Emergency Medical Care Systems, Research, and Public Health

Emergency Medical Care Systems, Research, and Public Health
Chapter 1 Emergency Medical Care Systems, Research, and Public Health Advance Preparation Invite the medical director to the first class session. Make arrangements to tour an emergency department and/or local public service answering point (PSAP). Obtain 911 recordings from an EMS agency to play for the class. Arrange to have an ambulance present at the class location. Bring in a couple of current EMS research articles from peer-reviewed publications. Ask a health department representative to speak on public health. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich • Keith J. Karren Copyright ©2010 by Pearson Education, Inc. All rights reserved.

Objectives Define key terms introduced in this chapter.
Describe the key historical events that have shaped the development of the emergency medical services (EMS) system, including (slides 17-19): Lessons learned in trauma care from experiences in the Korean and Vietnam conflicts Publication of Accidental Death and Disability: The Neglected Disease of Modern Society Highway Safety Act of 1966 Emergency Medical Services System Act of 1973 Public CPR courses Publication of the National Emergency Medical Services Education and Practice Blueprint The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Describe the key historical events that have shaped the development of the emergency medical services (EMS) system, including (slides 17-19): Publication of EMS Agenda for the Future and The EMS Education Agenda for the Future: A Systems Approach Development of National EMS Core Content, National EMS Scope of Practice Model, and National EMS Education Standards The Institute of Medicine report The Future of EMS Care: EMS at the Crossroads The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Briefly explain each of the components of the Technical Assistance Program Assessment Standards (slides 20-21): Regulation and policy Resource management Human resources and training Transportation Facilities Communications Public information and education Medical direction Trauma systems Evaluation The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Discuss the differences between 911 and non-911 EMS access systems, including the features and benefits of 911 systems (slides 23-24). Compare and contrast the scopes of practice of the following levels of EMS providers (slides 25-26): Emergency Medical Responder (EMR) Emergency Medical Technician (EMT) Advanced Emergency Medical Technician (AEMT) Paramedic Explain the importance of the EMT’s understanding of the health care resources available in the community (slides 27-29). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Give examples of how EMTs can carry out each of the following roles and responsibilities (slides 31-43): Personal safety and the safety of others Patient assessment and emergency care Safe lifting and moving Transport and transfer of care Record keeping and data collection Patient advocacy The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Describe the expectations of EMTs in terms of each of the following professional attributes (slides 44-53): Appearance Knowledge and skills Physical demands Personal traits Maintaining certification and licensure The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Discuss the purposes of medical direction/oversight in the EMS system (slides 54-55). Describe the purpose of quality improvement/continuous quality improvement programs in EMS (slide 56). Explain the EMT’s roles and responsibilities in quality improvement (slide 57). Identify activities in EMS that pose a high risk of mistakes and injuries (slides 59-60). Discuss steps that you can take to minimize mistakes and injuries in EMS (slides 59-60). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Discuss the steps of evidence-based decision making (slides 60-61). Explain the limitations of evidence-based decision making in EMS (slide 60). Describe the relationship between EMS and public health (slides 62-63). List the ten greatest public health achievements in the United States in the 20th century. The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Multimedia Directory Slide 29 EMS and the Community Video
Slide 64 Healthy People 2010 Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics The Emergency Medical Services System The EMT
Research and EMS Care Public Health Planning Your Time Plan 100 to 120 minutes for this chapter as follows: The Emergency Medical Services System (30 minutes) The EMT (30 minutes) Research and EMS Care (20 minutes) Public Health (20 minutes) Note: The total teaching time recommended is only a guideline.

CASE STUDY Dispatch Case Study Discussion
The following case study is intended to challenge your students to think about scene safety issues, the roles and responsibilities of the EMT, and working together with multiple agencies in a complicated extrication. Present the case in a way that your students will imagine being on the call and feel challenged by the circumstances of the incident. If appropriate, briefly relate a personal experience you’ve had running a similar call and how you managed it.

