Private and Public Agencies

Where local government has not assumed primary responsibility for EMS services, communities may depend on private providers. Financial responsibility varies but usually depends on federal reimbursement (Medicare or Medicaid) and user fees. A local government subsidy may or may not supplement the operation. If multiple providers are serving one jurisdiction, calls may be allocated by rotation or specified zone coverage. Dispatching varies by the system but may be by the provider or by a central agency. Medical direction is often provided by a contracted physician or physician oversight board.

Hospital-based EMS systems are few in number and may be managed by a single hospital or hospital corporation. Not all hospital-based EMS programs are considered private, in that the hospital may be a division under local or state government or operating under a public authority. As in private models, financial responsibility is usually in the form of user fees, with or without additional subsidy. Dispatching may be provided by a local public safety agency that may also be responsible for police and fire communications. An emergency physician from a sponsor or base hospital typically provides medical direction for these systems.

A public utility model is a hybrid between private and public design that allows local government to contract with a private or public provider. The successful bidder for service becomes a contracted entity that agrees to provide the specified services (ALS, BLS, or both) to the catchment area and, depending on the arrangement, may bill the patient directly or receive uniform reimbursement. Depending on local structure and interagency agreement, dispatching may be performed by an existing public safety organization or by the parent company. Medical direction is usually a specified individual subject to contractual terms.

When government officials were faced with planning and establishment of EMS systems during the early maturation periods, many decided that the fire department was the logical choice to incorporate EMS. Fire stations were strategically located throughout the community, and personnel were already used to providing emergency response. Firefighters could be cross-trained as a firefighter-paramedic or dedicated to either fire or EMS function with the opportunity for transfer. Public EMS systems that were not incorporated into fire departments evolved into their own separate entity, referred to as a municipal third-service system. Such agencies are operated by local municipalities and are endorsed and supported by local government. Many cities have been successful in combining police, fire, and EMS under a global public safety agency, with all department heads or chiefs reporting to one manager or administrator. Financially, public EMS systems may be supported by a tax base, which may or may not be supplemented by user fees. Regardless of design, medical oversight for a municipal EMS system may be provided by a physician appointed and contracted by a local hospital, an advisory council, or a medical oversight board.

Basic Life Support and Advanced Life Support Service

BLS describes the provision of emergency care without the use of advanced therapeutic interventions. Skills include airway management (oral and nasal airways, bag-mask ventilation), cardiopulmonary resuscitation (CPR), hemorrhage control, fracture and spine immobilization, and childbirth assistance. Defibrillation with an automated external defibrillator (AED) is often included by many BLS systems. Services are provided by certified or medical first responders or emergency medical technicians (EMTs) certified at the basic level (EMT-B).

BLS systems may be associated with poor survival rates from out-of-hospital cardiac arrest, especially those not incorporating AED technology.¹⁶ Alternatively, there is debate on the effectiveness of ALS for medical and traumatic emergencies.¹⁷ Despite this evidence, few urban communities across the United States operate solely at the BLS level. Many rural and some suburban EMS services rely on volunteers who may not wish to become advanced-level providers. Because these services may have low call volumes, it becomes more difficult for personnel to maintain advanced skills and a proficient knowledge base. Also, such communities may not have access to medical supervision or hospital sponsorship for ALS care.¹⁸

Systems categorized as ALS offer a more comprehensive level of service by highly educated providers, usually certified at the intermediate or paramedic level (EMT-I or EMT-P, respectively) or equivalent levels, depending on individual state certifications. Provider skills include advanced airway interventions, intravenous line placement, medication administration, cardiac monitoring and manual defibrillation, and certain invasive procedures. Most EMS systems in urban cities operate at the ALS level of care.

The number of EMT-Ps in any jurisdiction has come under scrutiny, in that cities with more paramedics per capita tend to have lower survival rates.¹⁹ Although this may seem implausible, one explanation might be that the number of patient encounters per paramedic decreases and the sharpness of skills degrades when that community is saturated with paramedics.

Single-Tiered, Multitiered, and First Responder Systems

In a single-tiered system, every response regardless of the call type receives the same level of personnel expertise and equipment allocation (all BLS or ALS). Multiple-tiered systems use a combination of ALS and BLS levels, depending on the nature of the call. Differences in cost and effectiveness between a mixed ALS-BLS service and an all-ALS service have been debated. A single-tiered ALS response may prove to be cost-effective in specific locales, ensures the capability of providing a consistent advanced level of care to all patients regardless of illness or injury severity, and obviates the potential for undertriage or overtriage by 9-1-1 telecommunicators. Alternatively, a multitiered system may meet the needs of individual communities or agency infrastructure. This design often meets with employee satisfaction and has the potential to preserve ALS resources for higher priority calls in that BLS transport of nonurgent patients allows ALS ambulances to be available for potential critical responses.

Regardless of single- or multiple-tier design, EMS systems usually include first responder services as part of their structure. The first responder, usually a police officer or firefighter, is the nontransport BLS or ALS provider who responds to the scene of an emergency to provide initial care before definitive medical care and transportation assets arrive. The first responder quickly assesses the situation and patients, determines whether additional resources are required, initiates patient care, and provides advance information to responding personnel.

