ch1 10e

PREHOSPITAL
EMERGENCY CARE
TENTH EDITION
1
Emergency Care
CHAPTER
Medical Systems,
Research, and
Public Health
Prehospital Emergency Care, 10th edition

Mistovich | Karren
Copyright 2014, 2010, 2008 by Pearson Education, Inc.

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Learning Readiness
EMS Education Standards
Preparatory
Public Health

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Learning Readiness
Objectives
Please refer to pages 1 and 2 of your
text to view the objectives for this
chapter.

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Learning Readiness
Key Terms
Please refer to page 2 of your text to
view the key terms for this chapter.

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Setting the Stage

Overview of Lesson Topics
The emergency medical services (EMS)
system
Roles, responsibilities, and attributes of
EMTs
State EMS agencies, medical direction,
and quality improvement (QI)
continued on next slide

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Setting the Stage

Overview of Lesson Topics
Patient safety
Research in EMS
Public health and EMS

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Case Study Introduction

Every Saturday Ben Melton has breakfast
at Daves Diner, a favorite with locals in
the small tourist town. Despite having
diabetes and carrying an extra 40 pounds
around his waist, 51-year-old Ben finds it
hard to pass on Daves breakfast platter
of eggs, steak, and fried potatoes.

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Case Study Introduction

This morning, by the time his coffee
arrives, Ben isnt feeling so well. Just as
his friend, Arnie, notices that Ben has
turned pale and broken into a sweat, Ben
collapses, pulling the tablecloth with him
to the floor.

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Case Study
What components of a health care
system must be in place for Ben to
receive immediate help?
What weaknesses in a system could
decrease Bens chances of getting help?

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Introduction
Sudden loss of life and disability from
catastrophic accidents and illnesses is a
major public health problem.
Every year thousands of people die or
suffer permanent harm because of lack
of access to adequate to emergency
medical services.
EMTs can make a positive difference.

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The EMS System: History

What happens to an injured or ill
patient before he reaches the hospital
can make a critical difference.
Lessons learned from observations in
the Korean and Vietnam wars have
impacted the development of modern
EMS systems.

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In the past, care did not begin until the
patient reached the hospital.
In 1966, the EMS white paper
identified deficiencies in prehospital
medical care, including lack of EMT
training and lack of organized systems.

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Modern EMS is part of a continuum of
care that begins at the scene of the
emergency and continues through
hospital discharge and rehabilitation.
Several significant developments
helped lead to this EMS system.

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The Highway Safety Act of 1966
Required each state to establish a
highway safety program that included
emergency services
The National Highway Transportation
Safety Administration (NHTSA), part of
the Department of Transportation
(DOT), led the development of EMS.
An early initiative was the development
of national standard curricula for EMS.

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The Emergency Medical Services
System Act of 1973 provided access to
millions of dollars of funding for EMS.
The American Heart Association (AHA)
began to teach CPR to the public.

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In 1993 the National Registry of EMTs
(NREMT) released the National
Emergency Medical Services Education
and Practice Blueprint, which:
Defined issues related to EMS training
and education
Served as a guide to the development
of national training curricula
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NHTSA documents
1996 EMS Agenda for the Future
Focused on making EMS a greater
component in the health care system
2000 EMS Education Agenda for the

Future: A Systems Approach
Focused on the need for nationwide
consistency in the education, training,
certification, and licensure of entry-level
EMS personnel
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NHTSA documents
2005 National EMS Core Content
Defined the domain of knowledge of the
National EMS Scope of Practice Model
2006 National EMS Scope of Practice

Model
Defines four levels of EMS licensure
National EMS Education Standards

Outline minimum terminal objectives for
EMS education programs
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The 2006 Institute of Medicine (IOM)
report The Future of EMS Care: EMS at
the Crossroads recommends:
Common scopes of practice to allow
reciprocity between states
National accreditation for all paramedic
programs
National certification as a prerequisite
for state licensure and local
credentialing
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The EMS System: Standards

NHTSA provides a set of recommended
state standards, the Technical
Assistance Program Assessment
Standards.
There are ten components.