EMS Unit 121 Respond to Pine Lake Road in Perry Township for an elderly male who has fallen. Perry Township Fire Department is also en route. Case Study Discussion, continued You and your partner are working on EMS Unit 121 today. You’ve been dispatched to Pine Lake Road in Perry Township for an elderly male who has fallen. Perry Township Fire Department has been notified and is en route. Time out is 1032 hours. While you confirm the address with dispatch, your partner pulls out the county map and confirms the incident location and directions. You pull the ambulance out of the garage and your partner operates the emergency lights and sirens. Within eight minutes, you turn onto Pine Lake Road and spot a police car and a fire truck already on the scene. Time out 1032

Upon Arrival Case Study Discussion, continued You position your ambulance in the driveway of the residence to afford an easy exit. The police officer—Emergency Medical Responder who radioed for EMS help—tells you that a 65-year-old male fell about 30 feet down a very steep embankment behind his house. He’s been at the bottom for about 30 minutes. The patient is conscious and able to tell you that his right arm and leg are injured. The rescue squad from the fire department is preparing to rappel down the embankment to extricate the patient. 65-year-old male fell approximately 30 feet down embankment Conscious; states injured right arm and leg Rescue preparing to extricate patient

How would you proceed? Case Study Discussion, continued
Why is it important for partners to work together as a team? Why is personal safety so important? How would you proceed?

The Emergency Medical Services System
Teaching Time 30 minutes Back to Topics

A Brief History Back to Objectives Points to Emphasize
Caring for the ill and injured outside of the hospital setting dates back hundreds of years, but EMS as we know it began in the 1960s. EMS is a developing profession. Even new students can make changes in their systems. NHTSA provides guidance for EMS systems and EMS education at the federal level. The EMS Agenda for the Future lays out the roadmap for enhancement of EMS education and practice. Back to Objectives

A Brief History Korean and Vietnam War “White paper”
Highway Safety Act of 1966 Emergency Medical Services System Act of 1973 American Heart Association CPR Talking Points During the Korean and Vietnam wars, injured soldiers were shown to benefit from emergency care in the field prior to transport. This realization helped civilian EMS systems dramatically evolve, and we continue to learn about trauma care even today from the wars in Iraq and Afghanistan. In 1966, the National Academy of Sciences published Accidental Death and Disability: The Neglected Disease of Modern Society that became known as the “white paper.” It identified severe deficiencies and made recommendations to improve prehospital care. In 1966, the Highway Safety Act required each state to establish a highway safety program including emergency services. The Emergency Medical Services System Act of 1973 provided millions in funding for EMS system planning, implementation, personnel, and training. The American Heart Association began to teach CPR and basic life support to the public. CPR is now a prerequisite to the EMT course.

A Brief History National Emergency Medical Services Education and Practice Blueprint in 1993 EMS Agenda for the Future EMS Education Agenda for the Future National EMS Core Content in 2005 National EMS Scope of Practice Model The Future of EMS Care: EMS at the Crossroads National EMS Education Standards Talking Points In 1993, the National Emergency Medical Services Education and Practice Blueprint defined issues related to EMS training and education. In 1996, the National Highway Traffic Safety Administration (NHTSA) published the EMS Agenda for the Future with the intent to make EMS a greater component in the health care system in the United States. In 2000, the NHTSA released EMS Education Agenda for the Future to address consistency in education, training, certification and licensure. In 2005, the National EMS Core Content defined the domain of knowledge found in the National EMS Scope of Practice Model, which later defined four levels of EMS licensure and the knowledge and skills for each of those levels. In 2006, The Future of EMS Care: EMS at the Crossroads recommended that all state governments adopt a common scope of practice, reciprocity between states, national accreditation for paramedics, and national certification as a prerequisite for state licensure and local credentialing. NHTSA’s National EMS Education Standards outlined minimum objectives for EMS personnel based on the National EMS Scope of Practice Model.