The design of an EMS system is targeted toward providing quality patient care in the briefest time after unexpected injury or illness. A desirable and cost-effective design might include BLS nontransport first responders with short response times (average 2-4 minutes), having the capability of providing early defibrillation and airway support, coupled with ensuing ALS care and transport services.²⁰

Emergency Medical Responder

The emergency medical responder, formerly referred to as first responder, is typically the first to arrive on the scene of an incident. Initial scene and patient assessment along with limited lifesaving interventions is the primary function. Along with CPR and basic airway management skills, the emergency medical responder should be able to control hemorrhage and initiate spinal immobilization.

The four elements referred to as the chain of survival by the American Heart Association, which decrease mortality from out-of-hospital cardiac arrest, are early access to care, CPR, defibrillation, and advanced airway management and medications.²³ Because early defibrillation may improve the odds of survival of out-of-hospital cardiac arrest, the use of an AED should be a mandatory procedure for the emergency medical responder.²⁴

Emergency Medical Technician

The EMT, formerly referred to as the EMT-Basic, is the minimum level required to staff a BLS ambulance and is commonly used for nonemergency and convalescent transport services. In addition to the skills of the first responder, the EMT is also involved with triage, more detailed patient assessment, and transportation. Like first responders, EMTs should have the capability of providing early defibrillation.

In 1995, the NHTSA released the revised EMT curriculum to include 46 lessons, each with cognitive, effective, and psychomotor objectives.²⁵ Many states expanded the course to include more skills, such as AED use, epinephrine autoinjections, albuterol administration by hand-held nebulizer or metered-dose inhaler, and use of adjunctive airway devices such as the extraglottic airway.

Advanced Emergency Medical Technician

The advanced emergency medical technician (AEMT), formerly referred to as the EMT-Intermediate, was established to allow a more comprehensive approach to care when paramedic services are unavailable or unobtainable. Many states recognize the AEMT certification, but others designate alternative but comparable levels, depending on specific skills and procedures. This level is useful for rural systems because it provides some ALS care for less cost and educational time expended. The scope of practice for the AEMT varies across the United States. Most systems allow the AEMT to establish an intravenous line, to manually defibrillate, and to administer limited medications.

Emergency Medical Technician–Paramedic

The EMT-P is the most advanced provider. Paramedics have the capability to address most prehospital emergencies. The scope of practice includes a wide variety of therapeutics and procedures including cardiac rhythm recognition, expanded pharmacologic treatments, and advanced airway interventions. Other important invasive procedures include needle decompression of a tension pneumothorax, needle or surgical cricothyrotomy, and transthoracic cardiac pacing.

The initial training course for the EMT-P includes didactic, clinical, and field education. All course content focuses on technical and professional competencies. Additional modules are included that allow programs to incorporate an expanded scope of practice.²⁶ With the expansion of EMS technology and management career options, many paramedic educational programs have advanced from 1-year certificate curriculums to 2-year associate or 4-year baccalaureate degrees. The National EMS Education Standards document recommends that all paramedic education programs be accredited in the future by the Commission on Accreditation of Allied Health Education Programs.

Future

To complement many of the educational issues addressed in the EMS Agenda for the Future document and at the request of the National Association of State EMS Officials (NASEMSO), the NHTSA along with the Health Resources and Services Administration under the Department of Health and Human Services published the Emergency Medical Services Education Agenda for the Future: A Systems Approach in 2000.²⁷ This document sets forth the processes required to improve EMS education delivery similar to what is realized with other allied health care professions, provides a means of ensuring more instructor flexibility and EMS adaptation to community needs and resources, and moves toward standardization of all levels of certification across the United States. From this document, multiple activities have been completed and published, including the National EMS Core Content, a National EMS Scope of Practice Model of minimum competencies, and the 2009 National EMS Education Standards, which would ultimately replace the current National Standard Curricula for each level of provider. The NASEMSO has been collaborating with multiple EMS stakeholders and the federal partner organizations to assist states in implementing this agenda. The National Registry of Emergency Medical Technicians is in the process of revising their examination, with a new paramedic examination being finalized by January 2013. Future goals include the establishment of a national EMS certification program, consistent levels of provider that build off of each advancing level (emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic), the requirement for educational programs to be nationally accredited, and the limitation of examinations only to those graduates who completed these accredited programs.

Medications

During the 1980s, many believed that prehospital drug administration was unjustified and simply delayed hospital transport.29,30 Moreover, although there was a profound paucity of outcomes-based research into the use of various medications and practices in the prehospital environment, this has been improved in recent years.³¹ There is significant evidence for early defibrillation and certain advanced cardiac life support medications, which are carried by most ALS services.^24,32 The wide variety of alternative medications is less uniform. This includes respiratory and anaphylaxis medications, preparations for altered mental status, analgesics, and antiemetics. Medications are traditionally administered in the field by the parenteral route, but the intranasal route is becoming popular for certain preparations. The beneficial aspects are that absorption is rapid with an onset of action similar to that of parenteral administration. Medications that are commonly administered intranasally are naloxone for narcotic overdose, midazolam for pediatric seizure, and fentanyl for pain control.^33,34