1. History of EMS Past, Present, Future
Jeff Dostalek
EMS Instructor, NREMT-P

2. Introduction EMS System Development History of EMS
Role of the Paramedic today versus the “ambulance driver” of yesterday
Paramedic professional responsibilities to enhance their ability to provide quality service
Licensure, Certification, Credentialing
So when did this role change for EMS?
Role is much different than that of the “Ambulance Driver” of yesterday. Today's medics are provided better training, better equipment and are involved in the industry.

3. Objectives Describe benefits of continuing education Medical Direction
List the benefits of professional association membership

4. Introduction The public perception of you is based on
TV and articles
Your treatment of their loved ones
Continuing education is a must
Treat everyone with respect and dignity

5. How far have we come

6. EMS System Development
1485
First use of an ambulance.
Transport only
1800s
First use of and ambulance/attendant to care for injured on site
1926
Service started similar to present day
1940
EMS turned over to fire and police department
No set standard of care

7. The 20th Century and Modern Technology
EMS Made major strides after WWII
Bringing hospital to filed gave patients a better chance for survival
Korean War
First use of helicopter
M*A*S*H* Units

8. The 20th Century and Modern Technology
1956
Mouth-to-Mouth resuscitation developed
Late 1950s/early 1960s
Focused shifted to bring hospitals to patients
MICU developed

9. The 20th Century and Modern Technology
1965: “The White Paper” released
Finding included:
Lack of uniform laws and standards
Poor-quality equipment
Lack of communication
Lack of training

10. The 20th Century and Modern Technology
“The White Paper: finding outlined 10 critical points for EMS Systems
Led to national Highway Safety Act
Created US Department of Transportation
1968
Training Standards implemented
9-1-1 created

11. The 20th Century and Modern Technology
1969
First true Paramedic program
Standards for ambulance design and equipment
1970
NREMT began
First paramedic trained in Miami
NREMT organized to standardize education, examinations and certifications

12. The 20th Century and Modern Technology
1970s (cont’d)
1971: Emergency Care and Transportation of the Sick and Injured published by AAOS
1973: Emergency Medical Services Act
1977: First National Standard Curriculum for Paramedics developed by US DOT

13. The 20th Century and Modern Technology
1980s/1990s
Number of trained personnel grew
NHTA developed 10 system elements to help sustain EMS System
Responsibility for EMS transferred to the stated
Major legislative initiatives
Human Resources
Training
Communications
Transportation
Medical record keeping
EMS Physicians and State EMS Director
Focused on public health and safety
Research Medical Direction Communications
legislation Education Clinical Care
finance Public education Information systems
HR Prevention
State preventative health service block grants.
Paid to State Health Dept.
Monies spent on other projects.
EMS funding was eliminated.
The Emergency Medical Treatment and Active Labor Act is a statute which governs when and how a patient must be (1) examined and offered treatment or (2) transferred from one hospital to another when he is in an unstable medical condition.

14. Licensure, Certification, and Registration
Certification examination
Ensure all health care providers have the same basic level of knowledge and skill
Once you pass certification you can apply for state licensure

15. Licensure, Certification, and Registration
How states control who practice
Also known as certification or credentialing
Unlawful to practice without license
Holding a license shows you:
Completed initial education
Met the requirement to achieve the license

16. Licensure, Certification, and Registration
Reciprocity
Certification granted from another State/agency
Requirements:
Hold a current state certification
Be in good standing
National Registry certification

17. The EMS System
Network of coordinated services that provide care to the community
The public needs to be taught how to:
Recognize emergencies
Activate the EMS System
Provide basic care

18. The EMS System Patient outcomes are determined by: Bystander care
Dispatch
Response
Pre-hospital care
Transportation
ER Care
Definitive care and Rehabilitation
Use Dad as an example:

19. The EMS System Dispatcher Scene may differ from what dispatcher relays
Usually the publics first contact
Training level varies from State to State
Scene may differ from what dispatcher relays

20. The EMS System As a paramedic, you must: Develop care plan
Decide on transportation mode
Determine receiving facility
Be active in your community

21. Levels of Education EMS System function from a federal to local level
Federal: National EMS Scope of Practice Model
State: Licensure
Local: Medical Director decides day to day limits

22. Levels of Education
The national guideline designed to create more consistent delivery of EMS nationally.
2009: national EMS Education Standard
NREMT provides a national standard for testing and certification
There are 20,410 licensed EMS personnel;
4,021 certified First Responders,
9,275 EMT-Basics,
3,027 Intermediate Technicians,
222 Intermediates,
3,865 Paramedics. For the year 2011, there were 598,416 calls for EMS in Wisconsin, which is almost 15% higher than the EMS calls in  

