Emergency Medicine Book


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
  1. See Also
    1. Emergency Medicine Treatment and Labor Act (EMTALA)
    2. EMS Trauma Triage Protocol
    3. Trauma Center
  2. 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]
  3. 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
  4. 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)
  5. 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
  6. 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
  7. 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

Ambulances (C0002422)

Definition (UMD) Vehicles designed for transporting the sick or wounded that are equipped with the necessary devices and supplies to maintain or improve the clinical status of the patient during transport.
Definition (MSH) A vehicle equipped for transporting patients in need of emergency care.
Concepts Medical Device (T074)
MSH D000552
SnomedCT 49122002, 44613004
HL7 2.16.840.1.113883.1.11.19734
Swedish Ambulanser
English Ambulance, device, ambulance, ambulances, Ambulance, Ambulance, device (physical object), Ambulance, NOS, Ambulances
Czech sanitky
Finnish Ambulanssit
Japanese 救急移動車, 傷病者運搬車, 患者運搬車, 患者搬送車, 移動救急設備, 救急車
French Ambulances
Polish Ambulansy, Karetki pogotowia ratunkowego, Samochody sanitarne, Ambulans
Norwegian Ambulanser
Spanish ambulancia (objeto físico), ambulancia, Ambulancias
German Krankenwagen
Italian Ambulanze
Dutch Ambulance, Ambulances, Ziekenauto's, Ziekenwagens
Portuguese Ambulâncias
Derived from the NIH UMLS (Unified Medical Language System)

Emergency medical service (C0013961)

Definition (MEDLINEPLUS)

If you get very sick or badly hurt and need help right away, you should use emergency medical services. These services use specially trained people and specially equipped facilities.

You may need care in the hospital emergency room (ER). Doctors and nurses there treat emergencies, such as heart attacks and injuries. For some emergencies, you need help where you are. Emergency medical technicians, or EMTs, do specific rescue jobs. They answer emergency calls and give basic medical care. Some EMTs are paramedics - they have training to do medical procedures on site. They usually take you to the ER for more care.

If you or someone you know needs emergency care, go to your hospital's emergency room. If you think the problem is life threatening, call 9-1-1.

Definition (MSH) Services specifically designed, staffed, and equipped for the emergency care of patients.
Concepts Health Care Activity (T058)
MSH D004632
SnomedCT 409971007
LNC LP57605-5
English Emergency Medical Service, Emergency Medical Services, Medical Service, Emergency, Medical Services, Emergency, Service, Emergency Medical, Services, Emergency Medical, Emergency Service, Medical, Emergency Services, Medical, Medical Emergency Service, Medical Emergency Services, Service, Medical Emergency, Services, Medical Emergency, MED SERV EMERGENCY, SERV EMERGENCY MED, EMERGENCY SERV MED, EMERGENCY MED SERV, EMS, emergency medical services, emergency medical service, emergency care, care emergency, emergency service, Emergency services, Emergency medical service, Emergency medical services, Emergency medical services (qualifier value), Emergency Services
Swedish Akutsjukvård
Czech rychlá zdravotnická pomoc, urgentní lékařské služby, záchranná zdravotní služba
Finnish Akuuttihoitopalvelut
Japanese 救急医療, 救急保健医療サービス, 入院前救急治療, イマージセンター, 救急医療サービス
French Services des urgences médicales, Services d'aide médicale urgente, SAU (Service d'Accueil et de traitement des Urgences), Samu, Services de réanimation médicale, Services d'accueil et de traitement des urgences, Services d'aide médicale d'urgence
Polish Pomoc medyczna w nagłych przypadkach, Pomoc doraźna, Medyczna pomoc doraźna, Pomoc przedszpitalna, Usługi medyczne w nagłych przypadkach, Pogotowie ratunkowe, Pomoc lekarska w stanach nagłych, Świadczenia z zakresu pomocy nagłej, Świadczenia z zakresu doraźnej pomocy
Norwegian Akuttmedisinske tjenester
Portuguese Pronto-Socorro, Serviços Médicos de Emergência
German Notfalldienste, medizinische
Italian Servizi di medicina d'urgenza
Spanish servicios médicos de emergencia (calificador), servicios médicos de emergencia, Servicios Médicos de Urgencia
Dutch Spoedeisende hulp, diensten
Derived from the NIH UMLS (Unified Medical Language System)

Emergency Medical Technicians (C0013963)

