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Chapter 1 Introduction to Emergency Medical Care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Case History You respond to a call for a patient in cardiac arrest. On arrival, you find a 52-year-old male who is pulseless and not breathing. A family member is performing CPR. The family states that he collapsed 4 minutes before your arrival. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Historical Perspective Battlefields Lay the Foundation Napoleonic Wars – Ambulance volantes Civil War – Horse-drawn ambulances World War I – Motorized ambulances Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Historical Perspective Battlefields Lay the Foundation Korean War – Helicopters and MASH units Mobile Army Surgical Hospital Death rates from battle casualties 8% WW I 4.5% Korea 2% Vietnam Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Historical Perspective Civilian Evolution • Civilian evolution varied from region to region in U.S. • Rural areas – Undertakers Fire departments and volunteer ambulance replaced funeral directors Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Historical Perspective Civilian Evolution • Civilian evolution varied from region to region in U.S. • Rural areas – Undertakers Fire departments and volunteer ambulance replaced funeral directors • Urban areas Hospital-based Fire departments Police departments Independent ambulance companies Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Historical Perspective Civilian Evolution • Mid-1860s – First hospital-based ambulance services Cincinnati General and Bellevue Hospitals • 1899 – The first motorized ambulance Michael Reese Hospital of Chicago Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Trauma as an Impetus for EMS Development • Preventable injury Leading cause of death in ages 1 to 45 • Automobile caused surge in trauma deaths 1900 – 7th leading cause of death 2000 – 4th leading cause of death Automobiles account for 50% Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Knowledge and Technology • 1960 – CPR developed Cardiopulmonary Resuscitation • 1960s – Portable defibrillators • First ALS units (Advanced Life Support) Belfast, Ireland St. Vincent’s Hospital (New York City) Only physicians provided advanced care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Knowledge and Technology • Late 1960s – Biotelemetry developed Space race • Allowed EMS providers to deliver ALS Defibrillation Advanced airway procedures Drug therapy • “Johnny and Roy” popularized paramedics on TV show Emergency! Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 The Physician and EMS • Physician societies organized early EMS programs American Academy of Orthopaedic Surgeons (AAOS) American College of Surgeons (ACS) • Worked with National Highway and Traffic Safety Administration (NHTSA) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 The Physician and EMS • Physician groups still involved American College of Emergency Physicians (ACEP) National Association of EMS Physicians (NAEMSP) National Association of State EMS Medical Directors (NAEMSD) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 The Landmark Paper – 1966 “Accidental Death and Disability: The Neglected Disease of Modern Society” Prompted federal money to develop EMS in 1973 “Provide safe handling and transportation of ill or injured.” Provided impetus for rapid proliferation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 EMS Agenda for the Future: 14 Components 1. 2. 3. 4. 5. 6. 7. Integration of health services EMS research Legislation and regulation System finance Human resources Medical direction Education systems 8. 9. 10. 11. 12. 13. 14. Public education Prevention Public access Communication systems Clinical care Information systems Evaluation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Elements of a Communications System The dispatch system – Enhanced 911 Formal national program to train dispatchers Emergency Medical Dispatch (EMD) Ambulance-to-hospital Radio Cell phone Landline Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Levels of Training Lay rescuer First responder EMT-Basic EMT-Intermediate EMT-Paramedic Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Lay Rescuer Carry little or no equipment Recognize life-threatening illness or injuries Provide lifesaving care until EMS arrives CPR Relief of airway obstruction Use of an AED Bleeding control Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 First Responders Equipped with Oxygen AEDs Airway equipment Provide lifesaving care until EMS arrives Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 EMT-Basic Provide basic, noninvasive skills Patient assessment CPR Airway adjuncts AED use Childbirth Splinting Spinal immobilization Administration and assistance with medications • Activated charcoal, metered-dose inhaler, nitroglycerin, epinephrine Use variety of transport devices Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 EMT-Intermediate Provide same skills as EMT-B Provide additional advanced skills, including Advanced airway techniques ECG recognition Intravenous fluid therapy Administration of multiple medications Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 EMT-Paramedic Expanded scope of practice beyond EMT-B and EMT-I Provides advanced techniques, such as ECG interpretation Drug therapy Invasive airway techniques Defibrillation Often have more standing orders in protocols than EMT-I Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Chain of Survival Early Access Early CPR Early