Emergency Medical Service

Aka: Emergency Medical Service, EMS Transport, Emergency Transport, Patient Transport, Ambulance, Prehospital Care, ALS Ambulance, BLS Ambulance, Ground Transport Ambulance, Air Ambulance, Helicopter EMS, Helicopter Ambulances, Mobile Intensive Care Unit, Emergency Triage Treatment and Transport, ET3, Emergency Medical Technician, EMT, Paramedic, Critical Care Transport

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II. Precautions

  1. Medical provider Transferring a patient to another facility is responsible for the patient in transfer
    1. See Emergency Medicine Treatment and Labor Act (EMTALA)
  2. Ambulance Diversion
    1. Avoid diversion if possible
    2. EMTALA applies to hospital owned Ambulances
    3. Follow a clearly defined hospital policy for Ambulance diversion
    4. Diversion is a courtesy only (Paramedics may still transport to your facility)
  3. Patient refusal of transport
    1. Obtain details from Paramedic
      1. Chief complaint for Ambulance call, patient history, exam findings, Vital Signs
      2. Determine if patient is refusing transport or the Paramedics deem transport unnecessary
      3. Determine why patient is refusing transport
    2. Does patient have decision making capacity to refuse?
      1. See CURVES Capacity Assessment Tool
      2. Can the patient express the risks, benefits and alternatives to hospital transport?
    3. Indications for patient to be transported against their will (with police involvement)
      1. Medical emergency AND
      2. Lack of decision making capacity or surrogate (See CURVES Capacity Assessment Tool)
    4. Pearls
      1. Best approach is to convince the patient to be transported voluntarily
  4. Lights and Sirens transport (Code 3) is overused with significant consequences
    1. Lights and sirens transport account for 91% of the thousands of Ambulance crashes each year in U.S.
    2. EMS providers are 50% more likely to die in a transport collision than police or firefighters
    3. Yet lights and sirens response and transport only cut 3-5 minutes from patient delivery and are often not needed
    4. Cities (e.g. Salt Lake City) are reworking their protocols to more appropriate use of lights and sirens
      1. https://iaedjournal.org/lights-and-siren/
      2. No change in patient safety, and a reduction in lights and sirens and in Ambulance crashes
    5. References
      1. Strayer in Herbert (2019) EM:Rap 19(7):12-3
      2. Watanabe (2018) Ann Emerg Med S0196-0644(18):31325-8 +PMID:30648537 [PubMed]

III. Types: Patient Transport Units

  1. Selection of transport type is based on multiple factors
    1. Situations where ground ALS Ambulance may be preferred
      1. Time sensitive conditions (e.g. STEMI, Trauma) where ground Ambulance is faster than Air Ambulance (including response time, loading)
      2. Weather conditions preclude air travel
        1. Avoid "weather shopping", querying multiple Air Ambulances until one agrees to fly despite weather
    2. Situations where Critical Care Transport (CCT, ground or air) may be preferred over ALS Ambulance
      1. Ongoing hemodynamic instability (e.g. requiring Vasopressors)
      2. Long distance transport (Air Ambulance) or heavy traffic impeding ground Ambulance travel
      3. Special devices required (e.g. mechanical Ventilator, infusion pumps)
      4. Specialty transport (e.g. neonatal or pediatric transport, high risk obstetrics)
    3. Alternative measures may be required when CCT is unavailable or delayed
      1. Ad hoc team (e.g. Critical Care or emegency RN or medical provider) available to travel with patient in ground ALS Ambulance
  2. Ambulette (Wheelchair van)
    1. No emergency services (transport only)
  3. Basic Life Support Unit (BLS Ambulance)
    1. Carries a stretcher and basic emergency equipment (e.g. oxygen, bandages)
    2. Patient is typically attended to by an EMT-basic who may obtain Vital Signs, basic assessment and perform CPR
    3. Advanced EMTs may start IV Lines and interpret EKGs
  4. Advanced Life Support Unit (ALS Ambulance)
    1. Paramedic staffed Ambulances able to perform Advanced Airway and ACLS management
    2. Initiates IV Access, ALS medications, as well as intubates and manages Ventilator
  5. Mobile Intensive Care Unit
    1. Physician, Intensive Care nurse or advanced-care Paramedic staffed Ambulances (air or ground)
    2. Provides full spectrum Critical Care for unstable, complicated patients especially on prolonged transport
    3. Manages medication drips, Chest Tubes, Blood Products, invasive line management
    4. Allows greater access to patients, than in the cramped quarters of a helicopter
  6. Helicopter (rotor wing aircraft)
    1. Travels 100-150 mph and can transport directly between facilities (assuming helipad availability)
    2. Not pressurized, and typically at <3000 feet elevation (gas expands 15%, unless crossing mountains)
    3. Unable to fly during poor weather conditions or decreased visibility as limited by visual flight rules (VFR)
    4. Mobile Intensive Care Unit level of care (unless air rescue helicopters which are typically BLS or ALS)
    5. Endotracheal Tube cuffs may need adjustment (Foley Catheter and Gastric Tube cuffs may remain unchanged)
    6. Discuss small Pneumothorax pre-flight management (consider Chest Tube before transport)
    7. Safety: 2.5 accidents per 100,000 flight hours in 2016 (non-medical accident rate 30 per 100,000 hours)
    8. Air Ambulance transport costs as of 2019, frequently exceed $50,000, often only partially paid by insurance
      1. Helicopter companies operate on a single digit profit margin
      2. Costs per mile are most expensive, followed by 24 hour readiness staffing and supplies
      3. Helicopter purchase, medical refitting and maintenance are also very expensive
      4. In rural areas, households may subscribe at $50-80/year to cover emergent Ambulance transport
      5. Swadron and Farah in Herbert (2019) EM:Rap 19(9): 1-2
  7. Fixed Wing Aircraft
    1. Travels 250 to 600 miles per hour, and preferred for distances >100 miles
    2. Travel at higher altitude and cabin pressurized to 7000 feet (gas expands 30%)
    3. Less limited by weather than helicopter as fixed wings can travel by instrument flight rules (IFR)
    4. Mobile Intensive Care Unit level of care
    5. As with helicopter, Endotracheal Tube cuffs and small Pneumothorax are pre-transport considerations