Technical Assistance Program Assessment Standards
Talking Point Even though each state has control of its own EMS system, NHTSA still provides a baseline set of recommended standards called the Technical Assistance Program Assessment Standards. Critical Thinking Discussion What would happen without regulation and policy as part of an EMS system? Why is medical direction a critical component of EMS? Back to Objectives

Standards Regulation and Policy Resource Management
Human Resources and Training Transportation Facilities Talking Points Regulation and Policy: Each state must provide leadership and have laws, regulations, policies, and procedures to govern its EMS system. Resource Management: In order for all patients to have equal access to acceptable emergency care, each state must have central control of EMS resources. Human Resources and Training: All personnel who staff ambulances and transport patients must be trained to at least the EMT level. Transportation: Patients must be provided with safe, reliable transportation by ground or air ambulance. Facilities: Each seriously ill or injured patient must be delivered in a timely manner to an appropriate medical facility.

Standards Communications Public Information and Education
Medical Direction Trauma Systems Evaluation Talking Points Communications: A system of communications must be in place to provide public access to EMS and communications between dispatchers, EMS personnel, and hospitals. Public Information and Education: EMS should participate in public education to promote injury prevention and public access to the EMS system. Medical Direction: Each EMS system must have a physician medical director for medical oversight. Trauma Systems: Each state must develop a system of specialized care for trauma patients, including one or more trauma centers and rehabilitation programs, plus systems for triaging patients to those facilities. Evaluation: Each state must have a quality improvement system for the continuing evaluation and upgrading of the system.

Access to the EMS system Discussion Question How do people in your community access EMS? Teaching Tip Play 911 recordings from your local communications center and discuss them with students (taking care that no confidential information is revealed). Class Activity Arrange a tour of a public service answering point (PSAP) to allow students to see how calls are received, processed, and dispatched. Back to Objectives

E911 Cell phones Talking Points
911 is used nationwide to access police, fire, and EMS. E911, or enhanced 911 systems, provide automatic number identification (ANI) and automatic location identification (ALI), which provide the exact address and phone number from which the call is being made. Using 911 is beneficial because (1) the PSAP is generally staffed by trained communications personnel—often certified as EMDs—and (2) the use of 911 reduces time and is easy for children to remember and dial. Cell phones have made emergency call tracking and routing a challenge in many areas because cell calls cannot be tracked in the same way as landline calls. Calling 911 on your cell phone may lead to a delayed response, but technology to avoid these issues and track the exact location of cell phone calls through GPS has been developed by many EMS systems. Knowledge Application If you just witnessed a vehicle collision with injuries, how would you access EMS and describe the location and situation?

Levels of Training Talking Point The National Scope of Practice Model identifies the following four levels of EMS practitioners: EMR, EMT, AEMT, and paramedic. Discussion Question Briefly describe the differences in the scope of practice among an EMR, EMT, AEMT, and paramedic. Teaching Tip Explain the importance of getting to know classmates. Learning in the course depends on teamwork, and teamwork is an important EMS competency. Class Activity Have pairs of students interview each other for five minutes and then have them introduce each other to the class. Back to Objectives

Emergency Medical Responder Emergency Medical Technician
Advanced Emergency Medical Technician Paramedic Talking Points Emergency Medical Responders (EMR) provide care through use of basic airway- and oxygen-therapy devices and by taking vital signs. EMRs also provide stabilization of spine and extremity injuries, eye irrigation, bleeding control, emergency moves, CPR, AED, and emergency childbirth care. Emergency Medical Technicians (EMT) include those interventions performed by the EMR but with basic equipment found on an ambulance. EMTs provide advanced oxygen therapy, pulse oximetry, automatic blood pressure monitoring, and limited medication administration. Advanced Emergency Medical Technicians (AEMT) provide all of the skills of the EMT with the addition of the use of advanced airway devices, monitoring of blood glucose levels, initiation of IV and IO infusion, and administration of some medications. Paramedics perform advanced assessments, form a field impression, and provide invasive and drug interventions.