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Regulation and policy
Laws, regulations, policies, and
procedures that govern the EMS system
A state-level EMS agency to provide
leadership to local jurisdictions
Resource management
Central control of EMS resources so that
there is equal access to acceptable
emergency care
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Human resources and training
All personnel who staff ambulances and
transport patients must be trained to at
least the EMT level
Transportation
Safe, reliable transportation by ground
or air ambulance

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Facilities
Patients must be delivered to
appropriate medical facilities
Communications
Public access to the system
Communication among dispatcher, EMS
personnel, and hospital

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Public information and education
EMS personnel should participate in
programs to educate the public in injury
prevention and how to access the EMS
system.
Medical direction
A physician medical director to provide
medical oversight
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Trauma systems
A system of specialized care for trauma
patients
Evaluation
A quality improvement system

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EMS System Access

The most common way of accessing
EMS is dialing 911.
Enhanced 911 (E-911) allows:
Automatic number identification
Automatic location information

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Communications play a vital role in the Emergency Medical Services (EMS) system.

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EMS System Access

Benefits of 911
Public safety answering point (PSAP) is
staffed by specially trained dispatchers.
The number is easy to remember and
use.
All emergency servicespolice, fire, and
EMSare accessible by dialing one
number.
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EMS System Access

Cell phones pose some challenges to
911 systems.
They are not identified with a fixed site,
so the location is identified as the
closest cell tower.
Calls near geographic boundaries can go
to a different PSAP.
FCC rules are being implemented to
improve cellular access to 911.
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EMS System Access

Voice over Internet Protocol (VoIP) also
poses potential challenges that are
addressed by FCC rules.
911 service must be a standard feature
to all customers.
The subscriber must give the physical
location of where the service will be
used.
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EMS System Access

Voice over Internet Protocol (VoIP) also
poses potential challenges that are
addressed by FCC rules.
The provider must transmit all 911 calls
and associated information to the
appropriate PSAP.

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Case Study
Charlene, one of the waitresses in the
restaurant, pulls a cell phone from her
pocket and dials 911. The dispatcher
immediately transfers the call to a
specially trained emergency medical
dispatcher. The EMD asks Charlene a
series of questions to get help on the
way, and gives her instructions for
checking and monitoring Bens condition
until help arrives.

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Case Study
What components of the EMS system
have been used in this case so far?
Click each item you select.
Regulations &
Policy
Resource
Management
Human
Resources &
Training
Transportation
Facilities
Communication
Public
Information &
Education
Medical
Direction
Trauma
Systems
Evaluation

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Case Study
EMTs Juliana Smock and Peter Saylor,
who had just finished their check of the
ambulance, respond to the dispatch,
heading down Highway 129 toward
Daves. An anxious customer holds open
the front door as Juliana and Peter pull to
a stop in front of the restaurant. Taking a
look around at the scene, the EMTs grab
their equipment and head for the door.
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Case Study
What EMT responsibilities have Juliana
and Peter demonstrated so far?
What EMT responsibilities do you
predict they will perform next?
How will the EMTs appearance and
actions determine how they are
perceived by others?

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Levels of Providers
The National EMS Scope of Practice
Model identifies four levels of EMS
practitioners.

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The four levels of EMS practitioners.

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Levels of Providers
Emergency Medical Responder
Provides immediate lifesaving care to
patients while awaiting response from a
higher-level EMS practitioner

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Levels of Providers
Emergency Medical Technician
Provides basic emergency medical care
and transportation using the basic
equipment found on an ambulance

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Levels of Providers
Advanced Emergency Medical
Technician
Provides basic and limited advanced
emergency medical care and
transportation to patients in the
prehospital environment

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Levels of Providers
Paramedic
Performs advanced assessments, forms
field impressions, and provides invasive
and drug interventions as well as
transport

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The Health Care System

A health care system is a network of
medical care that begins in the field
and extends to hospitals and other
treatment centers.
EMS providers are part of a
communitys health care system.

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The different health care facilities to
which EMTs may transport patients
have different capabilities.

