Emergency Medical Services

Key Points

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Emergency medical services (EMS) is the extension of emergency medical care into the prehospital setting.
The U.S. EMS Systems Act of 1973 established key elements for EMS systems to receive funding.
In 2012, the American Board of Medical Specialties approved EMS as a subspecialty.

Introduction

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Emergency medical services (EMS) is the medical specialty that involves the delivery of prehospital care. The use of the term “EMS” may refer solely to the prehospital element of care or be part of an integrated system, including the main care provider, such as a hospital.

Federal funding for emergency medical services came with the U.S. EMS Systems Act of 1973, which established 15 key elements that must be addressed by systems to receive funding. The elements are used here as an outline for discussion.

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, EMT-basic, EMT-intermediate, and EMT-paramedic. Currently, 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.

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 immobilization, 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 defibrillation, 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 cardioversion, 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.