The Health Care System Discussion Question What specialty medical care facilities exist in your area or within ground or air transport from your area? Class Activity Tour an emergency department to familiarize students with the facility. Back to Objectives

Specialty Facilities Obstetric Trauma Pediatric Burn Poison Stroke
Talking Points Specialty facilities include: Trauma center for rapid surgical intervention and specialized treatment of trauma injuries that exceed the capability of standard EDs Burn center for specialized treatment of serious burns and long-term care and rehabilitation Obstetrical center for high-risk obstetric patients Pediatric center for specialized treatment of infants and children Poison center for specialized treatment of poisoning victims Stroke center to provide specialized care for specific acute stroke patients Cardiac center for the rapid and advanced management of patients suffering cardiac emergencies Hyperbaric center for the treatment of certain toxic exposures, diving emergencies, and other conditions Spine injury center for the management of severely spine-injured patients Psychiatric center to care for patients with behavioral emergencies Stroke Hyperbaric Spine Cardiac Psychiatric

EMS and Community Video
Video Clip EMS, the Community, and Children Discuss the main purposes of EMS. Describe how most communities access EMS services. What is the role of the medical director? Describe some of the specific needs of children during an emergency. Click here to view a video on the topic of EMS, the Community, and Children. Return to Directory

The EMT Teaching Time 30 minutes Back to Topics

Roles and Responsibilities
Point to Emphasize Roles and responsibilities of EMTs extend well beyond direct patient care. Teaching Tip Have the medical director speak about his roles and responsibilities in the EMS system. Back to Objectives

Safe lifting and moving Transport and transfer of care
Personal safety Safety of others Patient assessment Emergency care Safe lifting and moving Transport and transfer of care Record keeping and data collection Patient advocacy Talking Points Specific responsibilities may vary from one area to another but general responsibilities of an EMT include: Assuring your personal safety and the safety of others Patient assessment and emergency medical care according to standards Performing safe lifting and moving procedures Safe patient transport and transfer Accurate record keeping and data collection Sincere and loyal patient advocacy

Personal Safety and the Safety of Others Point to Emphasize Your first and most important priority is to protect your own safety. You cannot help others if you yourself are injured.

Remember Point to Emphasize You also do not want to endanger other rescuers by forcing them to rescue you—instead of the patient. Once scene safety is assured, the patient’s needs become your priority. You cannot help the patient, other rescuers, or yourself if you are injured.

Scene safety Personal safety Patient safety Driving safety
Talking Points Drive safely and use a seat belt at all times; only remove it when absolutely necessary to care for the patient. Always wear body substance isolation gear such as gloves, eye protection, mask, and gown, as necessary to avoid infectious diseases. Avoid potentially hazardous sites such as high-traffic areas, downed power lines, gasoline leaks, fires, chemical spills, or radiation leaks. Never enter a volatile crowd situation until deemed safe by law enforcement. Take extra precautions if someone at the scene is under the influence of drugs or alcohol, has a behavioral disorder, or is emotionally charged. Follow directions from police, fire, utility, and other expert personnel. Wear reflective clothing at night and provide adequate lighting at all scenes. Always wear a helmet on roadway incidents, and wear a helmet or hard hat, protective outerwear, eye protection, and leather gloves to minimize personal injury from jagged metal or broken glass at collision scenes. Patient safety Driving safety

Patient Assessment and Emergency Care

Beware of changing conditions
Talking Points After scene safety has been assured, gain access to the patient(s). First, always perform a primary assessment to help identify and correct immediately life-threatening problems (airway compromise, respiratory insufficiency, cardiac arrest, or severe bleeding). Next, complete a secondary assessment, after which you can stabilize and treat other emergency injuries or conditions you discover or suspect. Finally, always be aware of changing conditions and ensure that the scene remains safe. Primary assessment Secondary assessment Beware of changing conditions

Safe Lifting and Moving

Safety in movement and equipment Proper body mechanics
Talking Points Prevent further injury to patients by always using the easiest and safest recommended emergency urgent or nonurgent moves and equipment. Prevent injuring yourself by always using proper body mechanics and by making sure you have sufficient help to lift and move patients and equipment. Safety in movement and equipment Proper body mechanics

