Chapter 1.

Emergency Medical Services

Emergency Medical Services: Introduction
EMS is the extension of emergency medical care into the prehospital setting. The concept of
bringing medical care to the sick or injured dates back to Roman times. However, EMS systems
as we know them today have their roots in legislative and clinical developments of the 1960s and
1970s. The 1966 report, Accidental Death and DisabilityThe Neglected Disease of Modern
Society, highlighted the deficiencies of prehospital care for trauma victims, which were
attributable to inadequate equipment and provider training. Up until that time, more than half of
ambulance services were run by funeral homes because hearses were among the few vehicles
able to transport a stretcher. The National Highway Safety Act, passed the same year, established
the U.S. Department of Transportation and made it the lead agency responsible for upgrading
EMS systems nationwide.1
In 1967, J. F. Pantridge began using a physician-staffed mobile coronary care unit in Belfast,
Northern Ireland, to extend cardiac care into the prehospital setting. By doing so he was able to
reduce mortality among myocardial infarction patients.2 The concept of using physicians to staff
ambulances never gained popularity in the U.S. However, in the late 1960s and 1970s,
prehospital personnel in the U.S. began to learn advanced medical skills, including IV placement
and administration of medications, cardiac rhythm interpretation, and defibrillation of cardiac
arrest patients.3
The U.S. EMS Systems Act of 1973 set aside large federal grants to develop regional EMS
systems across the country. Approximately 300 EMS regions were established and became
eligible for federal funding. To receive funding, the Act required that EMS systems address 15
key elements (Table 1-1). These 15 elements form the foundation of many EMS systems in their
present form.4
Table 1-1 Fifteen Key Elements of EMS Systems Defined by U.S. EMS Systems Act
of 1973

Manpower
Training
Communications
Transportation
Facilities
Critical-care units
Public safety agencies
Consumer participation
Access to care
Patient transfer
Coordinated patient record keeping
Public information and education

Review and evaluation

Disaster plan
Mutual aid

The 1970s became something of a Golden Age for EMS in the U.S. The U.S. Department of
Transportation developed curricula for EMTs, paramedics, and first responders. EMS
communications systems were formalized. In 1972, the Federal Communications Commission
recommended that 911 be implemented as the emergency telephone number nationwide. The
concept of designated trauma centers within EMS systems was introduced, the idea being that
EMS personnel would transport seriously injured patients preferentially to these facilities. Even
the general public was caught up in the enthusiasm for EMS, demonstrated by the popularity of
the long-running 1970s television series "Emergency," which chronicled the lives of Los Angeles
County firefighter/paramedics John Gage and Roy DeSoto.
The Omnibus Budget Reconciliation Act of 1981 eliminated direct federal funding for EMS.
Instead, federal funds were given to states in the form of block grants for health services. The
result was a decrease in overall funding of EMS as well as decreased coordination of EMS
systems. EMS systems took on a decidedly local flavor, with great variation between systems
within states and across the country. This trend has had long-term consequences for the field.1
EMS System Overview
A review of the 15 key elements of EMS systems identified by the EMS Systems Act of 1973
(Table 1-1) provides insight into the current structure of EMS systems and the challenges they
face.
Manpower
In most urban areas, paid public safety and ambulance personnel provide prehospital medical
care. In contrast, suburban, rural, or wilderness EMS systems commonly use volunteers, park
rangers, or ski patrols. Regardless of the setting, EMS personnel commonly fall into one of four
levels of training, in accordance with the U.S. Department of Transportation EMS provider
curricula. These are first responder, EMT basic (EMT-B), EMT intermediate (EMT-I), and EMT
paramedic (EMT-P) (Table 1-2). First responders are often the first to arrive at a medical
emergency, typically police officers, firefighters, or first aid teams. They are trained to perform
CPR, spinal immobilization, hemorrhage control, and other basic interventions while awaiting an
ambulance. The three U.S. Department of Transportation EMT levels refer to individuals who
function as part of an ambulance crew. EMT-Bs are trained to take care of immediately lifethreatening emergencies. Skills include oxygen administration, CPR, use of an automated
external defibrillator (AED), hemorrhage control, and extrication, immobilization, and
transportation of emergency victims. They are also trained to assist patients in using certain of
their own medications. EMT-I training includes additional patient assessment plus IV insertion,
basic ECG interpretation, and administration of some cardiac medications. EMT-Ps have the
highest skill level among EMTs, with greater training and broader scope of practice than EMT-Is.