Definition (NCI) A person with formal training in basic medical knowledge and skills, certified (requirements vary by state) to respond and to provide a competent prehospital care and transportation to patients in emergency situations including but not limited to medical emergencies, hazardous materials exposure, child birth, abuse, fires, flood, accidents, trauma, and psychiatric crises.
Definition (MSH) Paramedical personnel trained to provide basic emergency care and life support under the supervision of physicians and/or nurses. These services may be carried out at the site of the emergency, in the ambulance, or in a health care institution.
Concepts Professional or Occupational Group (T097)
MSH D004634
SnomedCT 397897005
English Emergency Medical Technician, Emergency Medicine Technician, Emergency Medicine Technicians, Emergency Paramedic, Emergency Paramedics, Medical Technician, Emergency, Medical Technicians, Emergency, Paramedic, Emergency, Paramedics, Emergency, Technician, Emergency Medical, Technician, Emergency Medicine, Technicians, Emergency Medical, Technicians, Emergency Medicine, TECHNICIAN EMERGENCY MED, TECHNICIANS EMERGENCY MED, MED TECHNICIAN EMERGENCY, MED TECHNICIANS EMERGENCY, EMERGENCY MED TECHNICIAN, EMERGENCY MED TECHNICIANS, emergency medical technician, emergency medical technician (EMT), emt, emergency medical technicians, Emergency medical technicians, EMERGENCY MEDICAL TECHNICIAN, EMT (emergency medical technician), Paramedic, EMT, Emergency medical technician, Paramedic (occupation), Emergency Medical Technicians
Swedish Ambulanspersonal
Czech urgentní lékařství - technici
Finnish Akuuttihoitohenkilökunta
Japanese 救急医療技術者, 救急救命士, 救急用パラメディカル, コメディカル-救急用, パラメディカル-救急用
Polish Paramedycy, Technicy medyczni pomocy doraźnej, Ratownicy medyczni
Italian Paramedici addetti alle emergenze
Norwegian Ambulansepersonell
French Technicien médical des services d'urgence, Techniciennes médicales des services d'urgence, Auxiliaires médicaux d'urgence, Techniciennes de médecine d'urgence, Techniciens de médecine d'urgence, Techniciens médicaux des services d'urgence, Auxiliaire médical d'urgence, Auxiliaires médicales d'urgence
Portuguese Paramédicos de Emergência, Auxiliares de Emergência
Spanish paramédico (ocupación), paramédico, Auxiliares de Urgencia, Paramédicos de Urgencia
German Notfallmedizin-Techniker, Paramedizinischer Notfalldienst, Rettungssanitäter, Sanitäter
Dutch Paramedici, eerstehulpverlenende, Paramedische eerstehulpverlener, Paramedische eerstehulpverleners
Derived from the NIH UMLS (Unified Medical Language System)

Paramedical Personnel (C0030450)

Definition (NCI) An individual trained and certified to provide all basic and intermediate life support measures in addition to using invasive medical procedures (including intravenous therapy, cardiac defibrillation, administering medications and solutions, and using ventilation devices) as dictated by state law and performed under medical control in case of medical emergencies, hazardous materials exposure, child birth, abuse, fires, flood, accidents, trauma, and psychiatric crises.
Concepts Professional or Occupational Group (T097)
MSH D000488
English Personnel, Paramedical, Paramedic, PARAMED PERSONNEL, paramedic, paramedics, PARAMEDIC, Paramedical Personnel, Medics, Paramedics
German Paramedics, Paramedizinisches Personal
Italian Paramedici
French Paramédicaux, Professionnels paramédicaux, Personnel paramédical, Personnels paramédicaux
Portuguese Pessoal Paramédico, Paramédicos
Czech střední zdravotnický personál
Norwegian Paramedisinsk personell
Spanish Paramédicos, Personal Paramédico
Dutch Paramedici, Paramedisch personeel
Derived from the NIH UMLS (Unified Medical Language System)

Transportation of Patients (C0040757)

