomacyRespectRespectPatient AdvocacyPatient AdvocacyCareful delivery of serviceCareful delivery of service
Roles and ResponsibilitiesRoles and Responsibilities
Teach the community Teach the community about injury about injury prevention and illnessprevention and illness– Appropriate use of Appropriate use of
EMSEMS– CPR TrainingCPR Training– Influenza and Influenza and
pandemic issuespandemic issues– Campaign for EMS Campaign for EMS
systemsystem
Medical DirectionMedical Direction
paramedic carry out advanced skillsparamedic carry out advanced skills– Must take direction from medical directorsMust take direction from medical directors
Medical Director may perform many rolesMedical Director may perform many roles– Educate and trainEducate and train– Recommend new personnel or equipmentRecommend new personnel or equipment– Develop protocols, guidelines, and QADevelop protocols, guidelines, and QA
Medical DirectionMedical Direction
Roles of the Medical Director (cont)Roles of the Medical Director (cont)– Provide input for patient careProvide input for patient care
– Interface between EMS and other agenciesInterface between EMS and other agencies
– Advocate for EMSAdvocate for EMS
Medical DirectionMedical Direction(Medical Control)(Medical Control)
OnlineOnline– Provides immediate Provides immediate
and specific patient and specific patient care resourcescare resources
– Allows for continues Allows for continues quality improvementquality improvement
– Can render on-scene Can render on-scene care assistancecare assistance
OfflineOffline– Allows for the Allows for the
development of:development of:Protocols or guidelinesProtocols or guidelines
Standing ordersStanding orders
ProceduresProcedures
TrainingTraining
Improving System QualityImproving System Quality
Goal: evaluating and improving patient careGoal: evaluating and improving patient care
Continuous Quality ImprovementContinuous Quality Improvement
Quality AssuranceQuality Assurance
Improving System QualityImproving System Quality
Continues quality improvement (CQI)Continues quality improvement (CQI)– Tools to continually evaluate careTools to continually evaluate care– Quality ControlQuality Control– Process of assessing current practice looking Process of assessing current practice looking
for ways to improvefor ways to improve– Dynamic ProcessDynamic Process
Improving System QualityImproving System Quality
Review ambulance Review ambulance runs when possibleruns when possible
Focus of CQI is Focus of CQI is improving careimproving care
CQI can be peer CQI can be peer review:review:– Be professionalBe professional– Should be a Should be a
constructive processconstructive process
Improving System QualityImproving System Quality
CQI programs helps CQI programs helps prevent problems by:prevent problems by:– Evaluating day-to-day Evaluating day-to-day
operationsoperations– Identify possible stress Identify possible stress
pointspoints
Look for ways to Look for ways to eliminate human eliminate human error:error:– Ensure adequate Ensure adequate
lightinglighting– Store medications Store medications
properlyproperly
Improving System QualityImproving System Quality
Ways to eliminate human errorWays to eliminate human error– Be careful when handing patients offBe careful when handing patients off– Three sources of errorsThree sources of errors
Rules-based failureRules-based failure
Knowledge-based failureKnowledge-based failure
Skills-based failureSkills-based failure
Improving System QualityImproving System Quality
Ways to eliminate human error (cont’d)Ways to eliminate human error (cont’d)– Agencies need clear protocolsAgencies need clear protocols– Be aware of your environmentBe aware of your environment– Ask yourself “Why am I doing this”Ask yourself “Why am I doing this”– Use cheat sheetUse cheat sheet– Be conscientious of protocolsBe conscientious of protocols
Patient SafetyPatient Safety
1996 Institute of Medicine1996 Institute of Medicine– Launched efforts to improve patient safety Launched efforts to improve patient safety
and quality of care.and quality of care.– At least 44,000 and may up to 98,000 people At least 44,000 and may up to 98,000 people
die in hospital each year as a result of die in hospital each year as a result of medical errorsmedical errors
Highest Risk for EMSHighest Risk for EMS
Ambulance CrashesAmbulance CrashesDropping PatientsDropping PatientsHand-offHand-offCommunication issuesCommunication issuesMedication issuesMedication issuesPoor sterile techniquePoor sterile techniqueAirway issuesAirway issuesSpinal ImmobilizationSpinal Immobilization
Preventing Medical ErrorsPreventing Medical Errors
Look-alike, Sound-alike MedicationLook-alike, Sound-alike MedicationPatient identificationPatient identificationCommunication on hand-offCommunication on hand-offPerform correct procedures Perform correct procedures Medication accuracyMedication accuracyPulling tubes and linePulling tubes and lineUsing proper technique Using proper technique Proper Hand hygieneProper Hand hygiene
Preventing Medical Error in EMSPreventing Medical Error in EMS
Environmental methodsEnvironmental methods– Clear-established protocolsClear-established protocols– Sufficient lighting for procedures and Sufficient lighting for procedures and
assessmentassessment– Performing patient care duties with minimal Performing patient care duties with minimal
interruptionsinterruptions– Organizing and packaging drugsOrganizing and packaging drugs– Securing equipment in patient care Securing equipment in patient care
compartments.compartments.
Preventing Medical Error in EMS Preventing Medical Error in EMS (cont’d)(cont’d)
Individual methodsIndividual methods– Reflection in actionsReflection in actions– Question assumptionsQuestion assumptions– Reflection biasReflection bias– Use decisions aidsUse decisions aids– Ask for helpAsk for help
SummarySummary
Ambulance corps were developed in WW Ambulance corps were developed in WW II to transport and rapidly care for soldersII to transport and rapidly care for solders
Helicopter implemented during the Korean Helicopter implemented during the Korean WarWar
SummarySummary
1966 the National Academy of Sciences 1966 the National Academy of Sciences and the National Research Council and the National Research Council released the “The White Paper”released the “The White Paper”
Paramedics must be licensed before Paramedics must be licensed before performing any functionperforming any function
SummarySummary
Standards for pre-hospital care are Standards for pre-hospital care are regulated by state law and State EMS regulated by state law and State EMS officesoffices
Four levels of trainingFour levels of training– First ResponderFirst Responder– EMTEMT– Advance EMTAdvance EMT– ParamedicParamedic
SummarySummary
Paramedics should be familiar with:Paramedics should be familiar with:– Roles of other health care providersRoles of other health care providers– Continuing education requirementsContinuing education requirements– Medical ControlMedical Control– Code of ethicsCode of ethics– Professional attributes of a health care Professional attributes of a health care
providerprovider– Quality Assurance Quality Assurance – Patient safety considerationPatient safety consideration
EMS Star of LifeEMS Star of Life
DetectionDetection
ReportingReporting
ResponseResponse
On Scene CareOn Scene Care
Care in TransitCare in Transit
Transfer to Definitive Transfer to Definitive CareCare