Because of their advanced level of training, paramedics function under a designated physician's
medical license.5
Table 1-2 EMS Personnel

Personnel

Comment

First responder

First professional or trained layperson to arrive at a medical emergency

EMT-B (Basic)

Oxygen, CPR, AED, extrication, immobilization, hemorrhage control

EMT-I
(Intermediate)

EMT-B plus IV insertion, some medication administration, ECG

interpretation

EMT-P (Paramedic) Advanced resuscitation techniques such as intubation

Abbreviation: AED = automated external defibrillator.
Training
Training includes initial provider training and continuing education. As EMS call volume
increases, providers often find themselves caring for a disproportionate number of patients with
minor medical issues. It may therefore be difficult for them to maintain proficiency in those very
skills they will need to manage a critically ill patient. Innovative training methods to ensure skills
retention must be investigated. The use of computerized patient simulators is one option, both for
reviewing skills and for learning new ones.
Communications
The adoption of 911 as a nationwide emergency telephone number in the U.S. has greatly
facilitated public access to emergency medical care. In many systems, the answering centers
have enhanced equipment that provides automatic number and location identification of the
caller. Widespread use of cellular telephones is prompting development of enhanced technology
to identify and locate these callers as well. Emergency call takers must be properly trained to
collect the necessary information from the caller, dispatch appropriate medical resources, and
offer first aid information or prearrival instructions while the ambulance is en route. Ambulance
personnel should also be able to communicate with the destination hospital. Most EMTs operate
under standing orders and patient care protocols developed by physicians. However, there are
times when EMTs may require online medical control, talking directly with a physician for
specific direction or orders.6 Historically, communications represent the weakest link in most
disaster responses. It is therefore important that EMS communication systems have built-in
redundancy to ensure uninterrupted service.
Transportation
Ambulances have evolved from simple transport vehicles into mobile patient care areas where
lifesaving maneuvers can be performed. The most important aspect of ambulance design is that it

allow providers the ability to provide airway and ventilatory support while transporting the
patient safely. BLS ambulances carry equipment appropriate for personnel trained at the EMT-B
level, such as oxygen, bag-mask ventilation devices, immobilization and splinting devices, and
dressings for wound care and hemorrhage control. BLS ambulances do not carry medication and
cannot transport patients requiring IVs or cardiac monitoring, although some may carry AEDs.
ALS ambulances are equipped for EMT-Ps or other advanced health care personnel with IV
supplies, IV medication, intubation devices, cardiac monitoring and defibrillation, and equipment
for other specialized techniques unique to specific areas, such as hypothermia application after
cardiac resuscitation. Ground transportation is appropriate for the majority of patients, especially
in urban and suburban areas. However, air transport, generally by helicopter, should be
considered for critically ill patients when the ground transport time would be dangerously long or
if the terrain is difficult to navigate.4
Facilities and Critical-Care Units
Emergency patients are often transported to the closest appropriate hospital or to the hospital of
the patient's choice. In recent years, the number of specialty hospitals, or hospitals with
specialized capabilities, has increased. These include pediatric hospitals, trauma centers, spinal
cord injury centers, burn centers, stroke centers, and cardiac centers. Tertiary care centers, often
affiliated with medical schools, provide many of these services and may also have a large
number of critical-care unit beds. The decision to bypass hospitals to take patients directly to a
specialty center or a hospital with a large critical-care capacity, often at greater distances, is not a
simple one. Although specialty hospitals often have more resources, transporting an unstable
patient past an ED to get to the specialty hospital is not without risks to the patient. Furthermore,
bypassing hospitals may have negative financial consequences for those facilities that are
bypassed.1 It is wise to solicit input from the local, regional, or statewide medical community
before developing destination policies addressing such specialty centers.
Because of increasing hospital inpatient censuses and ED overcrowding, at a given time, even
the largest hospitals may not have adequate resources to care for EMS patients. This may result
in prolonged waiting times for patients to be seen and ED boarding of admitted patients. ED
boarding is the term used when patients admitted to the hospital must be kept in the ED because
no inpatient beds are available. Furthermore, some EDs may request that EMS services divert
patients to other hospitals.7 Because of these issues, regional EMS systems should attempt to
develop methods to monitor in real-time the available resources of their receiving hospitals. A
secure, Internet-based Web site of current hospital resources, including ED and inpatient bed
availability, is one option.
Public Safety Agencies
EMS systems should have strong ties with police and fire departments; in fact, many large EMS
systems today in the U.S. are run by municipal fire departments. In addition to providing scene
security, public safety agencies can provide first responder services because their personnel are
often first on the scene of an emergency. Fire and police AED programs in which personnel are
equipped to use AEDs and trained in CPR are common.810 In some locations, these have been

