United States EMS Transport Program

EMS is a critical component within the survival of society. Society is predicated on the productivity of each of its constituents. However, as is often the case, these members are susceptible to sickness and ailments. EMS is therefore needed to provide aid to insure the proper treatment of society. Often, life can occur unexpected and without warning. A system is needed to responds to these emergencies in a timely manner. However, as we will discuss, EMS is not always timely.

Any delays in the system can result in still further injury or even death. This document will describe the pros and cons of EMS and offers suggestions on how to properly improve the system. First, the essential decision in EMS care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. Often this decision will be in the hands of the first aid provider. Depending on the EMS response time, the individual can literally live or die.

In very serious instances, EMS will elect to use the "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter. This allows EMS to respond very quickly to very life threatening medical emergencies. This is a significant pro-to the overall system. The variety of transportation methods can provide aid in a litany of different ways. This diversity of emergency solution can be very helpful when an unexpected emergency occurs. A prime example, of this pertains to the September 11th terrorist attacks.

The use of helicopters was pioneered in the Korean War, when time to reach a medical facility was reduced from 8 hours to 3 hours in World War II and again to 2 hours by the Vietnam war. Due to the sheer variety of EMS response mechanisms, New York was better able to help victims from the attack. EMS also uses a technique called the "stay and play." This technique is primarily exemplified by the French and Belgian SMUR emergency mobile resuscitation unit.

Although used throughout Europe does provide examples of an improvement that can be made to the United States EMS system. The strategy developed for pre-hospital trauma care in North America is based on the Golden Hour theory. With this theory, a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This theory, although controversial in some respects, appears to be true.

In particular, cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds have been found to be best treated when in the operating room as oppose to elsewhere. Under this theory, minimal time is spent providing pre-hospital care and the victim is transported as fast as possible to a trauma center. This theory however has its cons, as a victim often can experience very severe injury and even death waiting for the transport and within the transport vehicle itself.

Many critics believe that it is best to provide as much care that is needed upfront so that the chances of survival are better. They believe that each minute that passes, the likelihood of death is exacerbated. This in many instances is true for certain injuries. Increasingly, research into the treatment of myocardial infarctions occurring outside of the hospital have suggested that time to treatment is a clinically significant factor in heart attacks.

In essence, the longer the time interval between onset and actual arrival to the hospital, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival. This coincides with the Golden Hour Theory mentioned above. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies).

Another con to the EMS system is that it often doesn't take into account the varying circumstances prevailing. Emergencies are rarely the same. People are different. People react differently to treatment. People experience different symptoms. There should be some form of flexibility embedded within the system. Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room.

This information is very profound as the current system doesn't allow for proper treatment by paramedics. Instead, their primary responsibility is getting patients to the emergency room. This is a significant con, as proper treatment upfront can greatly lower balloon times. The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent for example. This same concept can be applied to the United States, greatly reducing deaths, and helping to save costs in the process.

In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals. This too is a significant con to the current system as it is not efficient in regards to resource utilization. It is better to transport patients to hospitals with less wait times, with properly trained personnel. The current system does not take this into account.

Instead, patients are often waiting or may simply not make it in time to receive treatment. Another important element is the model of care within the EMS system itself. The Franco-German model is physician-led, with doctors responding directly to all major emergencies requiring more than simple first aid. In many instances, the paramedics as seen in the United States are bypassed completely. The team's physicians and in some cases, nurses, provide all medical interventions for the patient.

Those who are not properly trained or apart of the medical staff simple drive the person to the appropriate destination. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is sharply restricted in terms of scope of practice. In these instances, the paramedic cannot provide any life support services unless in the company of a licensed praticitioner. Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient.

This is a con within our current system. The Ambulances are not properly equipped to deal with the very life threatening aspects of treatment like our European counterparts. In fact, they have the ability to essentially bring the hospital to the patients as oppose to the other way around. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable.

This system is used primary in Germany and has been proven to be very successful as oppose to the U.S. system. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances. This is yet another con to our system. The individual must.