Transport and Transfer of Care

Transport Facility determination Transport code Drive safely
Talking Points Before leaving the scene, determine which facility will be most appropriate (the local ED or a specialty center). Consider patient condition, the location of the patient’s medical records, the location of the patient’s relatives, hospital staffing, and destination protocols. Notify the receiving facility of the number of patients, the destination, and the nature and extent of injuries. Alert the emergency department or receiving facility early about high-priority patients and anything needed immediately upon arrival, such as a trauma team or a stroke team. Minimize further injury and maximize patient comfort by driving appropriately. Obey laws and regulations, and use lights and sirens properly. Report both verbally and in writing the patient’s condition, the care you’ve provided, and the response to treatment. Never leave before you have properly transferred the care of the patient to the receiving facility personnel. Facility determination Transport code Drive safely Report to hospital staff

Record Keeping, Data Collection, and Patient Advocacy Discussion Question What are some examples of patient advocacy?

Become a patient advocate
Complete report Become a patient advocate Be truthful Protect privacy Talking Points Record keeping is a critical aspect of the job. Maintain an accurate log of calls throughout your shift. Before leaving the hospital, or as soon as possible, complete the written or electronic prehospital care report (PCR). This report becomes part of the patient’s medical record and part of the EMS system’s permanent records. Patient advocacy is such an important role because the EMT protects patients’ rights at a time when they are ill, injured, and vulnerable. Do this by collecting and safeguarding valuables, protecting their privacy, shielding them from curious bystanders, and answering questions truthfully. Make sure friends or loved ones know how to get to the hospital and honor any patient requests that you reasonably can, such as notifying a relative or ensuring that a patient’s home is secure. Be sure to adhere to all confidentiality rules when doing such activities.

Professional Attributes
Appearance Back to Objectives

Appearance Groomed Neat, clean appearance In uniform Prepared
Talking Points Excellent personal grooming and a neat, clean appearance help instill confidence in your patient. Uniforms protect against contamination from dirty hands, dirty fingernails, or soiled clothing. Whether you like it or not, you send a message within the first few seconds of arrival. Your appearance tells whether you’re competent and can be trusted to make the right decisions. Responding to the scene in full uniform versus a faded shirt and backward baseball cap sends a very different message to the patient and your fellow colleagues.

Knowledge and Skills 46

Knowledge and Skills Safety Traffic laws Territory Medications
Talking Points In order to practice as an EMT, you must complete a basic training program for EMTs as outlined by the DOT, as well as know how to: Use and maintain common emergency equipment such as suction machines, oxygen-delivery systems, AEDs, spine immobilization equipment, splints, obstetrical kits, patient moving devices, and tools to access the patient. Assist with administration of medications approved by medical direction. Clean, disinfect, and sterilize nondisposable equipment. Practice safety and security measures for yourself, your partner, other rescuers, and the patient and bystanders. Navigate the territory and terrain within your service area to allow expedient response to the scene and receiving facilities. Follow specific traffic laws related to emergency transportation. Territory Medications Cleaning of equipment Use of equipment

Physical Demands 48

Physical Demands Must be able to lift 125 pounds Good vision
Communication skills Hearing Talking Points You must be in good physical health. You must be able to lift and carry up to 125 pounds. Your eyesight must be good (correction by lenses is permitted), and you must have good color vision in order to properly assess a patient and drive safely. You must communicate effectively, both orally and in writing. This will be necessary when communicating with patients, crew members, other emergency response personnel, and the medical staff. Your hearing must be good enough to accurately hear radio communications, patient and bystander responses, auscultated blood pressures, patient noises, communication from other crew members at the scene, and oral instructions. Physical Demands (© Craig Jackson/In the Dark Photography)

Personal Traits Discussion Question What are some personal traits and attributes important to being an excellent EMT? 50