IV. Types: Emergency Medical Personnel

  1. Emergency Medical Responder (EMR)
    1. EMRs undergo 45 to 60 hours of training
    2. EMRs can perform basic lifesaving measures (e.g. CPR, AED use, autoinjectors, Tourniquets, basic first aid)
  2. Emergency Medical Technician (EMT)
    1. EMTs undergo 150 to 180 hours of training
    2. EMTs can perform basic life support, and often accompany Paramedics as a second rescuer, and Ambulance driver
    3. EMTs can perform all EMR tasks, in addition to applying oxygen, Splinting, placing oral and Nasal Airways
  3. Advanced Emergency Medical Technician (A-EMT)
    1. A-EMTs undergo 200 hours of training
    2. A-EMTs can perform all EMT tasks, as well as IV/IO placement and some medication administration, Supraglottic Airway, cardiac monitoring
  4. Paramedic
    1. Paramedics undergo more than 1200 hours of training
    2. In addition to A-EMT tasks, Paramedics perform an extensive array of lifesaving measures
      1. Advanced Cardiac Life Support (e.g. ekg interpretation, medications, external pacing, cardioversion, Defibrillation)
      2. Advanced Airway management (NIPPV, Endotracheal Intubation, Cricothyrotomy)
      3. Paramedics may maintain Blood Products already infusing (but in most cases, may not initiate Blood Products)
  5. Critical Care Transport (CCT) Team
    1. Critical Care Teams are specific to patient (e.g. nicu team may include Neonatology NP, RT, Critical Care Paramedic or nurse)
    2. Critical Care Paramedic skills and training vary by unit, but typically expand on Intensive Care skills
      1. Tasks may include invasive line monitoring (e.g. Arterial Lines, Central Lines, Intracranial Pressure)
      2. May also be tasked in advanced medication delivery and Blood Product administration
    3. Critical Care certifications are available for Paramedics and Nurses
      1. International Association of Flight and Critical Care Paramedics (certifications include FP-C, CCP-C)
      2. Air and Surface Transport Nurses Association (certifications include CFRN, CTRN)

V. Types: EMS Response Codes

  1. Codes
    1. Code 1
      1. Non-Emergency Transport
    2. Code 2
      1. Semi-life threatening response
      2. Requiring expedited transport (but while following standard traffic rules)
      3. Typical inter-hospital transport
    3. Code 3
      1. Life-threatening response with lights and sirens
      2. Transport of Unstable Patients (e.g. STEMI, rupturing AAA, SAH)
  2. References
    1. http://en.wikipedia.org/wiki/Emergency_service_response_codes

VI. Management: Emergency Triage Treatment and Transport (ET3)

  1. Indications
    1. Medicare Fee-For-Service Patients AND
    2. EMS Service is enrolled in the ET3 program from Centers for Medicare and Medicaid (CMS)
  2. Emergency Triage Treatment and Transport (ET3) is an EMS protocol for Medicare Fee-For-Service Patients
    1. Historically, EMS is only Medicare reimbursed for transport, typically to an Emergency Department
    2. ET3 is a Five year pilot program allows EMS additional transport options beyond the Emergency Department
      1. EMS is reimbursed for all options as if transported to Emergency Department
  3. EMS options under Emergency Triage Treatment and Transport (ET3)
    1. Emergency Department transport (usual care) OR
    2. Appropriate medical facility (e.g. urgent care, clinic office, sober center, mental health facility) OR
    3. EMS coordinates qualified healthcare practitioner or QHP (Medicare enrolled physician, PA or NP)
      1. QHP must be able to formally disposition the patient
      2. QHP may be either on scene or via Telemedicine
      3. QHP is reimbursed based on home visit or Telemedicine rates
  4. Requires strong quality assurance program
    1. Risk of mistriage
  5. Efficacy
    1. Initial trials of the program prior to ET3 release demonstrated safety and cost reduction for Medicare population
  6. References
    1. Farah and Vithalani in Herbert EM:Rap 20(5):11-2

VII. References

  1. Aydin, Fritz, Duncan and Cohen (2022) Crit Dec Emerg Med 36(10): 23-29
  2. Katzer (2018) Crit Dec Emerg Med 32(6): 3-10
  3. Mell in Herbert (2015) EM:Rap 15(4): 10
  4. Mel in Herbert (2016) EM:Rap 16(3): 2

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