Prehospital Emergency Services: Introduction
Development of modern prehospital emergency medical services (EMS) stems primarily from lessons learned from providing medical care to soldiers in military conflicts and from government mandates.
In the 1960s, the President’s Committee for Traffic Safety recognized the need to address health, transportation, and medical care in order to reduce fatalities and injuries on our nation’s roadways.
In 1966, the National Academy of Science published a report entitled Accidental Death and Disability: The Neglected Disease of Modern Society. It described deficiencies in prehospital care regarding ambulance systems and the hazardous conditions of emergency care provision. The issues raised in this survey compounded with public outcry prompted the drafting of federal legislation, the Highway Safety Act of 1966. The legislation was intended to help states develop programs to improve emergency care. It required each state to have a highway safety program that complied with uniform federal standards including emergency services. Initial National Highway Transportation Safety Administration (NHTSA) efforts were focused on improving the education of prehospital personnel. Funding was provided to develop state emergency services offices. International activity around the same time included Professor Frank Pantridge (1916–2004) and colleagues demonstrating improvement in patient outcomes by outfitting cardiac defibrillators on ambulances in Belfast, Ireland.
The first national conference on EMS resulted in the development of a curriculum, certification process, and national registry for EMS personnel. In the 1970s, EMS systems were established by the Department of Transportation (DOT)–NHTSA in selected areas around the country to provide standardized ambulance services. As prehospital services expanded, so did the role of the EMS provider.
Components of an Emergency Medical Services System
Public law 93-154: Emergency Medical Services System Act of 1973 identified the following essential components of an EMS system:
Communications
Training
Manpower
Mutual aid
Transportation
Accessibility
Facilities
Critical care units
Transfer of care
Consumer participation
Public education
Public safety agencies
Standard medical records
Independent review and evaluation
Disaster linkage
Multiple changes have occurred over the ensuing years, and each component of the EMS system has gone through many stages of development. Federal financing has virtually been abolished by the Consolidated Omnibus Budget Reconciliation Act, which has shifted the burden on state and local agencies. In 1988, the Statewide EMS Technical Assessment Program was established by NHTSA and defined elements necessary to all EMS systems.
Communications are a critical part of prehospital emergency care. From universal access for the public to the EMS system, to adequate radio space for providers to communicate with each other in spite of disaster, communications are the lifeblood of EMS.
The 911 universal access system provides entry into the emergency system. The Wireless Communications and Public Safety Act of 1999 was enacted with the goal of implementing 911 as the universal access to emergency services. Enhanced 911 allows automatic reporting of number and location of the caller. Wireless enhanced 911 will soon provide the same automatic reporting from wireless phones. The FCC also regulates 911 services for satellite services, text telephone devices, and voice over Internet protocol devices.
A 911 call connects the caller with an emergency medical dispatcher (EMD), who then coordinates with other public agencies, for example, fire and police, and then prioritizes and dispatches resources available to the scene.
EMDs are trained to assign determinants that direct the level of response, that is, lights and sirens, and number of providers. They also give callers prearrival instructions for comfort and lifesaving interventions until prehospital personnel arrive on the scene.
Currently, EMS communications are changing from wide band to narrow band frequencies. Previously, prehospital providers used VHF or UHF 25-kHz bandwidths, but beginning in 2011, the FCC will no longer approve applications for these bandwidths. Nonfederal emergency providers that use frequencies below 512 MHz are required to transition to 12.5-kHz bandwidth by January 1, 2013. The goal of this change is to free up and streamline existing bandwidths, with a transition at some unspecified time in the future to a 6.25-kHz bandwidth.
Additionally, the FCC has designated the upper half of the 700-MHz public safety band for nationwide interoperable (real-time communication between different public safety groups) communications, to be administered at the state level. Most 700- and 800-MHz systems are trunked, meaning channels are shared among a group of users.
Federal goals for EMS communications include: demonstration of response-level communications within 1 hour for routine events involving multiple jurisdictions and agencies by 2010, by 2011 same for non-UASI jurisdictions, and by 2013 all jurisdictions’ response level within 3 hours of significant event (as outlined in the National Emergency Communications Plan).
Since 1966, requirements for vehicles used to provide emergency medical care have become standardized. Care is also provided in rotor- and fixed-wing aircraft. Many EMS services are fire based, and first responder vehicles include fire trucks and nonambulance trucks and automobiles. Bike EMS providers patrol civic events, and providers on motorcycles are a critical part of the system in Europe.
EMS vehicles may be equipped for basic life support (BLS), advanced life support (ALS), or specialty care depending on the need and availability (eg, specialized transport systems and vehicles for neonates, patients on ECMO, and intensive care transports).
EMS systems typically include hospitals with a variety of treatment capabilities. These may include any number and mix of local community hospitals with limited services, moderate-sized facilities with more advanced capabilities, and tertiary care facilities with capabilities to provide all levels of care. Hospital facilities are also frequently classified according to their relationship to EMS in addition to their ability to provide definitive care.
Base station hospitals: Physicians or specially trained personnel, generally paramedics or nurses, with physician backup provide EMS units with online medical supervision during treatment and transport. In many EMS systems, the base station hospital may also be the one most capable of providing definitive care.
Receiving hospitals: Receiving hospitals are facilities within the EMS’s geographic service area to which patients may be transported. The receiving hospital may be selected according to its proximity; capabilities; and patient, family, or physician preference.
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