..... Manpower

The workforce providing prehospital care varies largely

based on population density. Urban areas typically have

paid providers serving through government agencies or as

public safety officers in large public venues (airports,

amusement parks, etc). Volunteers are more commonly

found in suburban, rural, and wilderness areas.

..... Training

The U.S. Department of Transportation (DOT) National

Highway Traffic Safety Administration (NHTSA) National

Standard Curriculum for prehospital care providers historically outlined 4 levels of training: first responder, EMTbasic, EMT-intermediate, and EMT-paramedic. Currently,

• In 201 2, the American Board of Medical Specia lties

approved EMS as a subspecialty.

these levels are being transitioned to 4 nationally standardized levels of certification: emergency medical responder

(EMR), emergency medical technician (EMT), advanced

EMT (AEMT), and paramedic. Each level of training infers

a specific role, skill set, and knowledge base (Table 9- 1).

EMS provider training at all levels emphasizes airway,

breathing, and circulation (ABCs) and provider scene

safety as priorities in patient care. Although significant

efforts have been made to standardize education and certification throughout the United States, variability exists

from state to state in scope of practice and specific medication usage by each level of prehospital provider .

..... Communications/ Access to Care

In the early 1970s, "9-1-1" became the now ubiquitous

common point of access to emergency services. Call cen ­

ters are typically staffed by trained dispatchers who practice priority dispatching. Their job is to gather sufficient

information to triage and allocate the most appropriate

resources for a given response. It is becoming increasingly

common for dispatchers to provide pre-arrival

instructions to the caller, such as how to perform

layperson CPR.

..... Transportation

Transport vehicles vary in equipment based on the

intended response model and provider scope of practice.

30

EMERGENCY MEDICAL SERVICES

Table 9-1 . Prehospital care providers.

Certification Level Description

Emergency medical responder (EMR} The first responders to arrive on scene, they are trained to perform immediate lifesaving care with limited

resources until additional EMS responders arrive. Their skill set includes CPR, spinal immobil ization, oxygen administration, hemorrhage control, and use of an automated external defibrillator (AED}.

Emergency medical technician (EMT) This is the basic level of training necessary for ambulance operations. EMTs' skill set includes that of the

EMR, with the addition of transport operations and the assistance of patients in taking some of their

own prescription medications, such as metered-dose inhalers or nitroglycerine tablets. They may also

provide several medications including oral glucose, aspirin, albuterol, and epinephrine for anaphylaxis.

Advanced emergency medical

technician (AEMT}

Under medical direction, the AEMT may initiate intravenous or intraosseous access, perform manual defibril lation, interpret electrocardiograms, and administer an expanded range of medications.

Paramedic Traditionally the highest prehospital level of training with the broadest scope of practice. Their expanded

skill set includes endotracheal intubation, cricothyrotomy, needle thoracostomy. Drug administration

includes vasoactive agents, benzodiazepines, and opiates for pain control. They are also trained to perform higher level ECG analysis and to provide antiarrhythmic therapy with medications, electrical cardiaversion, manual defibrillation, and transcutaneous pacing.

Critical care paramedic This is a provider level that reflects additional training, knowledge, and scope of practice that is needed

for initiating or maintaining advanced level intervention during transport. Critical care paramedics often

have training in chest tube placement and management, balloon pump management, neonatal care,

central venous catheters, arterial lines, and hemodynamic monitoring. Additional medications including

neuromuscular blockers and sedation agents are commonly used at this level of care .

Basic life support ( BLS) ground units have automated

external defibrillators (AED) and supplies necessary for

basic wound care and airway management, including

oxygen, bag-valve-masks, suction equipment, and oral

and nasal airways. Advanced life support (ALS) units

have equipment necessary for a paramedic's scope of

practice, including equipment for IV access, medications,

and a cardiac monitor/defibrillator for rhythm analysis

and intervention. Some systems have uniquely equipped

critical care transport units that are designed to

accommodate patients with continuous IV infusions,

ventilators, or other specialized medical equipment such

as intra-aortic balloon pumps or neonatal incubators.

Air medical transport comprises both fixed-wing

(airplane) and rotary-wing (helicopter) vehicles. General

indications for air medical transport are outlined in

Table 9-2.

Table 9-2. Relative indications for air medical transport.

Distance by ground to the closest appropriate medical facil ity is too

great for safe and timely transport.

A delay during ground transport would likely worsen the patient's

clinical condition.

Special ized care is not available from local ground response

agencies.