23. The Dispatcher Plays a critical role Receives and enters information
Interprets it
relays it to appropriate service
Pre-arrival instructions

24. Emergency Medical Responder (EMR)
Formerly “First responder”
Requirements vary by state
Should be able to:
Recognize seriousness of condition
Provide basic first aid
Relay information
Might be a police officer
First in Fire Company
Staff at school

25. EMT Formerly EMT Basic Primary provider level in many systems
Most populous level in the system

26. Advance EMT (AEMT) Formerly EMT-I Trained in:
More advanced Pathophysiology
Some advanced procedures
Initially developed in 1985
Major revision in 1999

27. Paramedic Highest Level to be nationally certified
1999: Major revision to curriculum to increase level of training and skills
Even if independently licensed, you must:
Function under the guidance of physician
Be affiliated with a paramedic level service

28. Paramedic Education Initial education
Most states based on National EMS Education Standards
States require varying hours of educations
national Average: 1,000-1,500 hours
While it is a common belief that the local fire department also provides ambulance services, in Wisconsin,
40% of 911 responding ambulance services come from the fire department
60% are separate and apart from the fire department.
Fire department ambulance vehicles transport approximately 45% of patients each year
while 55% are transported by non-fire-based ambulance providers.
When taking into account all ambulance services including interfaculty, special event and intercept services, 68% are non-fire-based and 32% are provided by the fire department
Volunteer EMS providers are responsible for staffing nearly 75% of Wisconsin’s ambulance services. However, they are responsible for responding to only 25% of Wisconsin’s EMS calls. The majority of ambulance transports are provided by full-time, paid ambulance services and fire departments.

29. Paramedic Education Continuing Education
Most states require proof of hours
Attend conferences and seminars
Read EMS journals
Get involved in post run review

30. Continuing Education Maintenance of core knowledge and skills
Expansion of knowledge and skills
Awareness of advances in profession
Forms of CEU are many
Conferences
Seminars
Skills Labs
Journal studies
Case presentation

31. Working With Other Professionals
Hospital Staff
Become familiar with the hospital;
The best patient care occurs when emergency care providers have a close rapport with staff
ASK QUESTIONS

32. Health Care Professional
Conform to professional standards
Provide quality patient care
Instill pride in the profession
Strive for high standards
Earn respect of others
Societal expectations on & off duty
Position of public trust
Unprofessional conduct tarnishes the profession, the service, and you
Image and Behavior
Stories about firefighter and police offers arrested.
Darlington Firefighter for embezzlement
Milwaukee Firefighter for 3 offense OWI

33. Working With Other Professionals
Public safety agents
Some have EMS Training
Can better perform certain functions than you
Interagency cooperation benefits patients
A lot of police officers have EMT or paramedic training so they understand you

34. Working With Other Professionals
Continuity of care
the community has expectation of EMS
Focus on prevention
You will interact with many professional groups
Understand your role, as well as others

35. EMS Group Involvement National, state, regional, and local
Development, education, implementation and setting standards for EMS
NREMT: verifies competency and reciprocity
Wisconsin:
DHS EMS Advisory Board
WEMSA STAC / RTAC
PSOW WTCS
WPS,Inc. Others ?

36. Primary Responsibilities
Preparation
Response to scene
Scene assessment
Patient assessment
Recognition of injury or illness
Management
Appropriate disposition
Patient transport and transfer of care
Documentation
Return to service

37. Professionalism
Standards of conduct and performance established by the profession
You will be measured by:
Standard, competencies, and education requirments
Performance parameters
Adherence to a “Code of Ethics”

38. Professionalism You are in a highly visible role in your community
You must:
Instill confidence
Establish and maintain credibility
Show concern for your patients

39. Professionalism Your appearance is of utmost importance
Present a professional image and treat colleagues with respect.
Arguing with colleagues is inappropriate
Raising issues at the appropriate time and place

40. Professional Attributes of the Paramedic
Integrity
Empathy
Self-motivation
Appearance and Personal Hygiene
Self confidence
Excellent communications
Time management
Teamwork
Diplomacy
Respect
Patient Advocacy
Careful delivery of service
Integrity Honest in all actions
Empathy Caring and compassion
Self Motivation CQI Constructive feedback
Self confident- Strive to be the best
Documentation
Listening skills
Injury prevention

41. Roles and Responsibilities
Teach the community about injury prevention and illness
Appropriate use of EMS
CPR Training
Influenza and pandemic issues
Campaign for EMS system