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Trauma center
Burn center
Obstetrical center
Pediatric center
Poison center
Stroke center
Cardiac center
Hyperbaric center
Spine injury center
Psychiatric center

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Trauma centers

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A trauma center can provide rapid surgical intervention and treatment of injuries that generally exceeds hospital
emergency department capabilities. ( Edward T. Dickinson)

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EMTs work as team members with
other public safety personnel.

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The EMT works closely with other public safety personnel.

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You will often work as a team with paramedics and others.

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Case Study
After quickly determining the nature of
Bens problem, the EMTs head toward the
closest hospital, a 35-minute trip, with
Juliana behind the wheel and Peter in the
back of the ambulance, caring for Ben.
Having arranged for a paramedic unit to
meet them en route, Peter gives the
paramedics a quick radio report.
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Case Study
Peter continues patient care, following
protocols until they meet with the
paramedic unit.

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Case Study
How can requesting a paramedic
intercept benefit the patient?
What are some of the potential pitfalls
in patient safety at this phase of the
call?

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EMT Responsibilities
All EMTs share a common set of
responsibilities.

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Table 1-1 Roles and Responsibilities of the

Emergency Medical Technician

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Personal safety and the safety of others

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The EMT must ensure personal safety at all times. ( Pat Songer)

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You cannot help the patient, other
rescuers, or yourself if you are injured.
Use safe driving habits.
Do not enter or stay on an unsafe
scene.
Be alert to situations with a risk for
violence.
Wear reflective clothing and protective
clothing as indicated.
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Patient assessment and emergency
care

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The EMT is responsible for providing competent patient care.

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Gain access to patients, recognize and
evaluate problems, and provide
emergency care.
Primary assessment
Identify and manage immediate threats
to life.
Secondary assessment
Identify other problems.
Treat the conditions you find.

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Safe lifting and moving
Prevent further harm to the patient.
Prevent yourself from being injured
through good body mechanics and
having an adequate amount of help.

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Transport and transfer of care
Make a destination decision according to
protocols.
Notify the receiving facility of the
patients condition.

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The EMT can get on-line medical direction by telephone, cell phone, or radio.

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Continue care en route.
Drive safely.

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Assessment and emergency care are continued en route to the medical facility.

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Give verbal and written reports.
Provide additional assistance as needed.

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The EMT is responsible for properly transferring the care of the patient to the appropriate medical personnel.

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Record-keeping and data collection
Log the call.
Complete patient care reports.

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As soon as possible, complete the written or electronic prehospital care report.

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Patient advocacy
EMTs are responsible for protecting the
patients rights.
Secure and transport personal belongings
if needed.
Protect the patients privacy.
Make sure that the patients family
knows how to get to the hospital.

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Patient advocacy
EMTs are responsible for protecting the
patients rights
Provide necessary information to hospital
personnel.
Honor any patient requests you
reasonably can.
Maintain patient confidentiality.

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Case Study
At the designated point, the EMTs meet
the paramedic unit and give an update
on Bens status. The paramedic, Alexis
Brady, further assesses Ben and
implements advanced life support (ALS)
treatment. Following the treatment,
which was administered to increase Bens
abnormally slow heart rate, Ben regains
consciousness and is confused about
what is happening.

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Case Study
Now that Ben is conscious, what do you
think are his expectations for how Peter
and Alexis interact with him?
How could the nature of those
interactions affect the quality of patient
care?

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EMT Professional Attributes

Certain professional attributes are
important to maximize effectiveness as
an EMT.

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Table 1-2
for EMTs
Characteristics of Professional Behavior

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Appearance
Excellent personal grooming and a neat,
clean appearance help instill confidence
in patients and help protect them from
contamination that caused by dirty
hands, fingernails, or clothing.
Proper appearance can send the
message that you are competent and
can be trusted to make the right
decisions.
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Knowledge and skills
Required coursework
Use and maintenance of equipment
Safety and security procedures
Geography and travel routes
Traffic laws
Continuing education

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Physical demands
Ability to lift and carry up to 125 pounds
Good (or correctable) eyesight and color
vision
Ability to communicate effectively orally
and in writing
Good hearing

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Personal traits
Patients look toward someone to reestablish order in a suddenly chaotic
world.
That requires the characteristics listed
on the following slides.