Definition (MSH) Conveying ill or injured individuals from one place to another.
Definition (CSP) service which provides a means of moving persons, human tissues, or health care goods and materials from one place to another, with the intent of providing health care services; includes pharmacy deliveries, Life Flight, ambulances, coroner services, etc.
Concepts Health Care Activity (T058)
MSH D014187
English Patients Transportation, Patients Transportations, Transport of Wounded and Sick, Transport, Wounded and Sick, Transportation of Patients, health care transport service, TRANSPORT OF WOUNDED SICK, TRANSPORT WOUNDED SICK, patients transportation, transportation patients, patient transportation, Transport of sick and wounded
Swedish Patienttransporter
Czech převoz pacientů, transport pacientů, doprava pacientů
Finnish Sairaankuljetus
French Transport de blessés et de malades, Transport de patients, Évacuation sanitaire, Transport sanitaire
Italian Trasporto dei malati, Trasporto dei pazienti
Polish Transport pacjentów, Transport chorych, Transport rannych, Przewóz pacjentów
Japanese 患者の輸送, 患者搬送, 傷病者輸送, 患者輸送
Norwegian Transport av pasienter, Pasienttransporter, Transport av syke og sårede, Transport av sårede og syke, Syketransporter, Syketransport, Pasienttransport
German Krankentransport, Transport Verwundeter und Kranker
Dutch Vervoer van gewonden en zieken, Vervoer van patiënten
Portuguese Transporte de Feridos e Doentes, Transporte de Pacientes
Spanish Transporte de Heridos y Enfermos, Transporte de Pacientes
Derived from the NIH UMLS (Unified Medical Language System)

Ground transport ambulance (C0179021)

Concepts Manufactured Object (T073)
SnomedCT 44613004
English Ambulances, Ground Transport, Ground transport ambulance, device, Ground transport ambulance, Ground transport ambulance, device (physical object)
Spanish ambulancia de transporte terrestre (objeto físico), ambulancia de transporte terrestre
Derived from the NIH UMLS (Unified Medical Language System)

Helicopter Ambulances (C0206184)

Definition (UMD) Helicopters, designed for transporting the sick or wounded, that are equipped with the necessary devices and supplies to maintain or improve the clinical status of the patient during transport.
Concepts Medical Device (T074)
MSH D017732
SnomedCT 32472009
LNC LA9316-6
English Ambulance, Helicopter, Ambulances, Helicopter, Helicopter Ambulance, Medical Helicopters, Helicopters, Medical, Medical helicopter, device, Helicopter ambulance, Medical helicopter, Medical helicopter, device (physical object), Helicopter Ambulances
Portuguese Helicópteros para Transporte de Pacientes
Spanish Ambulancias Helicopteros, helicóptero médico (objeto físico), helicóptero médico
German Krankentransporthubschrauber
French Ambulances par hélicoptère, Ambulances héliportées
Italian Elicotteri ambulanza, Elicottero-ambulanza
Norwegian Helikopterambulanser
Czech letecká záchranka
Dutch Ambulancehelikopters
Derived from the NIH UMLS (Unified Medical Language System)

Air Ambulances (C0206185)

Definition (UMD) Aircraft (e.g., helicopters, airplanes), designed for transporting the sick or wounded, that are equipped with the necessary devices and supplies to maintain or improve the clinical status of the patient during transport.
Definition (MSH) Fixed-wing aircraft or helicopters equipped for air transport of patients.
Concepts Manufactured Object (T073)
MSH D017732
SnomedCT 73957001
English Ambulances, Air, Air Ambulances, Air Ambulance, Ambulance, Air, Ambulances, Air Transport, Air transport ambulance, device, air ambulance transport, air ambulance, Air transport ambulance, Air ambulance, Air transport ambulance, device (physical object)
Swedish Ambulansflyg
Finnish Ilma-ambulanssit
Japanese 航空機-救命, 救命ヘリコプター, ヘリコプター-救命, 救命ヘリコプタ, 救命航空機
French Ambulances aériennes, Ambulances aéroportées
Polish Samoloty sanitarne, Helikoptery sanitarne, Śmigłowce sanitarne
Norwegian Luftambulanser
Czech letecká záchranná služba, letadla pro transport pacientů
Portuguese Unidades Aéreas de Emergência, Transporte Aéreo de Pacientes, Ambulâncias Aéreas, Resgate Aéreo
Spanish ambulancia aérea (objeto físico), ambulancia aérea, Ambulancias Aéreas
German Luftrettungsfahrzeuge, Rettungsfahrzeuge, Luft-
Italian Eliambulanze
Dutch Ambulancevliegtuig, Ambulancevliegtuigen, Vliegtuigen, ambulance-
Derived from the NIH UMLS (Unified Medical Language System)

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