42. Medical Direction paramedic carry out advanced skills
Must take direction from medical directors
Medical Director may perform many roles
Educate and train
Recommend new personnel or equipment
Develop protocols, guidelines, and QA

43. Medical Direction Roles of the Medical Director (cont)
Provide input for patient care
Interface between EMS and other agencies
Advocate for EMS

44. Medical Direction (Medical Control)
Online
Provides immediate and specific patient care resources
Allows for continues quality improvement
Can render on-scene care assistance
Offline
Allows for the development of:
Protocols or guidelines
Standing orders
Procedures
Training

45. Improving System Quality
Goal: evaluating and improving patient care
Continuous Quality Improvement
Quality Assurance

46. Improving System Quality
Continues quality improvement (CQI)
Tools to continually evaluate care
Quality Control
Process of assessing current practice looking for ways to improve
Dynamic Process

47. Improving System Quality
Review ambulance runs when possible
Focus of CQI is improving care
CQI can be peer review:
Be professional
Should be a constructive process

48. Improving System Quality
CQI programs helps prevent problems by:
Evaluating day-to-day operations
Identify possible stress points
Look for ways to eliminate human error:
Ensure adequate lighting
Store medications properly

49. Improving System Quality
Ways to eliminate human error
Be careful when handing patients off
Three sources of errors
Rules-based failure
Knowledge-based failure
Skills-based failure

50. Improving System Quality
Ways to eliminate human error (cont’d)
Agencies need clear protocols
Be aware of your environment
Ask yourself “Why am I doing this”
Use cheat sheet
Be conscientious of protocols

51. Patient Safety 1996 Institute of Medicine
Launched efforts to improve patient safety and quality of care.
At least 44,000 and may up to 98,000 people die in hospital each year as a result of medical errors

52. Highest Risk for EMS Ambulance Crashes Dropping Patients Hand-off
Communication issues
Medication issues
Poor sterile technique
Airway issues
Spinal Immobilization

53. Preventing Medical Errors
Look-alike, Sound-alike Medication
Patient identification
Communication on hand-off
Perform correct procedures
Medication accuracy
Pulling tubes and line
Using proper technique
Proper Hand hygiene

54. Preventing Medical Error in EMS
Environmental methods
Clear-established protocols
Sufficient lighting for procedures and assessment
Performing patient care duties with minimal interruptions
Organizing and packaging drugs
Securing equipment in patient care compartments.

55. Preventing Medical Error in EMS (cont’d)
Individual methods
Reflection in actions
Question assumptions
Reflection bias
Use decisions aids
Ask for help
Reflection
Think during an event (Is this working, how can we do it better)
Question assumptions
Critical thinking to look for better ways to do things
reflection bias
Avoid the tendency to judge an event on a bad outcome. “See I knew that would happen” Review the events after the fact.
Use decision Aid
Pocket guide, protocol book
Ask for help
You have a partner, probably someone with more experience

56. Summary
Ambulance corps were developed in WW II to transport and rapidly care for solders
Helicopter implemented during the Korean War

57. Summary
1966 the National Academy of Sciences and the National Research Council released the “The White Paper”
Paramedics must be licensed before performing any function

58. Summary
Standards for pre-hospital care are regulated by state law and State EMS offices
Four levels of training
First Responder
EMT
Advance EMT
Paramedic

59. Summary Paramedics should be familiar with:
Roles of other health care providers
Continuing education requirements
Medical Control
Code of ethics
Professional attributes of a health care provider
Quality Assurance
Patient safety consideration

60. EMS Star of Life Detection Reporting Response On Scene Care
Care in Transit
Transfer to Definitive Care
The six branches of the star are symbols of the six main tasks executed by rescuers all through the emergency chain:
Detection: The first rescuers on the scene, usually untrained civilians or those involved in the incident, observe the scene, understand the problem, identify the dangers to themselves and the others, and take appropriate measures to ensure their safety on the scene (environmental, electricity, chemicals, radiation, etc.).
Reporting: The call for professional help is made and dispatch is connected with the victims, providing emergency medical dispatch.
Response: The first rescuers provide first aid and immediate care to the extent of their capabilities.
On scene care: The EMS personnel arrive and provide immediate care to the extent of their capabilities on-scene.
Care in Transit: The EMS personnel proceed to transfer the patient to a hospital via an ambulance or helicopter for specialized care. They provide medical care during the transportation.
Transfer to Definitive care: Appropriate specialized care is provided at the hospital.