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Emergency medical care outside of a hospital and the transportation of the sick and injured to definitive medical care can be traced back to ancient times. Those people were referred to as Good Samaritans, people who would stop and help an injured traveler on the roadside.

It was these people that inspired todays laws that protect people who stop to help others in time of need.

Good Samaritan laws provide protection for individuals who render aid freely and out of concern for other’s well being

Emergency medical services(EMS) is a relatively young field. In the late 1950’s and early 1960’s, Cardiopulmonary resuscitation (CPR) was taught to civilians for the first time. This life-preserving technique involves chest compressions and artificial respiration and can be taught to civilians as well as health care providers.

Prior to the 1950’s their was a total lack of organized training in pre-hospital emergency medicine. The father of EMS Dr. Joseph Farrington developed the first EMT-ambulance course at a Chicago fire department in 1958.

From this point to the 1980’s and through today this field has seen great advancements and movement towards the preservation of life.

The Star of life was adopted in 1973 as the national symbol of EMS. Each of the six points represents an aspect of the EMS system.

Detection Reporting Response On scene care Care in transit Transfer to definitive care

Today we see EMS as part of the chain of survival. Each segment of the EMS system is dependent on a preceding segment and affects the segment that follows it.

Early access of the emergency system is crucial to improving the outcome of time-critical illness. In the case of cardiac arrest, more commonly thought of as a heart attack early CPR can improve the chance of survival. The sooner defibrillation is performed the better the outcome is likely to be.

The EMS field has many levels of training and education that healthcare providers must obtain and maintain to practice medicine.

Emergency Medical Dispatch (EMD)- trained to provide specific medical care and instructions to 911 callers while emergency crews respond. Instructions can range from how to control bleeding from a gun shot wound (GSW), to how to deliver a baby, and giving cpr instructions.

EMS Levels

In almost every medical emergency, there is someone standing nearby who could provide assistance. With proper training, these people might make a significant impact on the outcome of an injury or illness.

The first person who arrives at the scene of an injury or illness can be referred to as a first responder. These people are often police officers, members of fire departments or citizens who elect to help. Many rural areas have volunteer firefighters and first responders standing by waiting to help when they get the call.

First Responders

EMT-B are persons who have completed the primary level of training for pre-hospital care. All Basic’s bring the same skills to a Pt’s side, whether they work onboard an ambulance, or as part of a fire department. This level includes the ability to perform the skills necessary to save a life. These skills include:

Airway management AED usage Oxygen administration Limited medication administration Bleeding control ASA, NITRO, GLUCOSE, and O2. CPR

EMT-Basic

EMT-I or today called EMT- Advanced is trained with the basic component and goes beyond with the training to perform advanced airways, cardiac arrest management with the introduction of electro cardio gram (ECG/EKG) intervention, intravenous therapy (IV), and trauma care

EMT-Intermediate

EMT-P is the highest level of pre-hospital care. Many Paramedics are career professionals. Most have college degrees resulting in A.A.S in emergency medicine. Paramedic skills include Advanced Airways, IV’s, expanded medication administration, and cardiac arrest management. Paramedics will have several additional licensures including advanced cardiac life support (ACLS), pediatric advanced life support (PALS), international trauma life support (ITLS), and CPR at a minimum.

EMT-Paramedic

First and foremost the safety of the EMT is of highest priority. If the responding EMS crew becomes injured they are part of the problem, or will take resources from the originally intended victims.

The EMT is expected to perform a wide variety of duties from receiving dispatch information, to driving the ambulance to a call, assessing a Pt and taking baseline vitals, moving the Pt to the stretcher, and assessing illness, disease, and trauma.

Roles of the EMT

Upon completion of the initial training course, the EMT will be required to take a standard certification exam. The national registry of emergency medical services (NREMT) is the national standard of EMS.

This national license allows an ems professional to go and work for any service in the US. Some states do require state level license as well.

Pt Abandonment Breach of Confidentiality Assault and Battery Negligence Breach of Duty

Issues of EMS

Stress is the physical, emotional, and behavioral response of the body to changing conditions in our lives.

Stressors- events that trigger stress Each individual may react differently to stress. Everyone expressing

emotion differently

Stress in EMS

Physiological stressors- Trauma, illness, Poor nutrition, sleep disturbances, hunger, discomfort, pain

Psychological stressors- worry, fear, anger, happiness Cognitive stressors- thoughts, perceptions, interpretation of events,

personal significance of events Environmental stressors- Temp., noise, crowding, time pressure Sociocultural- job loss, changes in interpersonal relationships

Although everyone experiences and copes with stress differently, there are ways that the body deals with stress physically that we can look for when we are treating our Pt’s.

Cardio/respiratory response Neurologic-Dizzy, Headache, Dilated pupils GI-N/V Behavioral

Body response to stress

10-89, DOA, death in the field- encountering death is considered the most stressful event we can encounter. It is not uncommon to feel sadness or grief. Feelings of helplessness, despair, or even failure are all common.