shown to improve outcome among cardiac arrest victims. Finally, EMS personnel often provide
medical support to police and fire departments in hazardous circumstances.
Consumer Participation
Public support, both political and financial, is necessary for a good EMS system. It is therefore
important that laypersons contribute to the policy-making process. One way to accomplish this is
to encourage representation of the general public on the membership of regional EMS councils.
In addition, the public can participate by volunteering for local EMS agencies.
Access to Care
A successful EMS system ensures that all individuals have access to emergency care regardless
of their ability to pay or type of insurance coverage. Often, the EMS system is a patient's primary
point of entry into the health care system. There should be no barriers or disincentives preventing
timely access to the system. A more difficult problem exists when terrain or low population
densities result in longer response times for some citizens than others, as in the many rural or
wilderness areas of the country. Possible solutions include stationing or predeploying
ambulances throughout the area with one central dispatching center. Another option is heavier
reliance on air medical services.
Patient Transfer
Patients are often transferred from one medical facility to another for a higher level of care. Safe
transfer is an important concept, and many problems can be avoided if both the transferring and
receiving facilities develop transfer agreements in advance. The U.S. Emergency Medical
Treatment and Active Labor Act, passed in 1986, sets forth rules that hospitals participating in
the U.S. federally financed Medicare program (health care for those >65 years or those <65 years
with some selected chronic illnesses) must adhere to when considering a patient transfer. Under
the Emergency Medical Treatment and Active Labor Act, all patients must receive a medical
screening exam and be stabilized before transfer to another facility is considered. There must be
explicit acceptance of the transfer by the receiving hospital.11
Coordinated Patient Record Keeping
Maintaining good medical records is important to any patient encounter, whether it be inhospital
or in the prehospital setting. Prehospital medical records need to be legible, intelligible, and
readily accessible to hospital providers. Standardization of EMS medical records among different
agencies within a region helps to streamline transfer of clinical information between prehospital
and hospital providers. The adoption of electronic charting by many EMS systems is a step
toward this goal. Electronic charts can be printed out in the receiving ED or downloaded from a
secure Internet Web site. Regardless of the charting system used, EMS systems must comply
with the stipulations of the U.S. Health Insurance Portability and Accountability Act of 1996,
designed to protect the privacy of patient health information.12