Personal Traits Calm and reassuring Leadership Good judgment
Good moral character Stability and adaptability Ability to listen Resourcefulness Cooperativeness Talking Points Patients call EMS because they need help managing a situation that has gotten out of control for them. Your success doing so depends a lot on your personality. Some effective personality traits are: Calm and reassuring personality: Speak in a reassuring and calm manner with all patients, especially those who may be agitated, altered, or in pain—all while providing patient care. Leadership ability: Assess the scene quickly, take control, delegate your resources, and give direction with confidence. Good judgment: Make appropriate decisions quickly, often in unsafe or stressful situations. Good moral character: You are in a position of public trust. Stability and adaptability: People expect you to be confident and unwavering. Ability to listen: Listen effectively in order to gather information efficiently. Resourcefulness and ability to improvise: Be resourceful and adaptable. Cooperativeness: Work with multiple jurisdictions effectively. Personal Traits

Maintenance of Certification and Licensure 52

Maintenance of Certification and Licensure
Continuing education Skill competency Avoiding criminal or unethical behavior Submitting all fees Talking Points Maintaining certification and licensure to practice involves: Meeting all of the necessary continuing education requirements each cycle Verifying minimum skill competency Avoiding any criminal or unethical behavior Submitting all required fees Point to Emphasize Maintaining one’s certification and licensure is the personal responsibility of the EMT. It is not the responsibility of the employer or educational program. Teaching Tip Explain your state’s requirements for maintaining certification and licensure. Critical Thinking Discussion How will you ensure that your knowledge and skills are up-to-date?

Medical Direction and Oversight
Point to Emphasize Whether medical direction is provided off-line through predetermined, written guidelines or on-line through direct radio or telephone communication, EMTs are the designated agents of the physician medical director and render care as an extension of the medical director’s authority. Discussion Question What are the differences between on-line and off-line medical direction? Back to Objectives

Off-line medical direction On-line medical direction Standing orders
Medical director Protocols Off-line medical direction On-line medical direction Standing orders Medical oversight Talking Points The physician medical director is legally responsible for the clinical and patient care aspects of the EMS system and is also involved in EMS education, overseeing and providing continuing education, and facilitating the quality improvement system. The medical director provides medical direction through guidelines, or protocols, that define the entire scope of medical care. Off-line medical direction is provided through predetermined, written guidelines that allow EMTs to use judgment to administer emergency medical care according to the written guidelines without having to contact a physician. On-line medical direction requires the EMT to acquire permission from a physician via cell phone, telephone, or radio communication prior to administering specific emergency care. Standing orders are a subset of protocols that do not require real-time physician input. In some systems, they are synonymous with off-line medical direction. Medical oversight is the emerging term that more comprehensively describes the EMS system medical director’s responsibilities.

Quality Improvement Back to Objectives Point to Emphasize
Quality improvement is not designed to evaluate individual performance but rather to determine how effective the system is and to identify what improvements can be made to deliver better service. The purpose of quality improvement programs is not to penalize EMTs but to improve the overall EMS system. Teaching Tip Describe how quality improvement is conducted in your EMS system. Discussion Question What are ways EMTs can participate in EMS quality improvement programs? Back to Objectives

Back to Objectives Talking Points
As an EMT, your role in quality improvement is to: Document every call carefully and thoroughly. Information gathered helps identify things like delayed response times (requiring deployment changes) or skills that may require system-wide refresher training. Perform reviews and audits and get involved in the quality improvement process. Obtain feedback to continually improve yourself. Be open to feedback from patients, other EMS personnel, and hospital staff either formally or informally. Maintain equipment and conduct preventative maintenance. Participate in continuing education and refresher courses to reinforce, update, and expand your knowledge and skills. Maintain skills through continuous practice. Class Activity Have groups of students develop a list of five benchmarks for EMS system quality improvement, and explain how the benchmarks could be measured. Back to Objectives

Issues in Patient Safety
Talking Points As EMTs, we sometimes encounter “high-risk” situations where the patient may be put at greater risk for medical mistakes, injury, or exacerbating an existing injury. Take steps to prevent potential errors in order to avoid these situations and deliver safe care. Discussion Question What are some examples of high-risk activities in the prehospital environment?

