EMS

1. EMS PAST PRESENT FUTURE

2. EMS PAST

3. Pioneers of PrehospitalTrauma Care • AMBROSE PARE • French surgeon in 1500s • Wrote first book on trauma care • Condemned use of boiling oil for GSW and reintroduced use of ligatures for amputations • No organized evacuation of wounded at this time

4. History of PrehospitalTrauma Care • No organized medical care for injured patients before 19th century • On the battlefield no organized evacuation of the wounded and no field hospitals to treat them • Generally women “camp followers” provided nursing care • Organized prehospital care began with the efforts of military surgeons to treat battlefield casualties

5. Pioneers of Prehospital CareEarly 1800s: Baron LarreySurgeon General, Napoleon’s Army Baron Larrey’s “Flying Ambulance”

6. Crimean War 1854-56 • Modern nursing care introduced by Florence Nightingale • Casualties begin to be evacuated by railroad FLORENCE NIGHTINGALE “THE LADY WITH THE LAMP”

7. Note a pattern developing: the faster the injured arrived at a hospital, the better the survival. This principle has not changed

8. Linda Richards • “America’s first trained nurse” • Traveled to England to learn from Florence Nightingale who had started a school for nurses • On her return to the U.S Richards pioneered the founding of nursing training schools across the nation. • In 1885 she helped to establish Japan's first nursing training program

9. Air Evacuation • First began in Paris in 1870 when hot-air balloons were used to evacuate 160 soldiers • Did not become common until the second world war

10. BEGINNINGS OF EMS IN THE U.S. LOAD AND GO ORIGINAL AMERICAN AMBULANCE AND ORIGIN OF THE TERM “HAUL ASS”

11. American Civil War

12. Civil War • Railroads continue to be used to evacuate casualties • Army still used ambulances much like Napoleon • Death rate very high because germs were unknown as the cause of infection – barns used as hospitals • U.S. Army set up the Medical Corps • System-wide approach with ambulances on the battlefield transporting to system of hospitals • Aid stations • Field hospitals • Rear general hospitals • This model was used until the Vietnam war

13. WORLD WARI

14. WORLD WAR I • Poor planning (no field hospitals) caused excessive evacuation times of 12-18 hours • High mortality rates >20% • Most died of hemorrhagic shock • No antibiotics so sepsis common • Blood transfusions just beginning to be used • Thomas half-ring femur splint was considered the greatest advancement in trauma care at this time

15. WORLD WAR II • Evacuation time for wounded decreased to 4-6 hours • Antibiotics developed • Plasma and blood transfusions common • Hospitals closer to the front to decrease time to surgery • Fixed wing air transport • Mortality rate 3.3%

16. KOREAN WAR • Evacuation time averaged 2-4 hours • Helicopter evacuation of wounded introduced • More use of electrolyte solutions • Better antibiotics • Surgical hospitals closer to front lines • Mortality rate 2.4%

17. VIETNAM WAR • Casualties taken directly from front lines to surgical hospital by helicopter • Average evacuation time 35 minutes • Average time to surgery 1-2 hours • Mortality 2.3% • Civilian systems have never matched this

18. IRAQ WAR • Rediscovered tourniquets • Development of hemostatic agents • Developed concept of CAB for patients with exsanguinating hemorrhage

19. Civilian Prehospital Medical Care • Before Vietnam War • A few large hospitals provided ambulance services (transport only) • Bellevue Hospital began horse drawn ambulances in 1869 • No trained providers • Rural areas used hearses for ambulances • This went on until the 1970s

20. ORIGINAL VOLUNTEER RESCUE • “Good” Samaritan was much like volunteer rescue folks • Considered 2nd class citizen • Cared deeply for his fellowman and was willing to go out of his way and furnish his own ambulance to help him • Set a standard we all have to live up to today

21. Beginning of EMTs • First prehospital training course taught to Chicago Fire Department in 1957 • Prehospital training did not catch on until the late 1960s and with few exceptions paramedic training did not begin until the 1970s

22. PARAMEDICS WERE INVENTED TO REPLACE DOCTORS IN TREATING PREHOSPITAL CARDIAC PATIENTS AT THAT TIME CARDIAC PATIENTS REQUIRED CAREFUL DELIBERATE CARE SPEED WAS NOT NEEDED THAT PRINICPLE IS NO LONGER TRUE

23. Frank Pantridge, MD1916-2004

24. Frank Pantridge, MD • Called the grandfather of prehospital ALS • In Belfast Ireland, in the 1950s he began using the new CPR system for cardiac resuscitation but realized he needed to get the treatment into the field • Developed the first portable defibrillator and then the mobile intensive care ambulance

25. Peter Safar, MD 1924-2003

26. Peter Safar, M.D. • Intensive care specialist who pioneered the “ABCs” of CPR including mouth-to-mouth resuscitation • Worked with Laerdal to develop the Resusci Anne • Helped develop the first ALS ambulances • In 1966 trained some of the first “paramedics” by taking 44 unemployed African-American men and giving them 3000 hours of training (doctors got 3500)