Public Information and Education

EMS systems have a responsibility to train the public how to access them when needed and how
to use them appropriately. As call volumes of many EMS systems rise and available resources
decline, educating the public to use 911 only for true medical emergencies is an appropriate
objective. However, given the obstacles that many patients encounter in trying to access officeor hospital-based medical care through other means, how to convey that message is not simple.
The general public needs to know that EMS will be there when they need it.
Another important educational message that EMS can convey to the public is the importance of
learning CPR, first aid, and basic disaster preparedness principles. The responses to Hurricanes
Katrina and Rita and other recent natural and manmade disasters illustrated that, at times, the
emergency response infrastructure may be so seriously disrupted that it may take hours, if not
days, for help to arrive. A public that is adequately prepared and trained to administer first aid to
themselves and those around them will be in a better position to safely await help.13
Review and Evaluation
To ensure the proper functioning of any EMS system and that patients receive the highest quality
medical care possible, there must be a process in place for ongoing review and evaluation. This
requires input from personnel involved in the day-to-day operation of the system and active
involvement of a physician medical director. A continuous quality improvement program should
be established to assess system performance and formulate improvements.14 Routine audits of
radio communications, response times, scene times, and patient care records are frequently
performed. Outcome studies of such conditions as cardiac arrest, stroke, and trauma may be
valuable. However, obtaining such outcomes may be problematic. An unforeseen consequence of
the Health Insurance Portability and Accountability Act legislation is that hospitals are often
resistant to releasing patient information, even to the EMS services that transported the patients
to them, for fear of liability. Possible solutions to this problem are being investigated.
EMS research is invaluable to evaluate the efficacy of prehospital interventions and to help
develop new ones. It is not valid to assume that what works in the hospital will also work in the
prehospital setting. Issues such as limited funding, barriers to obtaining patient outcomes, and
obtaining informed consent from critically ill patients, or waivers for consent, can make
prehospital research daunting. However, these barriers must be overcome if patients are to
receive quality care.15
Disaster Plan
The EMS system is an integral part of disaster preparedness and should be involved in
planning along with other agencies and the medical community. The Omnibus Budget
Reconciliation Act legislation of 1981 ended direct federal block grants to EMS. Because EMS is
often not considered to fall into the category of public safety, emergency preparedness funding
for EMS has fallen behind that of police and fire services.1 Despite this, EMS agencies must
maintain a high level of disaster preparedness. This involves having written policies and

procedures, stockpiling supplies that may be rapidly depleted in multi-casualty situations, and
participating in regional disaster drills with other emergency response agencies and hospitals.16
Mutual Aid
EMS services should develop mutual aid agreements with neighboring jurisdictions so that
uninterrupted emergency care is available when local agencies are overwhelmed or unable to
provide services.17 Depending on the size and resources of the EMS system, mutual aid may be
required frequently or only under the most dire circumstances. Working out in advance details
such as reimbursement, credentialing, liability, and chain of command at incident scenes will
streamline the process.
Current Challenges and Future Trends
The 2006 U.S. Institute of Medicine publication, Emergency Medical Services at the Crossroads,
detailed many of the challenges EMS faces today.18 These include fragmentation and lack of
interoperability from one system to the next, between EMS and other public safety agencies, and
between EMS and the rest of the health care infrastructure. These limit the efficiency of many
EMS systems on a routine basis and may have serious consequences in disaster response. In
addition, the fallout from the Omnibus Budget Reconciliation Act legislation of 1981 is still felt.
Funding for EMS continues to fall behind other public safety agencies, both for day-to-day
operations and for emergency preparedness. Also, a recent restructuring of how the U.S.
Medicare system pays for ALS and BLS services has resulted in a net decrease in
reimbursements. Therefore, many EMS agencies face either finding other sources of funding or
cutting services. This is occurring at a time when call volumes are rising in many parts of the
country, in part due to the aging of the population and limited access to health care.1
Although demands for EMS services steadily grow, in many parts of the country EMS staffing is
not increasing at a commensurate rate. Factors, such as low pay, high stress, and limited
opportunities for career advancement, result in high turnover rates among EMS providers. As the
length of training curricula for EMS providers increases, alternative careers in health care may
appear more appealing. Many EMS systems are currently experiencing real or perceived
paramedic shortages, prompting them to look at alternative staffing configurations or resource
deployment.
As a consequence of funding and staffing constraints amid increasing call volumes, many EMS
systems operate at full capacity on a daily basis. As a result, their surge capacity, referring to the
ability to accommodate a sudden, large increase in demand for services, is limited. Surge
capacity is determined by a system's staffing capabilities, its available physical resources, and the
ability of its organizational structure to react effectively to the increased demand. To enhance
surge capacity, EMS systems will need funding for additional personnel, vehicles, and stockpiles
of extra supplies that can be readily deployed. They must also participate in frequent training that
is realistic and based on those threats they are most likely to encounter.1922
Despite the many challenges EMS faces, the quality of care provided by EMS personnel
continues to improve, driven in part by EMS research. Some of the advancements involve

