Emergency Medical Service


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

  • 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
      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]
  • Types
  • Patient Transport Units
  1. Ambulette (Wheelchair van)
    1. No emergency services (transport only)
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  • 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
  • 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
  • References
  1. Katzer (2018) Crit Dec Emerg Med 32(6): 3-10
  2. Mell in Herbert (2015) EM:Rap 15(4): 10
  3. Mel in Herbert (2016) EM:Rap 16(3): 2