27. Nancy Caroline, MD1944-2002 “THE MOTHER OF PARAMEDICS”

28. Nancy Caroline, MD • She was influenced by Dr. Safar to believe that nonphysicians could be trained to perform physician skills • She worked in the field with Dr. Safar’s original paramedics • Was the original author of the DOT national standard curriculum for paramedics in 1974 • There were no paramedic textbooks so in 1975 she wrote the original textbook Emergency Care in the Streets • Now in its 6th edition

29. In 1968 the American College of Emergency Physicians was formed. This led to the development of residency training programs and eventually to the recognition of emergency medicine as a specialty in 1979.. Milestones In the House of Medicine, the light that is never turned off

30. R Adams Cowley 1917-1991

31. R Adams Cowley, MD • In the 1960s Dr. R Adams Cowley, a cardiovascular surgeon, did pioneer work in trauma care and helped bring about special training in trauma care for surgeons. • Developed the concept of the “Golden Hour” • He was responsible for the development of the Maryland Institute for EMS Systems (MIEMSS), the first statewide EMS system

32. EMERGENCY 1972-1977 RAMPARTS

33. 1968 – St. Vincent’s Hospital in New York City began first mobile coronary care unit 1969 Miami, FL Fire Department began the nation’s first paramedic program under Dr. Eugene Nagel 1972 The television show Emergency! Began Soon every town wanted their own “Ramparts” There were 12 medic units in the country at the time Four years later at least 50% of the population was within 10 minutes of a medic unit 1973 St. Anthony’s Hospital in Denver starts the nation’s first civilian aeromedical transport service (“Flight for Life”) Milestones

34. Rocco Morando

35. Rocco Morando • Was instrumental in establishing the National Registry of EMTs in 1970 and became its first executive director in 1971 • He retired in 1981 and the headquarters building was named after him • Was also instrumental in establishing the National Association of EMTs in 1975 • He and Dr. McSwain helped keep NAEMT afloat during the early years when support (and funds) was sparse

36. 1975 First paramedic textbook written by Nancy Caroline National Association of EMTs is formed 1978 American Heart Association begins the “Alphabet Courses” with ACLS 1980 American College of Surgeons begins the ATLS course for physicians 1982 Alabama Chapter of ACEP begins BTLS course 1983 NAEMT and ACS begin PHTLS Milestones

37. James O. Page1936-2004

38. James O. Page • Probably best known of all those mentioned so far • Untiring speaker who was always ready to tell people about EMS • A man of many parts, Fire chief, lawyer, technical consultant for Emergency!, first EMS director for North Carolina, prolific writer and speaker, founder of JEMS, most recognized spokesman for EMS until his death in 2004

39. Norman McSwain, MD

40. Norman McSwain, MD • Dedicated trauma surgeon and educator • Supporter of EMS for over 30 years • Founding father of NAEMT • Founding father of PHTLS and continues to serve as medical director • Gentleman and scholar • But don’t ever let him drive

41. EMS PRESENT

42. WE ARE AT THE END OF THE BEGINNING IN EMS Ray Fowler, MD

43. EMS at Present • Except for isolated instances, the whole country is within a reasonable distance of an ALS ambulance • EMS systems continue to vary widely with few states having centralized management of the system • Some states don’t even have a State EMS Medical Director • Many states do not require that their EMS training programs be accredited

44. Standardization of the Profession • In process of finally standardizing levels of prehospital EMS providers • EMT • BLS including AED and CPAP • Only a committee could have come up with the brilliant idea to take a generic term (EMT) that applied to all levels of providers and make it refer to only one level, thus rendering all previous references confusing • Advanced EMT • Above + Rescue airway, + IV fluids + limited medications • Paramedic • Above + intubation + Monitor Defibrillator + more meds

45. Have Yet to Prove to Everyone that Paramedics Make a Difference • “EMS is the largest hoax ever foisted on the American people. There is no data, not one study, which shows that anything beyond the intermediate level – basic EMT with a defibrillator capabilities – does anything in the long run to change the health care of the United States” • Gregory Henry, MD • Dr. Henry is an expert in risk management, not EMS, but he strikes a nerve

46. EMS FUTURE

47. WHERE DO WE GO FROM HERE?WE FACE SOME CHALLENGES

48. Must Recruit More EMTs • There is a critical need for competent, professional EMTs • Prehospital EMS is an exciting career that should be emotionally and financially rewarding • Somewhere we got the idea that only older men/women should be EMTs • “Students just out of high school are too immature to be EMTs” • Bill Brown, National Registry • Tell that to the nursing profession • We must begin recruiting students while they are in high school

49. Paramedics Must Change How They Define Themselves • At present too many define themselves by what procedures they can do • Too many dishonor the profession by being more interested in doing invasive procedures than caring for the patient • The worth of a prehospital provider is not in what procedures they do but how many people they save • Less may be more • Patient care must come first • In most instances this means “Load and Go” with most interventions done in the ambulance • ALS is almost impossible when there is only one EMT in the back of the ambulance

50. Critical Care Systems (STEMI, Stroke, Trauma) will allow Paramedics to prove their worth