resuscitation of cardiac arrest victims and management of acute myocardial infarction patients.
The clinical value of cardiac arrest studies has been enhanced by the widespread adoption of the
Utstein template for data reporting in prehospital research. Developed in 1990 by an
international working group, and with continual updates, the Utstein style presents a systematic
and standardized format for reporting cardiac arrest data that includes definitions, time intervals,
and descriptors of EMS systems. This facilitates comparison of results of studies performed in
different EMS systems.23 The importance of BLS skills in cardiac arrest and other emergencies is
being rediscovered. Basic interventions in some cases can have a greater impact on patient
outcome than ALS skills. More widespread use of AEDs by first responders has the potential to
increase rates of resuscitation in prehospital cardiac arrest. The emphasis on high-quality CPR
with a minimum of interruptions, as set forth by the international 2007 Guidelines for CPR and
ECC,24 is widely reflected in EMS protocols across the U.S.25,26 Devices that provide instant
feedback on the rate and depth of chest compressions and the rate of ventilations are being
introduced in the prehospital setting to improve the quality of CPR.27 Some EMS systems are
beginning to induce hypothermia in resuscitated patients.28,29 The use of 12-lead ECGs on
patients with chest pain in the prehospital setting is becoming common.3033 Some systems
transmit ECGs to receiving EDs. In other systems, when the EMS providers identify acute STelevation myocardial infarctions by ECG, they notify cardiac catheterization lab staff directly to
minimize door-to-balloon time at the receiving hospital.
EMS is maturing as an important subspecialty of emergency medicine both in the U.S. and
abroad. Growing populations and increasing urbanization are driving the development of EMS
systems worldwide, in some cases due to high mortality from trauma and cardiac disease.34,35 The
aftermath of the 2004 Asian tsunami emphasized the need for organized and effective prehospital
care in developing countries, as well as for international cooperation among EMS agencies.36,37
Although the EMS systems in some countries are very similar to those in the U.S., in other
countries, differences in geography, health care system design, funding, and political structure
present unique challenges and the potential for novel solutions. These developing EMS systems
have the advantage of not being encumbered by decades of tradition, so they can take advantage
of the lessons learned elsewhere. They also present the opportunity for collaboration on
international research initiatives that can lead to improved patient outcomes.38
See Table 1-3 for a list of abbreviations and acronyms.
Table 1-3 Abbreviations and Acronyms

AED

Automated external defibrillator

ALS

Advanced life support

CPR

Cardiopulmonary resuscitation

DOT

U.S. Department of Transportation

ED

Emergency department

EMS

Emergency medical services

EMT

Emergency medical technician

EMTALA U.S. Emergency Medical Treatment and Active Labor Act

EMT-B

Emergency medical technician-basic

EMT-I

Emergency medical technician-intermediate

EMT-P

Emergency medical technician-paramedic

E-911

Enhanced 911

FR

First responder

HIPAA

U.S. Health Insurance Portability and Accountability Act

OBRA

Omnibus Budget Reconciliation Act