High-Risk Activities Transfer of care Medical errors Carrying patients
Ambulance crashes Lack of spine immobilization Talking Points High-risk activities include: Transfer of care between emergency responders or at the medical facility Poor communication that leads to misunderstanding and medical errors Carrying and moving patients in a way that puts them at risk for being dropped Involvement in an ambulance crash while transporting Lack of spine immobilization or improper spine immobilization procedures Errors during patient care Discussion Question What steps can be taken to avoid these high-risk activities? High-Risk Activities Back to Objectives

Research and EMS Care Back to Topics Teaching Time 20 minutes
Points to Emphasize Evidence-based medicine focuses on the results of research to support medical care and use of procedures, equipment, and medications. Although research is a desirable approach in making decisions regarding patient management, very little research currently exists about prehospital care. Teaching Tip Provide examples of peer-reviewed research articles. Class Activity Have students read a short research article and then discuss the applicability and limitations of the article. Back to Topics

Evidence-Based Medicine
Formulate a question Search medical literature Appraise the evidence for validity and reliability If the evidence supports it, change protocols Talking Points Evidence-based medicine focuses on research to provide clear evidence that certain procedures, medications, and equipment improve patient outcome. These four steps are common in evidence-based decision making: Formulate a question about emergency care that needs to be answered. Search medical literature for data that is applicable to the question. Appraise the evidence for validity and reliability. If the evidence supports a change in practice, then change protocols and implement the change in prehospital emergency care. Discussion Questions Why is it not always possible to apply emergency medicine research to prehospital care? What are some reasons that research in EMS may be difficult? What is the benefit of a peer-review process for research articles? Back to Objectives

Public Health Back to Topics Teaching Time 20 minutes
Points to Emphasize Public health focuses on the health of communities rather than on individual patients. Public health activities include collecting data on illnesses and injuries and developing education and prevention strategies. EMTs can play an important role in collecting data, educating the public, and participating in prevention activities. Teaching Tips Invite a guest speaker from the health department. Arrange for students to assist at a health fair sometime during the course. Back to Topics

Roles of EMS in Public Health
Health prevention and promotion Disease surveillance Injury prevention Talking Points EMS is part of the public health system and plays an integral role in the following: Health prevention and promotion through primary prevention (vaccinations, education), secondary prevention of complications of disease, and health screening Disease surveillance through identifying and reporting certain diseases or conditions that are identified as public health issues Injury prevention through education, the promotion of safety behaviors (seat belt use, helmet use, fire prevention), and injury surveillance Class Activity Give groups of students a few minutes to identify a public health problem in their community and develop ideas for addressing the problem. Have each group share its ideas with the rest of the class. Roles of EMS in Public Health Back to Objectives

Click here to view a video on the Healthy People 2010 initiative.
Video Clip Healthy People 2010 What is Healthy People 2010? What are the two primary goals of Healthy People 2010? Who developed the standards outlined in Healthy People 2010? Discuss the role of Healthy People 2010 in EMS. Click here to view a video on the Healthy People 2010 initiative. Return to Directory

CASE STUDY Follow-Up Case Study Follow-Up Discussion
This case study is continued from the beginning of the presentation. Briefly remind students that they are working with a 65-year old man who fell 30 feet down a very steep embankment behind his house. The patient is conscious with a right arm and leg injury. The rescue squad is preparing to rappel down to extricate the patient.

CASE STUDY Primary Assessment 65-year-old male, Edgar Robinson
Chief complaint: right wrist and right thigh pain Respiration: 24 per minute Pulse: 90 beats per minute Skin warm and dry Case Study Follow-Up Discussion, continued The rescue squad officer informs you that you will be in no personal danger, but you and your partner are cautious as you carry your equipment closer to the embankment. The rescue squad officer tells you that his crew all have EMR training and will immobilize Mr. Robinson on a backboard before bringing him up. One EMR reports that the patient’s chief complaint is of right wrist pain and right thigh pain. The patient’s airway is patent with respirations of 24 per minute with an adequate volume, radial pulse is 90 per minute and strong, and the skin is warm and dry. As you begin your own primary assessment, you note that Mr. Robinson is an alert, robust older man. He explains to you that while disposing of yard wastes, he got too close to the edge of the embankment and slipped.