Trauma-situations involving traumatic injuries may provide stress to providers

Family, Friends, and Coworkers as Pt’s-Providers may feel overwhelming senses of fear, ax, and frustration

Abuse of Pt’s Disasters

Call related stress

Airway Control Respiratory Support Shock prevention Vital signs and Pt hx Lifting and Moving Pt Scene Size up Initial Assessment

Skills

The ability to open and maintain a Pt’s airway is the single most important lifesaving skill. Remarkably enough the most common airway obstruction is created by the Pt’s tongue

S/S of airway obstruction- LOC, cyanosis, and apnea Head tilt chin lift Jaw thrust Suctioning of oropharynx (OPA)- Yankauer vs. French Cather Nasopharyngeal airway (NPA)

Airway Control

Pt assessment begins with the evaluation of the Pt’s reparatory status. This can be done with a simple visual exam for Pt’s in no distress, or initiate the CPR sequence for Pt’s who are not breathing or unable to maintain their own airway.

Look, Listen, Feel Jaw thrust, Chin lift Color of skin-is your Pt diaphoretic? Rate/Quality LOC

Respiratory Support

Pulse Oximetry/SPO2 Dyspnea- difficulty breathing Auscultation Palpate (chest wall) – DCAP-BTLS Oxygen therapy- NC vc NRB Hypoxia= S/S- restlessness, confusion, tachypnea, hypoventilation,

tachycardia….. Contraindications????

Oxygen delivery systems – Fixed vs Portable Fixed found on board ambulance Portable moveable

Non-rebreather mask(NRB)-10-15 l/min Nasal cannula (NC)- 1-6 l/min % of oxygen administered Ra=21% 1=24 6=44 2=28 3=32 NRB= 80-100% 4=36 10-15 lpm 5=40

O2 delivery devices

Continuous positive airway pressure (CPAP) used for respiratory insufficiency or failure, in order to assist ventilations, improve a Pt’s cardiac and respiratory parameters. Used with the hope to avoid intubation.

BiPAP-is a variation of CPAP. BiPAP allows the provider to set separate levels of inspiratory positive pressure

CPAP and BiPAP

Laryngeal mask airway (LMA)- is indicated for assisted ventilations of the Pt whose LOC is diminished. Unlike intubation this device doesn’t go through the vocal chords, instead it rests over the epiglottis forming a seal.

LMA and Advanced Airways

These devices are for highly trained personnel. Typically on Paramedics and Doctors perform these procedures.

Intubation (tubing) should be based on 3 critical criteria. 1. failure to maintain or protect airway 2. failure of ventilation or oxygenation 3. anticipated need for intubation based on the Pt’s clinical course and

likelihood od deterioration.

Blind insertion Device

Homeostasis Shock (hypo perfusion)-has a mortality rate of 20%-90% Shock represents a sever disruption in homeostasis. Shock causes a

wide spread tissue hypo perfusion(decreased blood flow), resulting in the bodies inability to deliver oxygen and glucose to cells to maintain life.

5 classifications of shock

Shock

Hypovolemic shock- due to inadequate circulating blood volume

Distributive shock-due to peripheral vasodilation and misdistribution of blood flow

Cardiogenic shock- due to inadequate cardiac pump function

Obstructive shock-due to non-cardiac obstruction to blood flow Metabolic shock-due to toxic disruption of cellular function

Examples

Hypovolemic= Trauma, GI bleeding Distributive= Sepsis, Anaphylaxis, Spinal Cord injury Cardiogenic= MI, Dysrhythmias, OD Obstructive=PE, Cardiac tamponade Metabolic= Co2 poisoning

Hypovolemic shock-decreased blood volume. More common form of shock. Identified as either hemorrhagic or nonhemorrhagic.

Most commonly due to trauma. Possible non- trauma related hemorrhagic induced shock: GI bleeding,

abdominal aortic aneurysms(AAA), vaginal bleeding(ectopic pregnancy).

Nonhemorrhagic shock- Vomiting and diarrhea, fever in infants prolonged increased respiration rate.

Distributive shock-Widespread hypo perfusion. Not associated with blood loss, it is a result from peripheral vasodilation. Distributive shock is the final common pathway for most shocks and is untreatable always resulting in death. Cardiogenic shock- due to impaired cardiac output. Usually results when the heart has suffer damage to the cardiac tissue, particularly the left ventricle. The average time from the initial MI to cardiogenic shock is about 8 hours.

Obstructive shock- widespread hypo perfusion that results from blood being obstructed towards the heart. Pulmonary embolism(blood clot in lungs), cardiac tamponade are all causes of this kind of shock.

Compensated Stage- increased HR, normal or elevated BP, some variations in skin appearance, LOC normal, and increased resp. noted.

Decompensated Stage- Increased HR, Dropping BP, Resp. vary, delayed capillary refill, Lowered LOC, increased respirations.

Irreversible Stage- dropping HR, continuously dropping BP, mottled skin, coma, and eventually death.

Stages of Shock

Vital signs are the specific measurement of a Pt’s ventilator and circulatory status, and are the primary concern for pre-hospital care.

Resp- 12-20 breaths per min. Rhythm should be regular unlabored effortless in any position.

Heart rate- 60-100 BPM. Rhythm should be regular Perfusion- Blood pressure- 120/80 Remember: ABC Airway Breathing Circulation

Vital Signs

Lifting and Moving Pt

The scene size up occurs prior to ever touching a Pt. This is done by EMS personnel even before stepping out of the ambulance. We use this to determine if the scene is safe to enter.

The scene size up assessment begins upon receipt of the dispatch information.

EMS personnel have a responsibility for personal safety, crew safety, and Pt/bystander safety.

Scene Size Up