Defibrillation Early Advanced Care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 The Health Care System Emergency departments Specialty referral centers Hospital personnel Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Liaison with Other Public Safety Workers Conflicts may occur when overlaps with other public safety personnel Police take charge at crime scene, traffic and crowd control issues Fire take charge at fire scene EMS responsible for patient care Cooperation is essential Incident command system should be in place Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Professional Attributes Demonstrate skill and knowledge for the good of the patient Promote high standards of behavior Add to your body of knowledge to continue to advance in the profession Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Professional Attributes Appearance A professional appearance and attitude help evoke a sense of confidence in patients and family members. • Clean and appropriate clothing Attitude more important than outer appearance • Show an interest in your job • Possess a sensitive awareness of environment and needs others • Putting patient/family needs ahead of your own will protect and preserve safety Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 EMT-Basic Primary Responsibilities Patient assessment Personal safety and safety of others Patient care Lifting and moving patients safely Transport/transfer of care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Other Responsibilities Record keeping Patient advocacy Extrication Communications Vehicle and equipment maintenance Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Local, State, and National Issues National Registry of Emergency Medical Technicians National Association of Emergency Medical Technicians The American Heart Association Continuing education Refresher courses Record keeping/Data Collection Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Quality Improvement: Definition A system of internal/external reviews and audits of all aspects of an emergency medical services system that identifies aspects that need improvement to ensure that the public receives the highest quality of prehospital care Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Role of the EMT-Basic in Quality Improvement Documentation Run reviews and audits Gathering feedback from patients/hospital staff Conducting preventive maintenance Continuing education Skills maintenance Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Medical Direction Accountability for the medical conduct of EMS personnel by a physician knowledgeable in patient care Online medical direction Direct real-time contact via telephone or radio Offline medical direction Written protocols, policies, procedures Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Summary EMT-Basic plays a key role in EMS system Teamwork with other providers is essential for effective patient care Quality assurance is an important role of the EMT-Basic Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Basic or Advanced? Basic life support called BLS describes the care given by First Responders and EMTBasics Advanced life support, called ALS, is the higher level of care performed by EMTIntermediates and Paramedics Permitted to perform invasive procedures • Procedures that introduce foreign substances or equipment into the patient’s body Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Training The EMS provider is legally prohibited from performing skills that are beyond his or her level of training Each group of skills requires the proper certification The length of time required for learning the advanced skills is considerable Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35 First Responder Training Prerequisite: Health Care Professional level CPR 8 hours 24-hour class Three-year certification period Certification is maintained with a refresher course • 12 hours Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36 EMT Basic Training Prerequisite: Health Care Professional level CPR 110-hour class plus Five patient contacts State certification application and fee 8 hours $150.00 Two-year certification period 24-hour refresher course 28 hours of continuing education $150.00 recertification fee Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37 EMT Intermediate Training Prerequisite: Health Care Professional level CPR 8 hours 180-hour class plus 100 hours of clinical observations and skills • 30 i.v. starts • 10 intubations 100 hours of field observations and skills • 10 i.v. starts • 1 intubation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38 EMT Intermediate Training State certification application and fee State administered exam $150.00 Minimum passing grade: 70% Two-year certification period 24-hour refresher course 28 hours of continuing education $150.00 recertification fee Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39 EMT Paramedic Training Prerequisite: Health Care Professional level CPR & EMT-B certification X contact hours as an EMT-B 400-hour class plus 200 hours of clinical observations and skills • 60 i.v. starts • 10 intubations 200 hours of field observations and skills • 30 i.v. starts • 1 intubation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40 EMT Paramedic Training State certification application and fee State administered exam $150.00 Minimum passing grade: 70% Two-year certification period 24-hour refresher course 28 hours of continuing education $150.00 recertification fee Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41