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Leadership ability
Assess a situation quickly.
Step forward to take control when
appropriate.
Set action priorities.

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Leadership ability
Give clear and concise directions.
Be confident and persuasive enough to
be obeyed.
Carry through with what needs to be
done.

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Calm, reassuring personality
Be able to calm anxious and agitated
patients.
Good judgment
EMTs must make decisions in stressful
situations.

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Good moral character
EMTs are in a position of public trust
that cannot be defined by laws alone.
Stability and adaptability

EMTs are exposed to stressful situations
and must delay expression of emotions
until an appropriate time.

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Ability to listen
EMTs must accurately gather
information from patients and
bystanders.
EMTs must be accurate when receiving
orders from medical direction.

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Resourcefulness and ability to
improvise
Each call, situation, and patient is
different, requiring that EMTs be
resourceful to provide efficient, effective
care.

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Cooperativeness
The care of a patient requires the
cooperative interactions of many
personnel.
Maintenance of certification and

licensure
This is a personal responsibility that
involves obtaining continuing education
and submitting required forms and fees.
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State EMS Agency Role

There is overlap between the EMS,
public safety, and public health.
State EMS agencies act in ensuring that
high-quality EMS is provided in order to
protect the health and safety of the
public.

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State EMS Agency Role

Primary responsibilities include:
Overall planning, coordination, and
regulation of the statewide EMS system
Licensing EMS agencies and personnel

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Case Study
En route to the hospital, Alexis and Peter
continue their treatment and Alexis calls
in a report to the receiving hospital. As
Peter continues to reassure Ben and
monitor his condition, Alexis begins some
preliminary paperwork.

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Case Study
What is the legal basis for EMTs
providing medical treatment to
patients?
What mechanisms must be in place to
ensure that the care provided is of the
highest quality and conforms to the
standards of the medical community?

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Medical Direction
Every EMS system must have a
physician medical director.
EMTs are designated agents of the
medical director.
The medical director is legally
responsible for the patient care aspects
of the EMS system.

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Medical Direction
Medical directors participate in EMS
provider education and EMS system
quality assurance.
A primary charge of medical direction is
developing and establishing the
guidelines under which the emergency
medical service personnel function.

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Medical Direction
Protocols are a complete set of
guidelines that define the scope of
medical care provided by EMS
personnel.
Protocols may be used off-line or may
require on-line medical direction.

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Medical Direction
Off-line medical direction consists of a
set of written guidelines that allow
EMTs to use their judgment to provide
care without having to contact a
physician.
Sometimes called standing orders

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Medical Direction
On-line medical direction requires that
the EMT contact a physician for
consultation and authorization prior to
administering specific emergency care.

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Quality Improvement
Quality improvement (QI), or
continuous quality improvement (CQI),
is a system of internal and external
reviews and audits of all aspects of an
emergency medical system.

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Quality Improvement
The purpose of QI is to ensure that the
public receives the highest quality of
prehospital care.
The goals of quality improvement are
to:
Identify aspects of the system that can
be improved.
Implement plans and programs to
remedy shortcomings.
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Quality Improvement
QI is focused on how effective the
system is and to identify what
improvements can be made to deliver a
better service.
QI can assist individuals with poor
performance, but is should be used an
evaluation of system effectiveness, not
as a punitive mechanism.
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The EMT takes an active role in quality improvement.

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Issues in Patient Safety

Certain aspects of prehospital care are
high-risk in terms of patient safety.
High-risk activities include:
Transfer of care from one provider to
another
Communications with other providers
Carrying and moving patients
Ambulance transportation
Spinal immobilization decisions
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Errors during patient care can cause
harm, and usually result from:
Improper skill performance
Not following the rules
Lack of knowledge

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Steps to reduce errors include:
Clear protocols
Providing enough light to work
effectively
Minimizing interruptions during
assessment and care
Clearly marking drugs and packaging

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Steps to reduce errors include:
Reflecting on all actions

Questioning assumptions
Using decision aids
Asking for assistance when needed

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Research in EMS
Evidence-based medicine (EBM) uses
research to provide evidence that
certain procedures, medications, and
equipment improve the patients
outcome.