CASE STUDY Secondary Assessment S: Abrasions to arms
Pain and deformity of right wrist Deformity, swelling, abrasions, pain in right thigh No feeling or movement of right toes Pulses present in foot Denies losing consciousness Case Study Follow-Up Discussion, continued You perform a physical exam while your partner takes vital signs, which indicate no change from those reported by the EMR. Your exam reveals abrasions to the arms, with pain and a slight deformity to the right wrist. There are also superficial abrasions to the right leg, with deformity, swelling, and pain to the right thigh. You discover that the patient cannot feel or move the toes of his right foot. However, pulses are present in the foot. You initiate oxygen therapy via a nonrebreather mask. The history you take, by asking the patient questions, confirms sharp pain to the right wrist and thigh, which started immediately after he landed at the bottom of the embankment. Mr. Robinson also reports that he did not lose consciousness.

CASE STUDY Secondary Assessment A: Sulfa drugs M: Metroprolol P: HBP
Case Study Follow-Up Discussion, continued He denies any other complaints. He informs you that he is allergic to sulfa drugs and takes medication for high blood pressure.

Treatment and Reassessment
CASE STUDY Treatment and Reassessment O2 via nonrebreather mask Traction splint right leg Wheeled stretcher Reassess patient every five minutes Transfer care without incident Case Study Follow-Up Discussion, continued You place the patient on 15 lpm oxygen via nonrebreather mask. After checking the immobilization of the patient’s spine, you enlist your team’s help to apply a traction splint to the right leg. You then splint the injured wrist. You move Mr. Robinson to a wheeled stretcher and transfer him to the ambulance. You notify the hospital that you are en route and give details of his condition. You conduct a reassessment every five minutes to monitor his condition until you arrive at the hospital. Upon arrival, you transfer care of the patient to the emergency department staff and give your verbal report. You carefully complete your written prehospital care report and prepare the unit for the next call. Case Study Follow-Up Discussion Question What roles and responsibilities of the EMT were demonstrated in this case?

Critical Thinking Scenario
78-year-old male patient who appears to be suffering a stroke Patient is unable to speak and appears agitated The patient’s niece requests transport to a small local hospital near his residence A designated stroke center is 20 minutes from your location Critical Thinking Discussion This critical thinking scenario is intended to challenge your students to think about managing an agitated and potentially unstable patient at the same time as managing a family member requesting a hospital destination that may be contrary to the patient’s best interests. Ask students to briefly discuss the scenario before moving on to the series of questions on the next slide.

Critical Thinking Questions
What are your responsibilities while on this call? How can you serve as the patient’s advocate? How can you use medical direction in this situation? Critical Thinking Discussion, continued Answers: Ensure the safety of all individuals present including yourself. Next, properly assess the patient and provide any necessary emergency care. Safely move the patient to the ambulance and transport him to the most appropriate facility. Once at the receiving hospital, you should transfer the patient’s care to the facility staff and complete all documentation. Explain to the niece that the stroke center would be better able to care for her uncle than the local hospital and ensure that the niece knows how to get to the receiving facility. Shield the patient from curious neighbors. Provide all necessary information to the receiving facility staff and document and safeguard any valuables transported with the patient. You can use medical direction in at least two important ways. The first is to utilize the local standing orders to properly care for the stroke patient and the second is to seek advice from the on-line physician about which receiving facility would be most appropriate for managing the patient’s condition.

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and follow the myBradykit links to access content for the text. Please visit and follow the MyBradyKit links to access content for this text. Under instructor resources, you will find curriculum information, lessons plans, PowerPoint slides, TestGen, and an electronic version of the instructor’s edition. Under student resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Emergency Medical Care Systems, Research, and Public Health

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