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Research in EMS
There are four steps in evidence-based
decision-making:
1. Formulate a question that needs to be
answered.
2. Search medical literature for applicable
data.

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Research in EMS
There are four steps in evidence-based
decision-making:
3. Appraise the data for validity and
reliability.
4. If the evidence supports a change in
practice, change protocols and
implement the change in prehospital
emergency care.
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Research in EMS
Research does not exist to support
many practices in EMS.
Research in hospital settings does not
always transfer well to EMS settings.
If the opportunity arises, every EMT
has an obligation to participate in
research that contributes to the
profession.

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Case Study
Ben was seen in the emergency
department, and then admitted to the
cardiac care unit of the hospital. Bens
cardiologist told Ben that he has several
risk factors for heart problems, but that
some of the risk factors can be changed.

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Case Study
What are some public health efforts
that can help decrease the rate of
illnesses like Bens?
What role could EMS providers take in
such public health efforts?

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Public Health
EMTs are part of the public health
team.
Public health deals with protecting the
health of an entire population.
EMTs can play a role in identifying
public health problems and in attempts
to reduce injury and illness and
promote health.
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Public Health
The ten greatest public health
achievements in the United States in
the 20th century were:
Vaccinations
Motor vehicle safety
Workplace safety

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Public Health
Control of infectious disease through
clean water and sanitation
Reduction in death from coronary heart
disease and stroke

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Public Health
Safer, healthier foods
Decreased maternal and infant mortality
Use of barrier devices during sexual
contact
Fluoridation of drinking water
Reduction of tobacco use
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Public Health
Roles of EMS in public health include:
Health prevention and promotion
through primary prevention
(vaccinations, education), secondary
prevention of complications of disease,
and health screening
Disease surveillance through identifying
and reporting certain diseases or
conditions that are identified as public
health issues
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The roles of the EMS in public health include participation in public education programs (CPR).

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Public Health
Roles of EMS in public health include:
Injury prevention through education,
promotion of the use of safety
equipment (seat belt use, helmet use,
falls prevention, fire prevention), and
injury surveillance

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The roles of the EMS in public health include participation in health screenings.

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Case Study
After giving a report to the emergency
department (ED) about Bens condition
and prehospital treatment, Alexis
compliments Peter and Juliana on their
assessment and care. Peter takes the
opportunity to ask Alexis a few questions
about patients who present as Ben did.

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Case Study
Ben was discharged from the hospital
with a cardiac pacemaker to keep his
heart beating at the right rate. He
participates in a cardiac rehabilitation
program and is working with a
nutritionist on his diet. He still frequents
Daves, but more often than not, opts for
a bowl of oatmeal with fruit.

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Lesson Summary
The shape of the modern EMS system
has been influenced by many events
throughout history.
EMS systems must address 10 specific
areas as defined by NHTSA.
911 is the access number for EMS in
the United States.

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Lesson Summary
There are four nationally recognized
levels of EMS providers in the United
States.
EMTs have several specific
responsibilities.
Medical direction and QI are essential
components of all EMS systems.

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Lesson Summary
EMS practices change over time, based
on research findings.
EMS is part of the public health system
and can make an impact on the health
of the community.

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PREHOSPITAL

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Setting the Stage

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Setting the Stage

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Case Study Introduction

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Case Study Introduction

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

continued on next slide

Prehospital Emergency Care, 10th edition

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

2000 EMS Education Agenda for the

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

2006 National EMS Scope of Practice

National EMS Education Standards

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: History

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: Standards

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: Standards

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: Standards

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.

The EMS System: Standards

continued on next slide

Copyright 2014, 2010, 2008 by Pearson Education, Inc.